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VOLUME 2/ISSUE 10 - SEPTEMBER 2015
Not all HA
dermal fillers are
created equal.
OPTIMAL
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(CPM®) Technology1,2
INTEGRATION
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bio-integration of three Hyaluronic Acid fillers in human skin: a histological study.
Dermatology DOI: 10.1159/000354384.
Using Pulsed
Dye Lasers CPD
Treating
Keratosis Pilaris
Aesthetics
Awards
Winter01/04/2015
Marketing
Dr Justine Kluk shares
her techniques for
treating this common
skin condition
The finalists for
the prestigious
Aesthetics Awards
2015 are announced
Charlotte Moreso
discusses how
seasonal marketing
can boost trade
MZ084 185x192 AJ BELOTERO FC ADVERT BEL2020315LD.indd 1
Dr Firas Al-Niaimi details the history
and efficacy of pulsed dye lasers
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Contents • September 2015
06 News
The latest product and industry news
14 News Special: Holistic approaches to skin treatments
An investigation into how alternative treatments can complement aesthetic practice
CLINICAL PRACTICE
17 Special Feature: Lights
Special Feature
Lights
Page 17
Practitioners discuss the various modes and functions of light-
based treatments
22 CPD: Using Pulsed Dye Lasers
Dr Firas Al-Niaimi details the history and efficacy of pulsed dye lasers
29 Keratosis Pilaris
Dr Justine Kluk explores the aetiology of this genetic skin disorder
33 The Three-point Facelift
Dr Beatriz Molina presents her technique for non-surgical facelifts using cannulas
36 Managing Inflammation
Dr Kathryn Taylor-Barnes examines why inflammation occurs and how best to manage this for your patients
38 Aesthetics Awards 2015
The finalists for this year’s Aesthetics Awards are announced
45 Treating the Décolletage
Dr Aamer Khan outlines the procedures available to improve signs of ageing on the chest
51 Glutathione
Dr David Jack highlights clinical uses of the glutathione antioxidant
55 Treating Sunspots
Dr Daron Seukeran details the occurrence of photoageing and discusses treatment options for solar lentigos
A round-up and summary of useful clinical papers
IN PRACTICE
61 Building a women’s health clinic
Wendy Lewis investigates the incorporation of women’s health treatments into aesthetic practices
65 Winter Marketing
Charlotte Moreso explains how effective marketing can aid patient retention in the winter season
68 Staying Positive
Plastic surgeon Mrs Elena Prousskaia presents her key tips for developing a positive working environment
70 In Profile: Dr Kuldeep Minocha
Dr Kuldeep Minocha shares his journey from GP partner to successful aesthetic practitioner
72 The Last Word: Clinical Trials
Dr Martin Godfrey explains why high quality clinical trials are necessary for nutra-cosmeceuticals
NEXT MONTH
• IN FOCUS: Male Special • CPD: Male vs female facial rejuvenation
• Treating scars • Doctor to businessperson
Subscribe Free to Aesthetics
Clinical Contributors
Dr Firas Al-Niaimi is a consultant dermatologist
and laser surgeon. He trained in Manchester and
completed an advanced surgical and laser fellowship
at the St. John’s Institute of Dermatology at St. Thomas’
Hospital in London.
Dr Justine Kluk is a consultant dermatologist
based at London North West Healthcare NHS Trust
and European Dermatology London. Her particular
clinical interest is in skin cancer, having undertaken
a post-CCT fellowship in cutaneous oncology.
Dr Beatriz Molina practised general medicine for
12 years, before opening her first aesthetic practice in
Somerset in 2005. She is a member and the director
of conferences at the British College of Aesthetic
Medicine (BCAM).
Dr Kathryn Taylor-Barnes is a general
practitioner in Richmond and founder of The Real You
Clinics. She has presented her work at national and
international conferences and is currently completing
a postgraduate Masters qualification.
59 Abstracts
In Practice
Winter Marketing
Page 65
Dr Aamer Khan is an aesthetic practitioner
specialising in non-invasive treatments. He graduated
from The University of Birmingham in 1986 and is
dedicated to perfecting anti-ageing skin treatments.
He is also co-founder of The Harley Street Skin Clinic.
Dr David Jack is an aesthetic practitioner based
between his clinics in Harley Street in London and
Scotland. He graduated from the University of Glasgow
and later became a member of the Royal College of
Surgeons of Edinburgh.
Dr Daron Seukeran is a consultant dermatologist at
the James Cook University Hospital in Middlesbrough
and previously worked at the Royal Berkshire Hospital.
He undertakes general dermatology and dermatological
surgery, alongside his main interest in laser surgery.
Book your tickets now for
the Aesthetics Awards 2015
www.aestheticsawards.com
Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical
aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228
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Editor’s letter
This year seems to be flying past – or is it just
me? September always feels autumnal with
the change in temperature in the mornings
and evenings, dew on the grass and children
returning to the first term of a new school year.
Amanda Cameron
September is also an exciting time of year for the
Editor
aesthetic industry. Along with being the start of
the conference season, the Aesthetics Awards shortlist is announced
in this month’s journal! For those who haven’t already rifled through
the pages of this issue, turn to p.38 to see the lists of finalists in 23
prestigious categories. September’s issue also has some fantastic
articles on this month’s topic of rejuvenation. The word got me
thinking – what does it mean to rejuvenate? According to Chambers
dictionary, it means to make young again or to make someone feel or
look young again, and its derivation is from the Latin ‘juvenis’ meaning
‘young’. So is this what we aim to do for our patients; do we want to
make them look younger or simply look good for their age?
The décolletage is a notoriously neglected area of the body, and one
where many patients seek rejuvenation. As such, Dr Aamer Khan
gives a detailed overview on the different ways of treating the neck
and chest on p.45, sharing advice on the practicalities of each method
of treatment. Dr Beatriz Molina also presents her three-point facelift
technique for non-surgical rejuvenation on p.33, giving a detailed
overview for practitioners looking to adopt a new treatment approach.
And while well-performed aesthetic procedures are vital for successful
rejuvenation, it is also wise to complement both non-surgical and
surgical treatments with good skincare. As Dr Martin Godfrey argues
in this month’s Last Word opinion piece (p.72), practitioners should
be using scientifically-proven products and ingredients that are
well supported with clinical trials. With respect to this, Dr David Jack
examines the properties of Glutathione as a key antioxidant ingredient
in a fascinating article on p.51.
As always, we have a comprehensive CPD article that is sure to
educate and engage readers. This month Dr Firas Al-Niaimi looks
into the history and science behind the mechanisms of pulsed dye
lasers on p.22.
I shouldn’t leave without another final mention of the Awards.
December will be upon us before we know it, so be sure to book your
tickets in good time! Visit www.aestheticsawards.com to reserve your
place and to vote for your winners. And don’t forget to tweet us
@aestheticsgroup if you’re a finalist, or to show your support for those
on the shortlist!
Editorial advisory board
We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s
editorial advisory board to help steer the direction of our educational, clinical and business content
Mr Dalvi Humzah is a consultant plastic, reconstructive and
aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic
surgeon in the NHS for 15 years, and is currently a member of the
British Association of Plastic, Reconstructive and Aesthetic Surgeons
(BAPRAS). Mr Humzah lectures nationally and internationally.
Dr Raj Acquilla is a cosmetic dermatologist with over 11 years
experience in facial aesthetic medicine. UK ambassador, global
KOL and masterclass trainer in the cosmetic use of botulinum toxin
and dermal fillers, in 2012 he was named Speaker of the Year at
the UK Aesthetic Awards. He is actively involved in scientific audit,
research and development of pioneering products and techniques.
Sharon Bennett is chair of the British Association of
Cosmetic Nurses (BACN) and also the UK lead on the BSI
committee for aesthetic non-surgical medical standard. Sharon
has been developing her practice in aesthetics for 25 years and
has recently taken up a board position with the UK Academy of
Aesthetic Practitioners (UKAAP).
Dr Tapan Patel is the founder and medical director of VIVA
and PHI Clinic. He has over 14 years of clinical experience and
has been performing aesthetic treatments for ten years.
Dr Patel is passionate about standards in aesthetic medicine
and still participates in active learning and gives presentations
at conferences worldwide.
Dr Christopher Rowland Payne is a consultant
dermatologist and internationally recognised expert in cosmetic
dermatology. As well as being a co-founder of the European
Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was
also the founding editor of the Journal of Cosmetic Dermatology
and has authored numerous scientific papers and studies.
Mr Adrian Richards is a plastic and cosmetic surgeon with
12 years of specialism in plastic surgery at both NHS and private
clinics. He is a member of the British Association of Plastic and
Reconstructive Surgeons (BAPRAS) and the British Association of
Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards
and has written a best-selling textbook.
Dr Sarah Tonks is a cosmetic doctor, holding dual
Dr Maria Gonzalez has worked in the field of dermatology
qualifications in medicine and dentistry. Based in
Knightsbridge, London she practices a variety of aesthetic
treatments. Dr Sarah has appeared on several television
programmes and regularly speaks at industry conferences on
the subject of aesthetic medicine and skin health.
for the past 22 years, dividing her time between academic work
at Cardiff University and clinical work at the University Hospital
of Wales. Dr. Gonzalez’s areas of special interest include acne,
dermatologic and laser surgery, pigmentary disorders and the
treatment of skin cancers.
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Melanoma
Talk #Aesthetics
Follow us on Twitter @aestheticsgroup
#Motivation
Dr Justine Kluk @JustineKluk
There is no greater feeling as a doctor than seeing your
patients get better esp when their condition is so visible #skin
#MondayMotivation
#Device
Dr David Jack @drdavidjack
My new machine just arrived!
#laser #inmode #fractora
#aesthetics #ipl #london
#harleystreet #rosacea #beauty
#Regulation
Harley Academy @HarleyAcademy
The Joint Council for HEE recommendations has been formed.
Regulation is coming to the aesthetics industry at last
#Results
Dr Razwan @Skyn_Doctor
Always feel re-energised when clients return after treatments
and are highly satisfied with results #feelingblessed
#Training
Aesthetic Training
@GlowTraining
Hands on practical #mesotherapy training @58SouthMoltonSt.
Thank you to our delegates & models #skinpeel #hydration
#Clinic
TheGlasgowSkinClinic @KMcchord
Fantastic clinic today with Dr Stephen McChord &
KMcchord. From facial rejuvenation to axillary hyperhidrosis.
#safetyinbeauty #aesthetics
#Skin
BSF @BSFcharity
BSF & @TheCPTA survey: 4 out of 10 terms asked have seen
patients with skin reactions to black henna temporary tattoos
#AvoidBlackHenna
#Training
Julia Kendrick @JRKendrick
@SkinCeuticalsUK Training day 2:
skin analysis – nowhere to hide!
#nofilter #uvaware #fixmequick
New skin cancer
recommendations for
NHS England
New guidelines issued by the National Institute for Health and
Care Excellence (NICE) has recommended key points for NHS
England to address when treating melanoma. The document,
which was released in July, has outlined areas that NHS England
need to focus on, including information provision, support and
communication with patients. The guidelines suggest that written
information on the diagnosis and treatment should be made
available to patients and ‘information given must be specific to the
histopathological type of lesion, type of treatment, local services
and any choice within them, and should cover both physical and
psychosocial issues.’
It also discusses how every Local Hospital Skin Cancer
Multidisciplinary Team (LSMDT) and Specialist Skin Cancer
Multidisciplinary Team (SSMDT) should have a Cancer Clinical Nurse
Specialist (CNS) to provide a leading support role to patients and
carers, as well as provide psychological services. Professor Mark
Baker, director of the Centre for Clinical Practice said, “Melanoma
causes more deaths than all other skin cancers combined. Its
incidence is rising at a worrying rate – faster than any other cancer.
If it is caught early, the melanoma can be removed by surgery. If it
is not diagnosed until the advanced stages, it may have spread, so
it is harder to treat.” He continued, “However, there are a number
of options available to help slow the progress of the disease and
improve quality of life. This new guideline addresses areas where
there is uncertainty or variation in practice, and will help clinicians to
provide the very best care for people with suspected or diagnosed
melanoma, wherever they live.” The new guideline comes as Cancer
Research UK recorded 2,148 melanoma related deaths in 2012,
making it the eighteenth most common cause of cancer death.
Survey
BAPRAS calls for greater
psychological support
post treatment
The British Association of Plastic, Reconstructive and Aesthetic
Surgeons (BAPRAS) has called for greater measures of
psychological support for patients who undergo reconstructive
surgery. A survey of more than 100 BAPRAS members showed
that plastic surgeons frequently see patients who require
psychological support through a range of sub-specialities such as
burns treatments to breast cancer reconstruction.
Dr Jo Tedstone, consultant clinical psychologist said, “There
is plenty of evidence that providing these services improves
patients’ mood and quality of life as well as reducing overall
healthcare costs.” Of the survey respondents, 93% said that
access to psychological treatment is an important factor for their
patient group and 64% claimed to see patients who are in need
of psychological support every week.
Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015
aestheticsjournal.com
@aestheticsgroup
Aesthetics Journal
Aesthetics
Industry
Awards
Biopharmaceutical company
backs acne scar dermal filler
Spanish Biopharmaceutical company Almirall has announced it will support
startup aesthetic provider Suneva Medical with an equity investment, in
order to aid the launch of the acne scar dermal filler Bellafill.
The $15 million deal comes as Suneva Medical also secured a term loan of
$20.4 million from investment group HealthCare Royalty Partners. Eduardo
Sanchiz, CEO of Almirall said, “We have been attracted by the quality of
Suneva’s portfolio and its management team. This partnership will also
allow us to further build our understanding of the performance of the
aesthetic dermatology market in the US.” Approved by the Food and Drug
Administration (FDA) in January 2015, Bellafill aims to be a permanent solution
for acne scars and can also be used to treat nasolabial folds.
Research
Juvéderm Voluma research
indicates lasting results
A recent study from the American Society for Dermatologic Surgery
(ASDS) has indicated that results from Juvéderm Voluma can last for up
to one year with a small risk of adverse events. Led by Canadian
cosmetic dermatologist and clinical researcher Dr Shannon Humphrey, the
study was a retrospective review of 2,342 patients who underwent facial
augmentation treatment with Juvéderm Voluma between February 1, 2009
and October 1, 2014. A total of 11,460 ml of the HA filler was administered
during the course of the study in 4,702 treatments, with 50% of patients
receiving two or more treatments. Commenting on the research,
Dr Humphrey said, “With over five years clinical experience, a cumulative
volume injected greater than 11 litres, and increasing in popularity worldwide
we published the largest case series of patients treated with Juvéderm
Voluma.” She continued, “Our results confirm that this robust volumising
filler has a very good safety profile, high patient satisfaction and longer
durability than most hyaluronic acid fillers. This provides reassurance
and substantial case-based evidence that this volumising filler is in fact a
durable, safe and a valuable addition to our therapeutic armamentarium.”
Adverse events included erythema and bruising, which were both primarily
limited to transient injection site reactions and resolved within five to seven
In addition, temporary non-tender nodules developed at the injection site in
21 patients, lasting between one to 16 weeks.
Finalists announced
for the Aesthetics
Awards 2015
After months of deliberation, the finalists for the
Aesthetics Awards 2015 have been announced.
The ceremony, which will take place at the Park
Plaza Westminster Bridge Hotel on December
5, will celebrate the best in medical aesthetics,
recognising Commended and Highly Commended
finalists as well as inviting winners to the stage in
24 categories. The Awards recognise the highest
standards in achievement, clinical excellence and
product innovation, honouring individual practitioners,
companies, associations and treatments.
The evening will begin with a drinks reception,
followed by a formal sit-down dinner and
entertainment from British stand-up comedian Simon
Evans. The main event will then commence and
winners will be presented with trophies in front of 500
members of the medical aesthetics profession. The
evening will draw to a close after guests are invited
to enjoy music and dancing. Winners will be decided
either by a combination of Aesthetics journal reader
votes and scores from a panel of specially selected
judges, or by the judging panel alone. The winner of
The Schuco Award for Special Achievement award will
also be announced on the night and will be chosen by
the Aesthetics team. See pages 38-42 of this month’s
journal for the full list of finalists. To book your ticket
or to vote, visit www.aestheticsawards.com
Clinic
The Private Clinic opens flagship practice in Birmingham
The Private Clinic of Harley Street has opened a new practice in
the West Midlands. The aesthetic and medical cosmetic treatment
provider opened the clinic last month, located on Hagley Road in
central Birmingham. The clinic, which has three in-house theatres,
aims to provide patients with highly-experienced cosmetic specialists
and a wide range of cosmetic procedures. Valentina Petrone,
managing director of The Private Clinic, said, “As a business, we
have more than 30 years of Harley Street expertise and, over time,
we have grown our medical team to include some of the country’s
brightest and most highly regarded talent. In recent years, demand for
advanced medical expertise and specialist treatment from consumers
in the West Midlands has risen considerably. It was only right,
therefore, that we responded to this growing demand and extended
our operation on a regional level.” She continued, “The new facilities
will enable us to offer hair transplant procedures on the premises in
Birmingham for the very first time – a significant step forward for us.
Over time, we look forward to growing our presence in this region
further and continuing to cement our position as an industry leader.”
The practice will take the place of The Private Clinic’s former West
Midlands-based clinic that was located in Harborne.
@aestheticsgroup
Aesthetics Journal
Sun
Skincare
Murad and AAD partner for
child sun safety
Skincare brand Murad and the American Academy of Dermatology (AAD) have
announced their partnership in creating a programme to protect children from UV
rays when playing in public parks. The programme, named Shade America, will aim
to provide approximately one million children with shade over the next five years, by
initiating the build of shelter and shade structures in playgrounds across the US. It will
also offer children sun safety education classes.
Hilarie Murad, president of the Murad Family Foundation said, “We are extremely
excited about this partnership and also thrilled to be able to create a programme that
truly supports our mission to help young people lead healthier, happier and more
connected lives.” She continued, “Educating the youth in our community about sun
safety is a cause that Murad has been fully committed to and it is something I am
personally very passionate about.” The creation of Shade America comes as the
AAD has estimated that one in five Americans will be diagnosed with skin cancer in
their lifetime, therefore the programme is also designed to raise awareness of the
need to wear sunscreen and regularly check for suspicious spots.
Research
Skincare devices market
growing at significant rate
A study currently being conducted by P&S Market Research has suggested that
the global skincare devices market is continuously growing due to the increasing
number of non-invasive treatments performed.
The research, which predicts the growth of sales up to the year 2020, discusses
the popularity of various treatments and examines usage across all continents, with
North America currently taking the lead and Europe expected to transform into a
‘mature’ market. In addition, other factors considered are the manufacturing of more
affordable and advanced technologies including consumer devices and higher
investment rates from beauty product manufacturers. The research also categorises
devices by product type, such as LED therapy leading the treatment market with its
extended use in clinics and spas. The study has also reported that the rise in the
number of skin cancer patients, as well as disorders including acne, psoriasis and
moles in Brazil, China and India are expected to add to the growth of the devices
market in the coming years. The report will be published in full later this year.
Dermal filler
Study suggests Restylane Lip
Volume shows effectiveness
for nine months
A recent study on the effects of the HA lip enhancement gel Restylane Lip
Volume has shown that results of treatment can last up to nine months.
Research from the American Society for Dermatologic Surgery explains that
30 patients between the ages of 18 and 60 were treated with the gel, and
secondary treatment was offered after three months. Results indicated an overall
satisfaction rate, with 96% reporting a natural appearance and between 86% and
97% agreeing the upper and lower lips were ‘improved’. Patient diaries were also
used throughout, which recorded local injection site reactions in 10% of patients
and 17% of patients experiencing implant site hematoma.
SkinCeuticals
launches new
Blemish Control
Skin System
Skincare company SkinCeuticals has released its
new Blemish Control Skin System Kit that aims to
address problematic skin in adults. The kit, which is
available in the UK and Ireland, includes three products:
Blemish + Age Cleansing Gel, Solution and Defense.
The products contain active ingredients including:
dioic acid, salicyclic acid and glycolic acid, that aim to
improve the appearance of blemishes, fine lines and
post-blemish hyperpigmentation. Dr Firas Al-Niaimi,
consultant dermatologist at the Sk:n clinics, London,
said, “The Blemish Control Skin System provides a
much-needed solution for patients who are ready
for transition from years of effective but potentially
dehydrating and sensitising drug therapies to a more
tolerable yet efficient solution to treat their breakouts,
while improving overall complexion.”
E-Learning
Harley Academy
partners with OCB
Media
Cosmetic training provider Harley Academy is
working with OCB Media to launch its universitystandard e-Learning modules. OCB Media provide
online learning to healthcare organisations including
the Royal Colleges, the Department of Health and
NHS West Midlands. The modules available through
the partnership include dermatology, botulinum
toxin and dermal fillers. There will be more than
100 hours of online material that includes videos,
interactive diagrams and formative exercises.
Students can also access additional modules on
ethics, law, the role of the General Medical Council
(GMC), health & safety and consent. It is hoped that
this will give students a full understanding of the
landscape they will enter in as practitioners. Martin
Robinson of OCB Media said, “We are delighted to
be partnering with the Harley Academy and pushing
the boundaries of cosmetic e-Learning.”
@aestheticsgroup
Aesthetics Journal
Aesthetics
Vital Statistics
Awards
Institute Hyalual offers
cosmetic nurses the chance
to win tickets to Aesthetics
Awards 2015
Institute Hyalual is to offer two cosmetic nurses the chance to attend
the Aesthetics Awards 2015. The opportunity comes as Institute Hyalual
is set to sponsor the Aesthetic Nurse Practitioner of the Year Award for the
second year running, and is therefore inviting two cosmetic nurses to join
the team at its table. Iryna Stewart, managing director of Institute Hyalual
said, “Cosmetic nurses have always been a group valued by Institute
Hyalual. We constantly support their hard work and efforts, and we will be
delighted to reward the winner of this category on the night, but also want
to commend all cosmetic nurses for furthering the UK aesthetic market. We
are looking forward to maybe meeting some new colleagues to join in the
celebrations.” The event is the ideal opportunity to celebrate the aesthetics
industry and network with fellow industry professionals, and will be held on
December 5 at the Park Plaza Westminster Bridge Hotel in central London.
To be in with a chance of winning the tickets, nurses should contact Iryna
Stewart by emailing [email protected]. Winners will be chosen by the
beginning of October.
It is estimated
that 137,310
137,310
new cases of
melanoma will
be diagnosed in the US in 2015
(American Academy of Dermatology)
Since 1997, there has been a
273% increase in the number of
procedures performed on men
(American Society for Aesthetic Plastic Surgery)
Skincare products
make up the largest
part of the global
cosmetic market,
with 35.3% in 2014
35.3%
(Statista)
Cellulite
FDA clearance for Cellfina
System
Only 4.5% of
women said their
stomach is their
favourite body part
(Syneron Candela)
8 million
An estimated 8 million women in
the UK suffer from hair loss
(NHS)
Global medical device company Ulthera, Inc has been awarded
clearance from the Food and Drug Administration (FDA) for its
Cellfina System to improve the appearance of cellulite on the thighs
and buttocks. The device, which was acquired by Merz North America
in June 2014 and will become available to US-based practitioners this
autumn, was used in a multicentre clinical study of 55 patients using a
single treatment. Improvement was recorded in 98% of patients in the
appearance of their cellulite and 96% reported to be satisfied with the
result after two years. In a separate study, Dr Michael Kaminer, associate
clinical professor of dermatology at Yale Medical School said, “Our
clinical data shows that patient satisfaction with the results of Cellfina
treatment improved from 94% at one year to 96% patient satisfaction at
the two year mark, and my work in treating my own patients continues
to support these results.” A UK release date is expected to be in spring/
summer 2016.
44
In the UK, 44 is the
most popular age for
patients to undergo
a blepharoplasty
(MYA)
15% of all cases
of acne occur on
the chest
(NHS Inform)
@aestheticsgroup
Events diary
5th September 2015
BACN/BACM Joint Regional Scottish Meeting
www.bacn.org.uk/events/joint
17th – 18th September 2015
Beyond Aesthetics, Manchester
www.beyondaesthetics.org.uk
25th – 26th September 2015
F.A.C.E2F@ce conference 2015, Cannes
www.face2facecongress.com/en
26th September 2015
British College of Aesthetic Medicine
Conference, London www.bcam.ac.uk
3rd October 2015
British Association of Cosmetic Nurses
Conference, Birmingham
www.bacn.org.uk/events/bacn-annualconference-exhibition
5th December 2015
The Aesthetics Awards 2015, London
www.aestheticsawards.com
Accreditation
Aesthetics gains
ABC accreditation
The Aesthetics journal has received accreditation
from the Audit Bureau of Circulations (ABC). The
industry body for media measurement granted its
stamp of approval to Aesthetics in July and will
subsequently audit the journal on an annual basis.
The endorsement, given by the ABC, confirms that
a company is capable of facilitating print and digital
trading best practice and that it has transparency in
its claims of subscription and circulation. Through
its independent audit and compliance services,
the ABC delivers certification which verifies that
a publication has data and processes that meet
industry Reporting Standards and measures
reach, engagement and loyalty to demonstrate a
publication’s performance.
Aesthetics Journal
Skincare iS Clinical releases new
Copper Firming Mist
Skincare brand Innovative Skincare (iS) Clinical has
released a paraben-free Copper Firming Mist to
provide hydration and stimulate collagen synthesis.
The brand, which encompasses a range of skincare
products from cleansers to moisturisers and sun
protectants, created the mist for multiple skin concerns.
The key ingredients include copper PCA for improving
skin elasticity and firmness, kola seed extract to provide
antibacterial benefits, guarana extract for toning, and
resveratrol for protection against UV photo-exposure.
Speaking of the new product, Alana Marie Chalmers,
director of distribution of iS Clinical UK said, “As well
as being formulated with copper PCA, one of the new
miracle-working ingredients of 2015, this antibacterial
hydration mist is anti-acneic, sebum balancing, boosts
skin’s luminosity in addition to providing antioxidant
protection against UV photo-exposure and stimulating
collagen synthesis to firm and improve skin elasticity.”
The brand also claims that the mist can be well adapted
to an existing skincare regime and sprayed over
make-up to set the skin and refresh.
Patient Support
BAD launches skin support
website
The British Association of Dermatologists (BAD) has launched an online
psychological support service for people who suffer from various
skin conditions. Skin Support, which was awarded a three-year grant
by The Department of Health Innovation, Excellence & Strategic Development
Fund, provides links and information on self-help, support groups and patient
information leaflets. Dr David Edey, president of the BAD said of the support
website, “The problem is that finding self-help materials can be difficult –
patients don’t know where to look and resources are available across so
many different websites. The beauty of the Skin Support website is that it
brings together lots of content in one easy to navigate place, and it tailors the
materials to people’s individual skin disease and any physical impairment this
may involve.” According to the BAD, skin conditions are the most frequent complaint
recorded by GPs, and psoriasis alone is linked to 300 suicide attempts
annually. Dr Andrew Thompson, a member of the advisory panel associated
with the development of the website said, “Skin conditions can have a
significant psychological impact on people and it is well acknowledged that
access to psychological intervention and even to good quality evidence
based self-help is limited. Consequently, the Skin Support project is
an important development as it is unique in providing people with skin
conditions with information about emotional and social issues associated with
dermatological conditions.”
He continued, “People visiting the site can also download self-help materials
that have been written by qualified clinicians, such as myself, and have been
either tested in the NHS or in research. We also hope that the site will encourage
people to seek further help from their GP or dermatologist if needed.”
@aestheticsgroup
Aesthetics Journal
Aesthetics
Psoriasis
BJD publishes psoriasis survey
results
A recent survey from the International Psoriasis Council (IPC) identifying 21
research priorities has been published on the British Journal of Dermatology
(BJD) website. The non-profit council, founded in 2004, conducted the survey,
‘Prioritising the global research agenda in psoriasis: An International Psoriasis
Council Delphi consensus exercise,’ to further develop understanding of the
condition. The IPC adopted the Delphi method, a structured communication
technique to survey psoriasis professionals around the world, and to reach a
consensus on the 21 priorities. The three main factors considered throughout
were to identify biomarkers that correspond with psoriasis, identify genes that
advise awareness to developing psoriasis and whether early and aggressive
intervention can make a difference to the disease’s progression. Dr Bruce
Strober, the lead author of the article and board member of the IPC, said of
the survey, “The Delphi method has generated a more data-driven, unbiased
prioritisation of topics important for study. This list will provide both institutions
and individuals a better sense of the pressing and relevant research needs in
psoriasis.” The results of the survey are also expected to be featured in a future
print edition of the BJD.
Association
BACN appoints new board
member
The British Association of Cosmetic Nurses (BACN) has appointed Julie
Charlton as a new member of the board. Charlton is a partner in the clinical risk
team at the Bevan Brittan law firm, specialising in medical negligence, mental
health and human rights law. Sharon Bennett, BACN Chair said, “This appointment
reflects the growing involvement of the BACN in policy and procedural matters and
in its commitment to improving services to its growing membership base.”
Body contouring
CoolSculpting launches
mini applicator
ZELTIQ Aesthetics has expanded its CoolSculpting
portfolio by adding the new CoolMini applicator to
target smaller pockets of fat. The new addition has
been designed for specific areas such as the chin,
knees and underarms, to freeze any stubborn fat and
contour the body without any downtime. The CoolMini
follows the successful launches of the CoolSmooth and CoolSmooth Pro applicators
in 2014, with the company recently estimating that two million treatments have
been performed in more than 70 countries. Andy Vutam, director of International
Marketing at ZELTIQ said of the new applicator, “The CoolMini is the newest addition
to our growing CoolSculpting portfolio, which uses patented fat freezing technology
backed by scientific evidence. Our existing applicators for larger areas, such as the
abdomen and thigh, have seen great results and there was a demand from both
physicians and patients to treat smaller, more specific areas”. He continued, “We’re
excited to expand our offerings and further demonstrate the safety, efficacy and
long-lasting results of the CoolSculpting procedure with this new applicator.”
The UK launch of CoolMini applicator is estimated to be in the autumn.
60
Lee Boulderstone
UK Manager for BTL Aesthetics
What is the vision for BTL over
the next five years?
Our vision is to be the largest
manufacturer and supplier of
non-surgical devices in the
fat removal, body shaping
and skin tightening markets. With over 50
direct offices worldwide, this is becoming a
reality as our reputation for honesty and trust
in supplying medically and scientifically tried
and tested devices give clinics and consumers
the confidence that they have chosen the right
company and devices to work with.
What is BTL’s focus this year?
Education is greatly required in aesthetics,
especially with technology. Radiofrequency and
ultrasound come in many forms and mistakes
can easily be made. Many practices have
unfortunately made purchasing decisions after
being misled that all these technologies are the
same – a problem that could be so easily avoided
if the UK had a good regulation system. Once
educated correctly, practices can make the right
decision for their business and then it comes
down to training which is another great passion of
BTL. If the device isn’t used correctly, the results
will be less evident and too many companies do
not spend the time and effort helping the users
achieve the best results for their clients.
You have had some great success over the last
couple of years in being nominated for/winning
awards. What is the key to your success?
Honesty and trust, along with devices that work
with the best training and support programmes
is key. Thus giving our clients and consumers the
confidence in obtaining the best result-driven
treatments that are FDA approved and supported
by peer reviewed papers and articles. Our motto
is ‘Real People, Real Results’ and that is what
makes us an award winning company.
What products are you most excited about for
the UK market?
We’ve have had great success with the Exilis Elite
which we believe will continue to do well in the
future. The alternative is the BTL Vanquish that is
making amazing progress across the world and is
set to be the next big thing for BTL Aesthetics UK.
This column is written and supported by
@aestheticsgroup
Aesthetics Journal
Conference
First Expert Clinic sponsors
announced for ACE 2016
Eight medical aesthetics manufacturers and
distributors have been announced as sponsors
of Expert Clinic sessions at the Aesthetics
Conference and Exhibition (ACE) 2016 on April 15
& 16. Skinceuticals, Healthxchange, AestheticSource,
Aestheticare, BTL Aesthetics, Lynton Lasers,
Rosmetics and Fusion GT are the first companies to announce their involvement in
the comprehensive agenda, with respected names set to deliver live demonstrations
showcasing the latest techniques and innovations. Last year the Expert Clinic agenda
proved a resounding success, receiving overwhelmingly positive feedback from
delegates who were given the opportunity to appreciate exclusive demonstrations. The
Expert Clinic sessions at ACE 2016 promise once again to provide practice-oriented
and engaging education for delegates aiming to enhance their skills in injectables, skin
rejuvenation, body contouring and more.
To stay up to date with the latest ACE 2016 news, sign up to the Aesthetics weekly
e-newsletter by visiting www.aestheticsjournal.com and registering online.
Lasers
New picosecond laser launched
by Lynton Lasers
Medical device manufacturer Lynton Lasers has announced that the Discovery Pico
will be launched later this year. The new addition to the product range aims to combine
the efficacy and speed of picosecond pulses, with the safety profile of nanosecond
Q-switched pulses at 1064 and 532 wavelengths. It will have the shortest pulse
available (375ps), a high peak power of 1.8GW, and an optional upgrade to a ResurFACE
fractional attachment. Jon Exley, managing director at Lynton said, “A number of our
laser physicists have worked for many years with Picosecond lasers both at Lynton
and at the University of Manchester. Whilst I believe there are strong commercial
benefits surrounding the pico-lasers for tattoo removal, we at Lynton are convinced that
picosecond technology has a place alongside the Gold standard nanosecond Q-switch
treatment, and that’s why we’re extremely excited to be launching the Quanta Discovery
Pico laser, which incorporates both technologies in one system.” The company say that
the combination of both picosecond and nanosecond pulses helps to deliver quick and
safe treatments.
Submental fat
Kythera seeks European approval
of Kybella
Biopharmaceutical company Kythera Biopharmaceuticals has announced its
submission of a marketing authorisation application seeking EU approval of the
submental fat treatment Kybella, also known as ATX-101. The injectable treatment,
which was approved by the FDA in April, aims to improve the appearance of fat under the
chin with deoxycholic acid, which works to break down dietary fat and destructs fat cells.
Keith Leonard, president and chief executive officer of Kythera said, “The submission
in the European Union reflects our commitment to make ATX-101 broadly available and
marks a key milestone for the global development programme. We look forward to the
review of our application and to the potential approval of ATX-101 in Europe as a nonsurgical treatment for women and men seeking an improved chin profile.”
News in Brief
AestheticSource expands its team
Skincare distributor AestheticSource has
announced it has expanded its team to
continue their commitment in supporting
their practitioner customer base. Sharen
McBride, a qualified nurse and former
business development manager for a
collection of medical aesthetic products
which included NeoStrata, will join the group
as the business development manager and
training consultant, covering the north of
England and Scotland.
P-shot and O-shot now available in
Kent and Essex
Aesthetic practitioners Dr Shirin Lakhani
and Dr Kannan Athreya have teamed up to
offer the O-Shot and P-Shot treatments at
their clinics in Kent and Essex, respectively.
Dr Lakhani, the only woman in the UK to be
qualified to offer the treatment, was assisted
by Dr Athreya when she performed the first
P-shot treatment in Kent on August 5.
Lumenis launches new website for
skincare information
Medical device company Lumenis has
launched a new online resource that provides
information on the latest energy-based skin
treatments. AesthetiPedia, which also includes
information and key facts on skin conditions
such as acne, rosacea and stretch marks,
holds an extensive before and after image
collection for patients to consider before
opting for treatment.
Dermagenica welcomes six official
certified trainers to its team
PDO Threads training course provider
Dermagenica has greeted six new certified
trainers to its group. Dr Hassan Soueid, Dr
Sherif Wakil, Dr Yen Lam and Dr Diana C
Marquez Ruiz will be offering training to
doctors and dentists, while Lynda Smith and
Victoria Parsons will deliver training to nurses.
Majestic releases new range of
disposable bath sheets
Towel and disposable-product manufacturer
Majestic Towels has released a new range
of disposable bath sheets and towels.
The eco-friendly range includes a flexible,
multi-purpose disposable bath sheet that
measures 100cm x 150cm, which makes it
large enough to wrap around patients and
cover treatment couches.
MEET US AT
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Aesthetics Journal
immunomodulation, with probiotic supplementation preventing child
allergies, and atopic eczema occurring 50% less in supplemented
individuals than those in the placebo group.7
TCM
As a practitioner of Chinese medicine, John Tsagaris’ ethos is
analogous to Vidhi’s ‘heal from within’ philosophy, he also utilises
the mechanical tools of acupuncture in TCM, the synergistic
nature of antioxidants and plant actives as topical treatments,
and the use of TCM herbs. Tsagaris explains, “The medicinal use
of each Chinese herb is determined by the herb’s properties,
therapeutic functions and by the herb’s ability to influence certain
energetic bodily functions or organs to treat a patient’s condition.” Holistic approaches
to skin treatments
Charlotte Maria Mawn investigates
the growth of the holistic approach
within the aesthetic industry
A 2015 study by Wang et al.,1 defined holistic medicine as ‘an
interdisciplinary field of study that integrates all types of biological
information (protein, small molecules, tissues, organs, external
environmental signals, etc.) The holistic approach to medicine can
be seen as integrative, multi-tiered and progressive. The approach
encapsulates the ethos of treating a patient as a whole, utilising
the scope of worldwide medicine to achieve optimal health and
wellness. Yet the practice currently exists under the surface of
recognition and acceptance from Western medicine. Nutrition and supplementation
Vidhi Patel, an Indian-trained homeopathic doctor and nutritionist
believes the rationale behind adopting an holistic approach in
aesthetic medicine is to cushion the impact of any non-invasive or
invasive treatment. Patel’s ethos is, “Health is what you eat, drink and
think.” Patel works with aesthetic practitioners to recommend tailored
dietary supplementation two weeks prior and post treatment. With
the aim of minimising inflammation, side effects, and downtime, she
advocates the use of supplements such as Turmeric,2 green tea
extract,3 cod liver and flax seed oil,4 as well as resveratrol5 pre and post
treatment. Diane Nivern, clinical director and holistic skin therapist at
Diane Nivern Holistic and Aesthetic Clinic, argues that practitioners
should aim to recognise internal issues that could be causing an
aesthetic concern, before prescribing potentially unnecessary or
expensive invasive treatment. She exemplifies the case of a patient
presenting with acute cystic acne. After testing for food intolerances,
eliminating foods and the use of a probiotic, Nivern’s patient’s skin
resolved itself almost completely. Nivern explains that the ecology
of the gut has a strong link to inflammation and skin condition.
This is supported in clinical literature, which links imbalances in gut
microflora to numerous conditions such as obesity, allergies and
Crohn’s disease.6 Notably, a Lancet study implicated gut microflora in
Acupuncture
Acupuncture needles are inserted into the skin, causing micro-trauma
to stimulate nerves under the skin and in muscle tissue. Commonly
used for pain relief from conditions such as headaches and lower
back pain, a 2015 study suggested certain types of acupuncture
improve the appearance of nasolabial folds via a fibroblast-collagen
synthesis and neovascularisation mechanism.9 “Side effects are
minimal, and, if any, it will be light bruising which can be helped
by the use of Arnica,” said Tsagaris. He advises that patients with
hypersensitivity may be unsuitable for acupuncture treatment.
Hormones and the aesthetic link Dr Harpal Bains, clinical director of The Harpal Clinic, an aesthetic
practice utilising integrative medicine, explains that she often sees
patients presenting with chronic acne and pigmentation, which, are
shown to be the result of hormonal imbalances. As such, Dr Bains
prescribes hormone therapy while simultaneously treating any skin
parameters such as the acne and pigmentation. She says, “Treating
the internal factors puts patients on a path of wellbeing, and improving
their appearance becomes part of that journey of well being too.”
Conclusion
The resounding conclusion from the holistic-aesthetic practitioners
interviewed is the aim to balance physiological systems through
dietary, hormonal, psychological, supportive or topical treatment,
collaboratively with aesthetic procedures. While some may argue
that evidence for certain alternative therapies is predominantly
anecdotal, a growing number of practitioners are adopting holistic
approaches to their aesthetic practice in order to endeavour not
only to enhance a patient’s appearance, but also improve their
overall health, vitality and quality of life.
REFERENCES
1. Y. Wang, C. Zheng, C. Huang, Y. Li, X. Chen, Z. Wu, Z. Wang, W. Xiao, and B. Zhang, ‘Systems
Pharmacology Dissecting Holistic Medicine for Treatment of Complex Diseases: An Example Using
Cardiocerebrovascular Diseases Treated by Tcm’, Evid Based Complement Alternat Med, (2015).
2. Nita Chainani-Wu. The Journal of Alternative and Complementary Medicine. February 2003, 9(1): 161168. doi:10.1089/107555303321223035. pp. 1-2.
3. E. Roh, J. E. Kim, J. Y. Kwon, J. S. Park, A. M. Bode, Z. Dong, and K. W. Lee, ‘Molecular Mechanisms of
Green Tea Polyphenols with Protective Effects against Skin Photoaging’, Crit Rev Food Sci Nutr (2015).
4. Artemis P. Simopoulos.’ Omega-3 Fatty Acids in Inflammation and Autoimmune Diseases’,
Journal of the American College of Nutrition 21 6 (2002).
5. J. Soeur, J. Eilstein, G. Léreaux, C. Jones, L. Marrot, Skin resistance to oxidative stress induced by
resveratrol: From Nrf2 activation to GSH biosynthesis, Free Radical Biology and Medicine, 78 (2015)
p.213-223.
6. Jose C. Clemente, Luke K. Ursell, Laura Wegener Parfrey, Rob Knight, ‘The Impact of the Gut
Microbiota on Human Health: An Integrative View’, Cell, 148, 6, (2012) p.1258-1270.
7. M. Kalliomäki, S. Salminen, H. Arvilommi, P. Kero, P. Koskinen, and E. Isolauri, ‘Probiotics in Primary
Prevention of Atopic Disease: A Randomised Placebo-Controlled Trial’, Lancet, 357 (2001).
8. Jin Hyong Cho, Ho Jin Lee, Kyu Jin Chung, Byung Chun Park, Mun Seog Chang, and Seong Kyu
Park, ‘Effects of Jae-Seng Acupuncture Treatment on the Improvement of Nasolabial Folds and Eye
Wrinkles,’ Evidence-Based Complementary and Alternative Medicine, (2015).
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Aesthetics Journal
Aesthetics
Lasers and lights
Allie Anderson speaks to practitioners about the various modes and
functions of light-based treatments that are routinely used for a number
of aesthetic indications
Light-based technologies have, over the years, become
commonplace in medical and aesthetic clinics as the treatment of
choice for a range of problems, from hyperpigmentation and fine
lines to acne scarring and skin cancer. Some of the most established
modalities are lasers, light-emitting diode (LED) therapy, intense
pulsed light (IPL) therapy and photodynamic therapy (PDT), which are
discussed in turn herein.
Laser treatment
There are numerous indications for light-based therapies, each
responding better to specific types of treatment. One of the most
commonly used is laser treatment, and the indications it can be
effectively used to treat can be broadly summarised as:1
• Unwanted hair
• Vascular lesions, scars and acne
• Pigmented lesions (including tattoos)
• Skin rejuvenation
• Varicose/leg veins
“Every laser device can do something different,” explains Mr Taimur
Shoaib, who uses 10 lasers in his clinic. “Some treatments are good
for the skin’s surface, some for segments of the skin a little bit deeper,
and some for even deeper skin treatments. There are so many
different areas of the skin that we can treat, such as bacteria and fine
lines and wrinkles at the top of the skin, hair follicles at the bottom,
and sun damage in the middle. Each laser system has to be quite
specialised in order to deliver the treatment to the area concerned.”
The molecules in the skin contain substances called chromophores,
which are responsible for the molecule’s colour and which absorb
light. When a wavelength of light is applied to the skin, it selectively
targets a particular chromophore, which then absorbs the light. The
light is then turned into heat energy sufficient to break down the target.
In other words, it damages the chromophore.2 The way a wavelength
of light affects the skin is in part determined by how deep beneath
the skin’s surface it penetrates. The longer the light’s wavelength,
the deeper it will penetrate. Therefore, different wavelengths with a
different absorption coefficient will target a particular chromophore at a
particular depth.3
There are three major chromophores in human skin, which are each
associated with different indications that are treatable with lasers:
• Haemoglobin, the target chromophore for treating vascular lesions:
port wine birthmarks, haemangioma, rosacea, facial telangiectasia,
spider naevi, cherry angioma, erythematous (acne) scarring and warts.4
• Melanin, the target chromophore for treating unwanted hair and
pigmented lesions: freckles, solar lentigines, café au lait spots, and
nevae of Oto and Ita.1
• Water, the target chromophore for skin rejuvenation: lines and
wrinkles.5
In skin rejuvenation, lasers are used to target water in the dermis.
This water absorbs light at longer wavelengths, and triggers a
cellular reaction that, in turn, stimulates the formation of collagen
and elastin, which keep the skin firm, plump and supple. Figure 1
outlines indications that respond to laser treatment, the chromophore
involved and some of the light wavelengths that effectively target
that chromophore. The light emitted by a laser (an acronym for light
amplification by stimulated emission of radiation) is what’s known as
coherent light. This is where the photons (tiny light particles) travel in
phase with one another, all photons changing phase at the same time
(see Figure 2). As a result, lasers concentrate the light extremely well
and therefore tend to penetrate much more effectively.7 This makes
lasers the treatment of choice for some practitioners, who argue that
only highly coherent laser beams can produce significant results.
“The laser beam is highly concentrated, so it is applied for a very short
duration – milliseconds or nanoseconds,” says Mr Shoaib. “Because
of that, it doesn’t actually cause damage to any of the surrounding
tissues.” Side effects are minimal too, he adds, reporting that patients
Figure 1: wavelengths targeting three main chromophores for various indications4,6
Indication
Vascular lesions
- port wine birthmarks
- haemangioma
- rosacea
- facial telangiectasia
- spider naevi
- cherry angioma
- erythematous (acne)
scarring
- warts
Pigmented lesions
- freckles
- solar lentigines
- café au lait spots
- nevae of Oto and Ita
Chromophore
involved
Haemoglobin
Melanin
532 nm
542 nm
578 nm
585 nm
532 nm
694 nm
755 nm
1,064 nm
(deep lesions)
510 nm
694 nm
755 nm
1,064 nm
Hair removal
Skin rejuvenation
- fine lines
- wrinkles
Wavelength
(nanometres)
Water
2,940 nm
10,600 nm
are advised to avoid sun exposure after treatment as this could
cause unwanted pigmentation. “The only other potential difficulty is in
managing a patient’s expectations of the treatment.”
Light-emitting diodes (LED) light therapy
Other types of light-based treatment use incoherent light, where
the photons do not travel in a unified manner, changing phase
randomly. As a result, the light spreads over a wider area rather
than being concentrated. Thus, even at a high power, incoherent
light is transmitted over shorter distances and doesn’t penetrate as
deeply as coherent light.6 An example of an incoherent light source
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is LEDs. LEDs are tiny light bulbs that emit nonthermal, visible wavelengths of light. The treatment
covers a larger area than a laser, but being more
diffuse also means it needs to be applied to the skin
for longer.6 However, LED is used successfully to
treat many of the same indications, with anecdotally
good results. Lisa Monaghan-Jones is a proponent
of this type of treatment, which she performs at her
practice – Internal Beauty Clinic in Huddersfield.
Aesthetics
Travel patterns of laser light and LED light
Before
After
the use of a lay-in device
that is fully automated and
does not require staff to be
present. She explains that it
uses blue light at 470 nm to
target acne and blemishes;
red light at 660 nm to
activate cells to produce
Dermalux Dual Wave: Red & NIR treatment. Total 12 sessions:
collagen and elastin, as well
three sessions per week over a period of four weeks
as to reduce inflammation
and redness associated with rosacea; and, as an additional benefit, infrared
light at 940 nm to relieve muscle and joint pain, as well as the pain and stiffness
associated with arthritis. “The device is suitable to be used before or after any other
treatment to enhance the results of that treatment or to alleviate any side effects
such as inflammation,” says Dr Nguyen, adding, “It can also be used to soothe skin
immediately after IPL, laser or dermabrasion treatment.” While LED therapy can be
used to treat all skin types, it can trigger seizures in patients with epilepsy7,8 and
has not been trialled in pregnant women. It is also contraindicated in patients with
porphyria,8 a rare hereditary disease affecting the metabolism of haemoglobin, as
well as with certain medications.9
“I choose LED phototherapy because it’s clinically
proven technology-wise, it has guaranteed results and
it’s suitable for all skin types,” she says. “It promotes
regeneration and healing on the skin, so it increases
collagen, enhances the function of enzyme repair,
helps the lymph system, and stimulates new capillaries
and new cell growth.” LED is indicated for a range of
problems, she says, including acne, eczema, psoriasis,
rosacea, pigmentation and ageing skin, as well as
to promote healing after radiofrequency treatment,
laser treatment, peels and surgery. Dr Rekha Tailor,
medical director of Health + Aesthetics in Surrey, uses
the same LED treatment protocol, whereby three
different coloured lights of specific wavelengths work
to combat different skin concerns. “It uses red light at
633 nm to reduce lines and improve tone and texture.
It stimulates the fibroblast cells, which triggers the
production of collagen and elastin, increases hydration
and plumps up the skin,” she explains. “Blue light,
which is 415 nm, can help to treat acne by damaging
porphyrins, which naturally occur in acne bacteria. It
reduces active acne and helps prevent break-outs, by
normalising oil production.” An 830 nm near-infrared
light has a similar effect, Dr Tailor adds, while also
soothing redness and irritation, thereby accelerating
skin healing. Alternatively, Dr Ahn Nguyen advocates
Intense pulsed light (IPL) treatment
An adaptation of laser phototherapy comes in the form of IPL treatment. IPL works in
the same way as a laser, but instead of emitting light of one specific wavelength, as
lasers do, the light IPL produces is composed of a spectrum of colours from different
wavelengths – commonly 550 to 950 nm. As a result, it can select different targets
for absorption, much like using a number of different lasers in a single treatment. Dr
Maria Gonzalez from the Specialist Skin Clinic in Cardiff states that IPL has two main
skin indications: a condition called poikiloderma of Civatte, whereby (mainly female)
patients present with erythema and mottled pigmentation on the neck as a result of
sun damage; and red-coloured sun damage on the chest. “These treatments tend
to be suitable for patients who are very fair skinned – typically Fitzpatrick skin types
I and II – so people who have fair skin and eyes and burn easily in the sun,” she
comments. Conversely, she explains, IPL is not suitable for those with olive-toned,
Asian or black skin, particularly type VI, who, according to Dr Gonzalez, don’t suffer
from these conditions anyway. Dr Gonzalez suggests that the advantage of IPL is that
one machine, in its nature, can treat all manner of indications. “With lasers, you have
to use a different one for each distinctive problem, which makes it a very expensive
way to set up a clinic,” she says. “On the other hand, a laser tends to be able to
produce extremely good results for specific, individual problems.” IPL has also been
shown to be safe and effective in treating specific concerns, including vascular and
pigmented lesions, photo-ageing, and skin conditions such as acne, rosacea and
non-melanoma skin cancers.12 Moreover, the results of IPL can be improved by using
it in combination with other anti-ageing treatments. For example, IPL combined with
botulinum toxin injections has been shown to produce better results in correcting
wrinkles that appear when the face is animated or in motion, called dynamic rhytids,
than using IPL alone.13
Before
Befores and after 4 IPL treatments for poikiloderma of civatte
After
Before and after 14 treatments with Body Boost Bed lay-in device
@aestheticsgroup
Aesthetics Journal
Photodynamic therapy (PTD)
PTD is a treatment that uses a drug called a photosensitising agent, combined with a
particular wavelength of light, such that when the photosensitising agent is exposed
to that light wavelength, it produces a form of oxygen that kills adjacent cells. PTD is
licenced for treating non-melanoma skin cancers,14 with evidence demonstrating that
PTD has significantly better outcomes for actinic keratosis, superficial and nodular
basal cell carcinoma, and squamous cell in situ (known as Bowen’s disease) than
other standard treatments.15 Nurse prescriber and aesthetic practitioner Anna Baker
performs this treatment protocol using a topical photosensitising agent methylaminolevulinate (MAL, known as Metvix). Baker explains how the procedure works,
“Metvix is applied to the skin cancer lesion, and left under an occlusive dressing
for three hours, during which time the patient can go off and do what they want to
do. The drug is very selective and only binds to certain kinds of cells – dysplastic or
neoplastic cells – within the lesion, in which uptake of the drug is rapid. During that
three-hour timeframe, these cells become saturated with photoactive porphyrins.”
When the wavelength of light is applied later and mixes with these porphyrins,
a chemical response is generated, the by-product of which is a form of oxygen
called singlet oxygen, which in turn breaks down the damaged cells in the lesion.
Sometimes, a small amount of the photosensitising agent is taken up by healthy
tissue around the dysplastic or neoplastic cells, but this is minimal. The treatment
uses a red LED light with a wavelength of around 630 nm, administered after the
area to which the drug has been applied has been cleansed thoroughly. “This light
wavelength is typically capable of treating an area roughly around 6x16cm,” Baker
adds, “but this is very much dependent on how much patients can tolerate in one
Figure 3 – main indications for light colours18
Light colour
RED light
BLUE light
NEAR-INFRARED light
Main indication
Main indication: rejuvenation
• Stimulates collagen synthesis and growth factor
production
• Increases hydration levels and moisture retention
• Evens skin tone and texture
• Reduces pigmentation
• Calms redness and inflammation
• Shrinks pores and sebaceous glands
• Stimulates circulation & lymphatic system
• Accelerates skin repair
Main indication: acne
• Powerful anti-bacterial treatment
• Treats all grades of acne without irritation
• Reduces oil production
• Prevents future breakouts
• UV free alternative for eczema and psoriasis
• Anti-inflammatory / cooling effect
Main indication: deep pigmentation
• Most deeply absorbed wavelength by skin tissue
• Increases cell permeability and absorption
• Reduces pain and inflammation
• Accelerates wound healing
• Heals cystic acne
session.” One advantage here is that PTD can be repeated as often as is required
– particularly useful in cases of field cancerisation, in which multiple lesions cover
large areas. “We treat these patients on a maintenance basis, maybe every six
months or every year, often for several years.” explains Baker. In addition, there is
evidence that PTD can potentially delay the development of actinic keratosis and
basal cell carcinoma, with limited evidence that it can prevent invasive squamous cell
carcinoma.16 Interestingly, PTD has also been indicated for skin rejuvenation, in which
aesthetic results can be significantly improved when combined with pre-treatment
systems such as microneedling, microdermabrasion or fractional lasers.17
Before
After
In safe hands
The light-based
technologies
discussed are
routinely used
in a number of
treatments and
are safe and
treatment with Dermalux
effective in skilled Dermatitis
TriWave: Combined Red & NIR (12
hands. However, treatments over five weeks)
severe adverse events can occur when administered
by untrained practitioners: Mr Shoaib recalls treating
a patient who had been left with a 4cm-diameter hole
burnt into their skin due to poorly performed laser
tattoo removal. “When you’re performing a treatment,
you need to be able to look after and manage the side
effects,” he says. That being the case, light-based skin
treatments not only remain an established protocol for
a range of medical and aesthetic indications, but also
show a great deal of promise in treating many more in
the future.
REFERENCES
1. Patil, UA and Dhami, LD. Overview of lasers. Indian Journal of Plastic
Surgery. October 2008; 41 (Suppl): S101-S113. <http://www.ncbi.nlm.nih.gov/
pmc/articles/PMC2825126/>
2. Fodor, L, Elman, M, Ullmann, Y, ‘Aesthetic Applications of intense pulsed
light’, Light Tissue Interactions, (2011), p.11-20.
3. Ryan, T, and Smith, RKW., ‘An investigation into the depth of penetration of
low level laser therapy through the equine tendon in vivo,’ Irish Veterinary
Journal, 60(5) (2007), p.295-299
4. Farhadieh, R, Bulstrode, N and Cugno, S. ‘Plastic and Reconstructive
Surgery: Approaches and Techniques’, John Wiley & Sons, 2015.
5. Ashton, R and Leppard, B. Differential diagnosis in dermatology. Radcliffe
Publishing, 2005.
6. Larsen, Dr AP, ‘Laser vs. LED: What’s the difference?’ Acupuncture
Technology News, (2014). <http://www.miridiatech.com/news/2014/02/laservs-led-whats-the-difference/>
7. ‘Photosensitive Epilepsy’, Epilepsy Action, (2010), p.11. <http://neurology.
dundee.ac.uk/files/epilepsyaction-booklet-photosensitive.pdf>
8. ‘European Commission, Health and Consumers Scientific Committees’,
Health effects of artificial light. 5. What are the effects on people who have
conditions that make them sensitive to light? <http://ec.europa.eu/health/
scientific_committees/opinions_layman/artificial-light/en/l-3/5-light-sensitivity.
htm#3p0>
9. Dermalux FAQs (UK, Dermalux, 2013) <http://www.dermaluxled.com/FAQ/>
10. Julius, H – ‘ Intense Pulsed Light Complications’, in Management of
Complications of Cosmetic Procedures: Handling Common and More
Uncommon Problems, ed. by Tosti A et al, (Springer, 2012) pp.57-64.
11. Goldberg, DJ, Complications in cutaneous Laser Surgery (CRC Press, 2004)
12. Goldberg, DJ, ‘Current trends in intense pulsed light’, Journal of Clinical and
Aesthetic Dermatology. June 2012; 5(6): p.45-53. <http://www.ncbi.nlm.nih.
gov/pmc/articles/PMC3390232/>
13. Khoury, JG, Saluja, R, Goldman, MP. The effect of botulinum toxin type A on
full-face intense pulsed light treatment: a randomized, double-blind, splitface study. Dermatological Surgery. 2008; 34(8): p.1062–1069. Epub 2008
May 6. <http://www.ncbi.nlm.nih.gov/pubmed/18462423>
14. NICE interventional procedure guidance IPG155, Photodynamic therapy
for non-melanoma skin tumours (including premalignant and primary nonmetastatic skin lesions): Overview. February 2006. <http://www.nice.org.uk/
guidance/ipg155>
15. NICE interventional procedure guidance IPG155, Photodynamic therapy
for non-melanoma skin tumours (including premalignant and primary nonmetastatic skin lesions): The procedure. February 2006. <http://www.nice.
org.uk/guidance/ipg155/chapter/2-The-procedure>
16. Morton, CA, Szeimies, RM, Sidoroff, A, Braathen, LR. European guidelines
for topical photodynamic therapy part 2: emerging indications – field
cancerization, photorejuvenation and inflammatory/infective dermatoses.
Journal of the European Academy of Dermatology and Venereology. 2012;
27(6): p.672-679.
17. Szeimies, RM, et al. Photodynamic therapy for skin rejuvenation: treatment
options – results of a consensus conference of an expert group for
aesthetic photodynamic therapy. Journal der Deutschen Dermatologischen
Gesellschaft. July 2013; 11(7): p.632-636. <http://onlinelibrary.wiley.com/
doi/10.1111/ddg.12119/full>
18. Dermalux LED Phototherapy (UK, Dermalux, 2013) http://www.dermaluxled.
com/LED-Phototherapy/
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@aestheticsgroup
Aesthetics Journal
Pulsed Dye
Lasers
Dr Firas Al-Niaimi details the history
and efficacy of pulsed dye lasers
Abstract
The pulsed dye laser (PDL) is a vascular laser that emits a
wavelength of 585 or 595 nm in the yellow band of visible light.
It is one of the early lasers used in dermatologic practice, which
had a fixed short pulse width and was invented primarily to treat
vascular malformations. Over the years, technology has evolved
and the modern PDL machines now offer a range of selected pulse
widths which offer a broad range of treatments, in keeping with
the principle of selective photothermolysis which will be discussed
below. Currently, this kind of laser technology successfully treats
a long list of conditions in dermatologic practice, which will be
highlighted in this article.
Introduction
Lasers have evolved over the past five decades to become an
integral part of some aesthetic and dermatological treatments.
The current dermatological arena contains a plethora of lasers
that can largely be categorised into vascular, pigment-specific, and
rejuvenation (both ablative and non-ablative). The PDL has been
an evolutionary product, developed over the last four decades
and initially conceived to treat congenital vascular conditions.1
Beginning with its early work in the treatment of port-wine stains and
haemangiomas, the dye laser has now become one of the key tools
both in cosmetic and medical laser treatments.
History
The first working laser was developed in 1960 by T H Maiman,
using a rod of Ruby to emit photons of light.2 In that same decade
many other lasers were being invented and trialled in medicine
and, in 1963, dermatologist Leon Goldman used the first lasers in
dermatologic practice. These included the Ruby, Argon, and Carbon
dioxide continuous wave lasers.3 In 1981, a collaboration with John
Parish – then the chairman of dermatology at Harvard University –
resulted in the first working dermatology laser; a flash lamp pumped
organic dye laser.4 The medium used within a flash pump laser was
a fluorescent dye that is housed in a transparent cell and powered
by a flash lamp, emitting a wavelength of 577 nm.4 Further research
led to the discovery of a new wavelength – 585 nm instead of the
577 nm – only to be replaced later by 595 nm, which is still used
in two main PDL machines today.5 Studies showed that by shifting
the wavelength from 577 nm to 585 nm, and eventually to 595 nm,
resulted in a preferential depth of penetration, albeit slightly at the
cost of higher fluences requirement.6 Several dyes were considered
and used and these included: fluorescein, coumarin, stilbene,
tetracene, and umbelliferone.7 Currently most PDL use rhodamine
due to its efficiency and relative long life-time.
Laser physics
The term ‘laser’ is an acronym for ‘Light Amplification of Stimulated
Emission of Radiation’, and is based on the concept of electron
stimulation whereby release of energy occurs as a result.8 The
ultimate light and tissue interaction that takes place results, one way
or another, in a biological response. This response can broadly be
subdivided into thermal, chemical, and mechanical (acoustic).8 Putting
it in very simplistic terms; the thermal effects rely on the heat that is
produced by the laser energy to either selectively or non-selectively
target a tissue component. Photochemical effects occur due to the
up- or down-regulation of certain biological pathways, occurring as
a consequence of light and tissue interaction.10 This photochemical
effect may require the addition of a photosensitiser (a topical drug), a
phenomenon called photodynamic therapy. Lastly, photomechanical
effects occur predominantly due to the acoustic effects on the tissue
(though thermal effects due to the laser energy play a role). This is
caused by the combination of short rapid pulses and a rapid peak in
the energy that is produced in tissues as a result.
The PDL is a vascular laser that has haemoglobin as a target
(chromophore), which is present in the red blood cells circulating
in blood vessels, and acts predominantly through photothermal
effects. Haemoglobin shows absorption peaks in the blue, green,
and yellow bands (414, 542, and 577 nm), as well as a peak in
the near-infrared portion of the electromagnetic spectrum (700
to 1100 nm).10 It is important to note here that these peaks relate
mainly to the oxygenated form of haemoglobin – the so called
Purpura following treatment with a PDL (courtesy of Graham Bissett)
one
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@aestheticsgroup
oxyhaemoglobin.10 Other forms of haemoglobin, such
as deoxyhaemoglobin and methaemoglobin, have
other absorption spectra, and this will be discussed
later in the article.
Aesthetics Journal
Key facts
• The PDL is a vascular laser that emits 585 or 595 nm wavelength
• It was one of the first lasers to be used in dermatology and was invented to
treat vascular malformations
• Current PDL machines have ‘tuneable’ pulse widths ranging from 0.45 to
40 ms allowing for greater versatility of treatments
• The advent of longer pulse widths allows for some conditions (erythema of
rosacea for example) to be treated in a non-purpuric mode to reduce social
downtime
• Smaller vessels need shorter pulse durations and the reverse is the case
with larger vessels
• Deep vessels tend to have a larger diameter and therefore require
a deeper penetrating mode (large spot size with PDL or the 1064 nm
Nd:YAG) and a longer pulse duration
• PDL for the treatment of post-procedural purpura is a novel and effective
new use of this laser
Current laser systems used in the treatment of
vascular lesions emit wavelengths near these
peaks,11 however the depth of penetration here is
important too. For example, 414 nm has a shallow
depth of penetration hence there is no use for it in
clinical practice when treating vessels. Green light,
emitting a wavelength of 532 nm, is already used
in clinical practice (potassium titanyl phosphate
‘KTP’)12 although with a somewhat shallower depth
of penetration compared to PDL (585-595 nm). The
595 nm penetrates deeper than the 585 nm but
requires higher fluences due to the relatively lower
absorption compared to the 585 nm wavelength. It
is therefore important that when switching between
these two wavelengths, adjustment of the fluences
should take place to account for the increased absorption required
by the 595 nm compared to the 585 nm. The long-pulsed Nd:YAG
laser (1064 nm) is used for deep vessels (predominantly on legs or
large blue vessels on the face) due to its advantageous depth of
penetration compared to both the KTP and PDL.8 The absorption
of 1064 nm Nd:YAG is almost a tenth of the PDL, hence higher
fluences are required.
In clinical practice, this means that the incoming pulsed laser will
be absorbed by the circulating haemoglobin in the vessels that
transform this energy to heat, which radiates to the vascular wall
and results in heating up the endothelial vessel wall. In reality, it is
the endothelial wall that is the ultimate ‘target’ of the PDL in treating
vessels. As described briefly above, the photothermal effects of the
laser can either be selective or non-selective. In the selective case,
destruction of the chosen target (in this case vessel) should occur
without any collateral damage to the surrounding tissue. In order to
achieve this, the pulse duration here plays an important role and is
based on the so-called ‘selective photothermolysis’ theory founded
by Anderson and Parish, which revolutionised the modern use of
lasers in dermatology and aesthetics.13 An example of non-selective
photothermal effect of lasers is the use of Carbon dioxide lasers
which would ablate tissue and cause non-selective heating.
Choosing the right parameters
One of the main difficulties for novice laser practitioners is
identifying the correct parameter for treatment when using any
laser modality. The chosen parameters are of great importance
both in maximising the clinical effect as well as minimising
collateral damage.
There are three key components to this: spot size, pulse duration
and fluence. The spot size matters both for coverage area as well
as depth of penetration. A smaller spot size would have more light
scattering and a shallower depth of penetration compared to a
larger spot size for a given fluence. When treating vessels this is
important as the chosen spot size should correlate to the depth of
the vessel.
Pulse duration selection relates to the thermal relaxation time
of the object which is based on the selective photothermolysis
theory.13 This means that a small diameter vessel will cool off
quicker than a large diameter vessel, hence the thermal relaxation
time of the former is shorter and therefore requires a shorter pulse
duration.
Fluence relates to the total amount of energy measured in joules
per centimetre square and dictates the total amount of thermal
energy given in the chosen pulse duration.8 A given biological
target – for example, haemoglobin – requires a certain amount of
‘energy’ to undergo a biological change in structure or function to
have, as a consequence, a biological effect on the tissue. In simple
terms, a low fluence given over a relatively long pulse duration
may not confine and create a biologically important temperature
rise in the target to undergo a desired effect, leading to irreversible
coagulation and clearance of the targeted vessel. In vessels,
a temperature of around 70 degrees Celsius is necessary for
coagulation. Conversely, a high fluence in a short pulse duration
may lead to an unwanted rise in temperature in a target leading
to collateral damage. The chosen fluence per indication is often
achieved through a combination of factors including light-tissue
interaction, laser physics and experience from clinical settings or
studies.
Finally, cooling is essential when using the PDL as melanin,
which is found in the epidermis, is a competing chromophore
which can absorb the incoming laser beam (melanin absorption
is a downward curve from 300 to 1100 nm roughly) and this will
minimise any epidermal injury such as crusting, blistering, postinflammatory hyperpigmentation, etc.14
Cooling of the epidermis can either be achieved by cold air,
contact, or cryogen spray cooling. A sophisticated technology
enabling a spatial cooling confined predominantly to the epidermis
is the dynamic cooling device (DCD), which allows for a cooling
spray of tetrafluoroethane, followed by a delay period before
the laser is fired on the skin. This allows for spatial cooling
of the epidermis, without significant vessel cooling, that may
lead to vasospasm with reduced circulating chromophore as a
consequence.15 Currently there is only one PDL machine in the
market with this DCD technology (VBeam by Syneron-Candela).
Laser tissue interaction in vessel treatment
The ultimate goal in vascular laser treatment is to induce vessel
wall damage leading to vessel clearance with minimal collateral
damage to the epidermis or surrounding tissue. Although
@aestheticsgroup
Aesthetics Journal
haemoglobin is the chromophore or absorbing target of the
PDL, radial diffusion of the generated heat will ultimately lead
to the vessel wall lining being targeted. Scientific studies have
demonstrated that the vascular lining (endothelium) needs to be
sufficiently heated to a temperature of around 65-70 degrees
Celsius for at least one millisecond (ms) in order to cause denature
of structural proteins leading to vessel closure and clearance.16
Therefore, in this case, the fluence chosen and the pulse width
are very important parameters. Too much heat delivered can result
in collateral damage or a rapid rise in intravascular temperature,
which leads to steam formation and vessel rupture, clinically
evident as purpura. Very short pulse durations additionally lead
to a photomechanical effect, again leading to vessel rupture and
purpura.17,18 In summary, vessel clearance can be achieved through
a photothermal, (choice of fluence and pulse width should get the
endothelium temperature to around 65-70 degrees Celsius for at
least one ms), or photomechanical effect, (short pulse width with
sufficient energy leading to vessel rupture).
Vessels have different diameters and therefore the ‘length’ that is
required for the heat to diffuse and reach the vessel wall is variable
and is termed the ‘thermal diffusion length’.19 It is therefore apparent
that larger diameter vessels need more time for the diffused heat
to reach the vessel wall compared to a smaller diameter vessel.
Clinically, this is reflected in the chosen pulse duration.
In practice this means that if the chosen fluence is too low,
insufficient heating of the endothelium occurs and vessel closure
will not take place. In my experience, most of the individuals seeking
treatment for vessels and diffuse erythema do not desire to have
purpura and, therefore, one should optimise the photothermal effect
of vessel coagulation rather than vessel rupture in this case. Pulse
stacking or multiple passes often add a beneficial effect due to the
stepwise rise in temperature formation leading to vessel clearance,
however this should be performed carefully.
Oxygenated haemoglobin is altered following a laser pulse and is
transformed into methaemoglobin, which has a higher absorption
affinity to light, in particular to the 1064 nm Nd:YAG wavelength.20,21
It is through this understanding that pulse stacking or multiple
passes work more efficiently22 and is also the concept of which the
dual wavelength vascular laser was designed, using a sequential
pulse of 595 nm followed by 1064 nm (Cynergy MultiPlex by
Cynosure). The concept is that the first laser shot will be with
the PDL which leads to formation of methaemoglobin, allowing
the 1064 nm Nd:YAG to have a much better effect in the second
pulse.23 I prefer to use this technology on port wine stain blebs or
resistant facial telangiectasia and telangiectatic matting on the legs
as, in my experience, the PDL alone may often offer suboptimal
clearance by simply increasing the fluences. As such, the risk of
epidermal injury also increases accordingly. The multiplex mode
should not be used in diffuse erythema due to the high risk of
‘bulk heating’ generated from the 1064 nm Nd:YAG.
It should be clear now that if a single pulse in a non-purpuric
mode is used, the target is oxyhaemoglobin, whilst in stacking,
multiple passes, and/or in the use of multiplex technology, the
methaemoglobin and formed clot ultimately become the targets.
Vessels are heterogenous with varying degrees of depths and
diameters so the parameters will need to be adjusted accordingly.
Vessels smaller than 0.1 mm on the face are often invisible and
present with diffuse erythema. In such cases multiple passes or a
purpuric mode tends to yield better results than a single nonpurpuric pass. Vessels between 0.1 to 0.4 mm on the face would
Aesthetics
require a pulse width of 6-10 ms (10 ms pulse width if the multiplex
is used), whilst larger vessels between 0.4 and 1.0 mm on the
face would require longer pulse widths such as 20-40 ms (40 ms
pulse width if multiplex is used). Leg telangiectasia greater than
0.3 mm generally tend to lie deeper than the reach of PDL and are
preferably treated with the 1064 nm Nd:YAG. This is because of
the wavelength’s deeper penetration profile and relative selectivity
for haemoglobin compared to water, which is abundantly found
in the dermis. In general, blue and purple vessels contain more
blood (larger diameter) and therefore a high chromophore content
which requires less fluences compared to small red vessels that
contain less chromophore and, therefore, need higher fluences for
coagulation.
Furthermore, leg veins are generally harder to treat compared to facial
telangiectasia due to their increased hydrostatic pressure, thicker
vessel wall, and the fact they contain less oxygenated haemoglobin as
a chromophore (particularly the blue and purple vessels).
Understanding and recognising the clinical endpoints in vessel
treatment is essential for optimal results. These include: colour
change in vessel (often darkening), vessel blurring, low refill rate
(gentle compression on the vessel does not lead to a refill which
indicates coagulation of the vessel), and vessel disappearance
(often with 1064 nm Nd:YAG). Erythema with subsequent oedema
is an expected reaction afterwards. Greying or whitening are
ominous signs and imply an epidermal injury with the risk of
crusting and/or blistering, and the fluences should be lowered
subsequently.24 It should also be noted that purpura on the limbs
tend to clear more slowly compared to the face and often results
in post-inflammatory hyperpigmentation. Unless indicated per
condition, it is therefore preferable to treat vessels off the face in a
non-purpuric mode.
Clinical indications requiring a purpuric endpoint
Despite the increased demand from individuals seeking laser
treatments with no or minimum downtime (bruising in the case of
vascular treatments); there are certain conditions in which optimal
clearance is often only achieved through treatment with purpura
as a clinical endpoint.25 Steel-grey purpura is undesirable, implies
excessive fluence, and may lead to fibrosis or epidermal injury.
In such conditions, the primary vascular pathology is such that
vessel rupture is often the only effective way of maximising clinical
efficacy. These conditions include: port wine stains, haemangiomas,
The ultimate goal in
vascular laser treatment is to
induce vessel wall damage
leading to vessel clearance
with minimal collateral
damage to the epidermis or
surrounding tissue
@aestheticsgroup
Micropulse Technology
• Classic PDL Technology 4 pulses,
dissimilar distribution
• New PDL technology 8 pulses,
equal energy
Purpura Threshold
Fluence
spider angiomas, cherry
angiomas, warts, erythematous
striae, and scars.5 The
latter two conditions, in my
opinion, can also be treated
in a non-purpuric mode as,
often, post-inflammatory
hyperpigmentation due to
haemosederin deposition
occurs. Facial telangiectasia
can be treated in a purpuric
mode, as explained above,
or in a non-purpuric setting
often through pulse stacking
or multiple passes. Thick
vessels, or those with high
‘intravascular pressure’ such
as those on the sides of the
nose, require higher fluences
and are generally best treated
in a purpuric or stacking nonpurpuric mode.
Aesthetics Journal
Time (ms)
This table gives an example of how the micropulse technology breaks energy into small pulse trains (in this case using eight
pulses) to ensure the energy is gentler on the tissue
Miscellaneous clinical
conditions treated with PDL
(purpura not necessary as endpoint)
The mechanism is thought to be due to the enhanced clearance
The PDL, though initially designed for the treatment of congenital
of the extravasated haemoglobin that is targeted by the PDL.4 My
vascular malformations, has now been used in multiple clinical
typical settings in this case are a fluence of 6.0-7.0 joules/cm2 with
settings for various conditions with a good degree of success
6 ms pulse width often with two passes. Interestingly, this method
and relatively low level of complications. Advances in the current
of treatment seems ineffective in the treatment of purpura caused
technology in terms of ‘mico pulses’ or so-called ‘pulse train’,
by PDL (in the treatment of port wine stains, for example) and, in this
whereby an individual pulse is broken down into six or eight micro
case, relates to the presence of a vasculitic inflammatory aggregate
pulses has led to the advantage of delivering the total fluence in
with clotting, which is absent in a non thermally-induced purpura
a gentle fashion without causing purpura.26 Furthermore, effective
such as vessel puncturing with a needle.
cooling has ensured a greater margin of epidermal protection
Conclusion
and safety. As a result, the PDL has successfully been used in
The PDL is primarily designed as a vascular laser and uses
the treatment of conditions beyond its initial primarily vascular
rhodamine dye as its lasing medium. The wavelength emitted
indication without the need to cause purpura as an endpoint. These
is in the yellow band between 580-600 nm. Currently there
include: inflammatory acne, cutaneous sarcoidosis, discoid lupus,
are two devices with the 595 nm wavelength (Cynergy from
psoriasis, molluscum contagiosum, melasma, and sebaceous gland
hyperplasia.27 The exact mechanism is not yet entirely clear, however Cynosure and VBeam from Candela) and one device with the 585
nm wavelength (Regenelite from Chromogenix). The latter was
it appears to be a mixture of microvascular targeting, as well as
previously called N-lite when it had a fixed pulse width. All three
dermal remodelling, and an anti-inflammatory response elicited by
currently available PDL machines have ‘tuneable’ pulse widths
the PDL. Studies have shown an inflammatory response as a result
to allow for greater versatility use in keeping with the selective
of treatment with PDL, with upregulation of mast cells, TGF-beta, and
photothermolysis theory. There are currently numerous conditions
other cytokines.28 The response of the above named conditions to
that can be treated with the PDL and it is still the laser of choice in
the PDL, in my opinion, is variable and, as such, this modality should
most vascular malformations, in particular port wine stains. When
not be the first-line treatment. Rosacea can be treated in a nonused in a short pulse and a sufficient fluence, purpura occurs
purpuric mode but does, however, require more sessions compared
which is a desired endpoint in some conditions. One limitation
to the purpuric mode. The desired endpoint in the non-purpuric
of the PDL is its relatively limited penetration depth of maximum
setting is a ‘transient purpura’, lasting just a few seconds, and is
1.5 mm with a 10 mm spot, hence, with the exception of very fine
generally a reliable marker of adequate vessel coagulation.
telangiectasia measuring less than 0.3 mm, which lie relatively
superficial, it is not the laser of choice for the treatment of larger
Novel use of PDL
and deeper leg vessels.
A relatively novel, successful, use of the PDL has been in the
The PDL technology has seen significant advances in recent years,
treatment of post-filler injection purpura. The first report was
published a few years ago but since then there have been numerous such as the incorporation of the DCD, as well as the enhanced
pulse structure and delivery pattern, and continues to be used
articles on the successful use of this modality.29 In my personal
and explored in a multitude of conditions, with post-procedural
experience, the PDL works very well for this indication once the
(predominantly filler injection) purpura being a relatively novel one.
swelling has settled and often after a period of at least 24 hours.
@aestheticsgroup
Aesthetics Journal
Acknowledgement: The author would like to thank Michaela Barker
from Syneron-Candela for providing some of the historical data and
literature.
Aesthetics
Disclosure: The author has either received speaker’s fee or acted
as an opinion leader for Syneron-Candela and Cynosure.
Dr Firas Al-Niaimi is a consultant dermatologist and
laser surgeon who trained in Manchester and London.
He is a group medical director at sk:n clinics London
and an honorary consultant at St. Thomas Hospital
where he runs a weekly tertiary referral laser clinic.
Dr Al-Niaimi has in excess of 90 scientific publications and is a key
opinion leader for the major laser companies.
REFERENCES
1. Tan OT, Morelli J, ‘Laser treatment of congenital vascular birthmarks’, Paediatrician 18(3) (1991) p.204-10.
2. Alster TS, ‘Manual of cutaneous laser techniques’, Lippincott Williams and Wilkins, (2000) p.11.
3. Tanzi EL, Lupton JR, Alster TS, ‘Lasers in dermatology: four decades of progress’, J Am Acad
Dermatol, 49 (2003) p.1-31.
4. ‘International Directory of Company Histories’, St. James Press, 48 (2003).
5. Wall TL, ‘Current concepts: Laser treatment of adult vascular lesions’, Semin Plast Surg 21 (2007)
p.147-158.
6. Bernstein EF, Lee J, Lower J, et al., ‘Treatment of spider veins with the 595 nm pulsed-dye laser’, J Am
Acad Dermatol, 39(5 Pt 1) (1998) p.746-750.
7. Libertini LJ, Small EW, ‘On the choice of laser dyes for use in exciting tyrosine fluorescence decays’,
Anal Biochem., 163(2) (1987) p.500-5.
8. Sakamoto FH, Wall T, Avram MM, Anderson RR, ‘Lasers and flash lamps in dermatology’, In Wolff K,
Goldsmith LA, Katz SI, et al (eds), Fitzpatrick’s dermatology in general medicine (7th ed), McGraw-Hill,
(2008) p.2263-78.
9. Britton JE, Goulden V, Stables G, et al., ‘Investigation of the use of the pulsed dye laser in the
treatment of Bowen’s disease using 5-aminolaevulinic acid phototherapy’, Br J Dermatol., 153(4)
(2005) p.780-4.
10. Van Gemert MJ, Henning JP, ‘A model approach to laser coagulation of dermal vascular lesions’, Arch
Dermatol Res, 270(4) (1981) p.429-39.
11. Tanzi EL, Lupton JR, Alster TS, ‘Lasers in dermatology: four decades of progress’, J Am Acad
Dermatol, 49 (2003) p.1-31.
12. Patel BC, ‘The krypton yellow-green laser for the treatment of facial vascular and pigmented lesions’,
Semin Ophthalmol, 13(3) (1998) p.158-70.
13. Anderson PR, Parrish JA, ‘Selective photothermolysis: precise microsurgery by selective absorption of
pulsed radiation’, Science, 220(4596) (1993) p.5247.
14. Nelson JS, Majaron B, Kelly KM. ‘Active skin cooling in conjunction with laser dermatologic surgery’,
Semin Cutan Med Surg, 19(4) (2000) p.253-66.
15. Nelson JS, Milner TE, Anvari B, et al, ‘Dynamic epidermal cooling during pulsed laser treatment
of port-wine stain. A new methodology with preliminary clinical evaluation’, Arch Dermatol., 131(6)
(1995) p.695-700.
16. Suthamjariya K, Farinelli WA, Koh W, Anderson RR, ‘Mechanisms of microvascular response
to laser pulses’, J Invest Dermatol., 122(2) (2004) p.518-25.
17. Garden JM, Tan OT, Kerschmann R, et al, ‘Effect of dye laser pulse duration on selective cutaneous
vascular injury’, J Invest Dermatol., 87(5) (1986) p.653-7.
18. Trelles MA, Svaasand LO, Verkruysse W, et al., ‘Purpura without structural vessel damage’, Lasers Med
Sci., 13(4) (1998) p.299-303.
19. Kimel S, Svaasand LO, Hammer-Wilson M, et al., ‘Differential vascular response to laser
photothermolysis’, J Invest Dermatol, 103(5) (1994) p.693-700.
20. Randeberg LL, Bonesronning JH, Dalaker M et al., ‘Methemglobin formation during laser induced
photothermolysis of vascular skin lesions’, Lasers Surg Med, 34 (2004) p.414-9.
21. Mordon S, Brisot D, Fournier N, ‘Using a “non- uniform pulse sequence” can improve selective
coagulation with a Nd: YAG laser (1.06 microm) thanks to met-haemoglobin absorption: a clinical study
on blue leg veins’, Laser Surg Med, 32 (2003) P.160-70.
22. Rohrer TE, Chatrath V, Iyengar V, ‘Does pulse stacking improve the results of treatment with variablepulse pulsed dye lasers?’, Dermatol Surg 30 (2004) p.163-7; discussion 167.
23. Karsai S, Roos S, Raulin C, ‘Treatment of facial telangiectasia using a dual-wavelength laser system
(595 and 1,064 nm): a randomized controlled trial with blinded response evaluation’, Dermatol Surg., 34(5) (2008) p.702-8.
24. Nanni C, ‘Complications of laser surgery’, Dermatol. Clin 15(3) (1997) p.521-34.
25. Adamic M, troilius A, Adatto M, et al., ‘Vascular lasers and IPLS: guidelines for care from the European
Society for Laser Dermatology (ESLD)’, J Cosmet Laser Ther., 9(2) (2007) p.113-24.
26. Tanghetti E, Sherr E. ‘Treatment of telangiectasia using the multi-pass technique with the extended
pulse width, pulsed dye laser (Cynosure V-Star)’, J Cosmet Laser Ther., 5(2) (2003) p.71-5.
27. Erceg A, de Jong EM, van de Kerkhof PC, Seyger MM, ‘The efficacy of pulsed dye laser treatment
for inflammatory skin diseases: a systematic review’, J Am Acad Dermatol., 69(4) (2013) p.609-615.
28. Omi T, Kawana S, Sato S, et al., ‘Cutaneous immunological activation elicited by a low-fluence pulsed
dye laser’, Br J Dermatol., 153 Suppl (2005) p.57-62.
29. DeFatta RJ, Krishna S, Williams EF,’ Arch Facial Plast Surg., 11(2) (2009) p.99-103.
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Aesthetics Journal
Aesthetics
Treating Keratosis
Pilaris
Dr Justine Kluk details the aetiology of this
genetic skin disorder and shares best practice
techniques on managing the condition
Introduction
Keratosis pilaris (KP) is a common inherited
disorder of the skin with an incidence
of between 4%-12% in the paediatric
population.1,2 It occurs due to excessive
keratinisation within the hair follicle orifice,
which leads to stubborn horny plugs. This
happens at specific anatomical locations
which are described later in this article. It can
be recognised clinically by the presence
of small, scaly folliculocentric papules
often surrounded by a rim of erythema.
These papules give a stippled or speckled
appearance to the skin and may resemble
‘goose bumps’.3 The disorder usually
becomes apparent during childhood and is
most likely to arise on the extensor aspects
of the upper arms, anterior surface of the
thighs and on the lateral aspects of the
cheeks, where there may be a background
of generalised or confluent redness.3 In
severe cases, the skin lesions may be more
widespread and can extend to the distal
extremities, trunk and buttocks.4
Presentation and associations
Although it is most often noted incidentally
in otherwise healthy individuals, when
diagnosing keratosis pilaris, clinicians and
other healthcare professionals should
be aware that this dermatosis belongs
to a wider group of disorders of follicular
keratinisation.5 As such, there is a spectrum
of clinical presentations, all of which are
characterised by a prominent plug of
keratin within the follicular orifice. In most
cases, the cause is unknown. The different
dermatoses are usually distinguished on
the basis of the size, extent and distribution
of the keratotic lesions, as well as the
presence of perifollicular erythema and
associated scarring. Some of these variants
include keratosis pilaris rubra (associated
with prominent redness),6 keratosis pilaris
atrophicans (a scarring variant which leads to
skin atrophy),7 folliculitis spinulosa decalvans
(follicular plugging complicated by scarring
alopecia)8 and erythromelanosis follicularis
faciei et colli (a triad of well-demarcated
erythema, hyperpigmentation and follicular
papules on the face and neck).9 Furthermore,
there are a number of other cutaneous and
internal diseases that may be associated with
keratosis pilaris. Many of these have a genetic
basis with potentially significant implications
for the patient and their children, for example
Noonan syndrome and cardiofaciocutaneous
syndrome. Features of the former include
short stature, distinctive facies and cardiac
anomalies.10 Those with the latter tend to
have a peculiar craniofacial appearance
with sparse curly hair, low-set posteriorly
rotated ears, moderate to severe mental
retardation and cardiac defects.11 Referral to an
appropriate specialist such as a dermatologist,
paediatrician or clinical geneticist should
be considered if the lesions are particularly
extensive and persistent, or if there are other
indications that one of these syndromes may
be present. Within the last decade, mutations
in the filament aggregating protein (filaggrin
or FLG) gene have been identified as the
cause of the common genetic skin disorder
ichthyosis vulgaris.12,13 This condition typically
presents with keratosis pilaris, xerosis (dry
skin), fine scaling on the limbs, hyperlinearity
(increased skin markings) of the palms and
soles and a predisposition to developing
atopic eczema.12,13 Better understanding of
this related condition may help to improve
our understanding of the pathogenesis of
keratosis pilaris in due course.
Another fascinating observation in recent
years has been the increased incidence
of keratosis pilaris secondary to the use of
targeted oncological therapies, such as those
prescribed for the treatment of metastatic
melanoma; e.g. BRAF inhibitors, such as
vemurafenib, and immunotherapies. The use
of these agents is rapidly expanding and
cutaneous toxicities such as the development
of keratosis pilaris are amongst the bestrecognised and most common adverse
effects observed.14 Healthcare workers can
offer valuable supportive advice to cancer
patients who have developed keratosis pilaris
as a result of one of their treatments.
Other associations with keratosis pilaris have
also been described. Like acrochordons
(skin tags) and acanthosis nigricans, keratosis
pilaris is observed more frequently in obese
individuals, particularly females.15 It also
appears to be more common in those with
type 1 diabetes.16 The precise reason for these
observations is unclear, however obesity is
responsible for a number of physiological skin
changes e.g. effects on skin barrier function,
collagen structure and function and wound
healing to name a few.15
Treatment options
Keratosis pilaris is usually asymptomatic
and, in most cases, no specific intervention
is required. The size of the lesions are said
to increase and decrease over a period of
months and can fluctuate in different hormonal
states such as pregnancy. Even without
therapy, the condition tends to become
less prominent with age, although this is not
always the case. Some patients describe
mild itching, but the majority of those affected
are most troubled by the appearance of
the skin lesions. This has led to the disorder
being regarded by many as a predominantly
cosmetic complaint. In light of the genetic
predisposition, there is unfortunately no cure
for keratosis pilaris and treatment is difficult
and may be unsatisfactory.
Topical therapies are usually the first line
of treatment. As keratosis pilaris is often
accompanied by the sensation of skin dryness
or roughness, it would seem sensible to avoid
harsh soaps and cleansers. Wash products
containing 2% salicylic acid or glycolic acid can
be helpful and the addition of gentle massage
with a polyester sponge in the bath or shower
has been demonstrated to improve results.17
Vigorous scouring, however, is likely to cause
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irritation and should be discouraged.
After bathing, a moisturising cream or lotion
should be applied to damp skin. Creams
should always be massaged into the skin
in a downward direction, i.e. in the same
direction as the hair growth. Glycolic acid,
ammonium lactate, salicylic acid and urea
containing humectants may be chosen in
preference to simple hydrating emollients for
their added keratolytic effects. Salicylic acid
2-3% and 20% urea cream,17 or salicylic acid
in propylene glycol combine the properties of
an emollient with a keratolytic agent.
Patients should be encouraged to apply
their treatment cream on a twice-daily
basis for a trial period of approximately
four to six weeks. When adequate relief of
symptoms has been achieved, use of the
treatment cream can slowly be tapered
to a maintenance phase of once-daily
application initially, followed by twice-weekly
application if symptoms remain controlled
after a further four to six weeks. Patients
can return to the more intensive regime
if their symptoms recur at any point and
some will find that continuous treatment is
necessary. Should symptoms persist despite
the measures already described, patients
may benefit from the addition of a topical
retinoid. Lower concentrations of tretinoin
such as 0.025% cream should be trialled
in the first instance, as irritation is common
and treatment may not be tolerated if large
areas are involved. Higher concentrations of
tretinoin, or alternatives such as adapalene
or tazarotene creams, can also be used if
tolerated and may help address the redness,
roughness and itching of keratosis pilaris
if present.18 I would usually recommend
applying a topical retinoid twice-weekly at
night for four weeks, then on alternate nights
for four weeks, and then once-daily at night
Aesthetics Journal
Aesthetics
thereafter if tolerated. Once again, frequency
of application can be tapered down when
relief of symptoms has been achieved. A
short defined course of a medium potency
topical corticosteroid (e.g. twice-daily for
seven to ten days), may sometimes be
necessary if there is a significant inflammatory
component and should be discontinued
when inflammation has resolved, allowing
treatment with an emollient or keratolytic to
resume. Other topical agents that have been
reported in the medical literature include the
immunomodulator tacrolimus 0.1% ointment,
although the improvement demonstrated
was similar to that achieved with Aquaphor
ointment (Eucerin) in a small double-blinded
study.19 Topical vitamin D analogues such
as calcipotriol do not appear to have a role
in the treatment of keratosis pilaris as no
therapeutic effect was demonstrated in a
small randomised right/left comparative
study in nine affected individuals.20 Skin
discolouration, or hyperpigmentation,
following resolution of keratosis pilaris
lesions may fade to some degree on its
own, but can also be tackled with skin
lightening creams containing hydroquinone,
azelaic acid or kojic acid. Oral treatment
of keratosis pilaris is not usually necessary
and would not be considered routinely,
however oral isotretinoin has been helpful
in patients with some of the more pernicious
variants of keratosis pilaris atrophicans,
such as ulerythema ophryogenes and
atrophoderma vermiculatum where
prevention of scarring and disfigurement
necessitates a more aggressive approach.21
Laser and light therapies have been used
in the management of keratosis pilaris
with varying outcomes. In the past, lasers
have tended to be better at addressing the
redness rather than the textural irregularity
REFERENCES
1. Inanir I, Sahin MT, Gunduz K et al. Prevalence of skin conditions in primary school children in Turkey:
differences based on socioeconomic factors. Pediatr Dermatol 2002; 19 (4): 307-11.
2. Popescu R, Popescu CM, Williams HC et al. The prevalence of skin conditions in Romanian school
children. Br J Dermatol 1999; 140: 891.
3. Hwang S and Schwartz RA, ‘Keratosis pilaris: a common follicular hyperkeratosis’, Cutis 82(3)
(2008), p.177-80.
4. Castela E, Chiaverini C, Boralevi F et al. Papular, profuse and pernicious keratosis pilaris. Pediatr
Dermatol 2012; 29 (3): 285-8.
5. Weedon D. Weedon’s Skin Pathology, 3rd ed, Churchill Livingstone, Edinburgh 2010.
6. Marqueling AL, Gilliam AE, Prendiville J et al. Arch Dermatol 2006; 142 (12): 1611-6.
7. Callaway SR, Lesher JL Jr. Keratosis pilaris atrophicans: case series and review. Pediatr Dermatol
2004; 21: 14.
8. Di Lernia, Ricci C. Folliculitis spinulosa de calvans: an uncommon entity within the keratosis pilaris
spectrum. Pediatr Dermatol 2006; 23 (3): 255-8.
9. Watt TL, Kaiser JS. Erythromelanosis follicularis faciei et colli. A case report. J Am Acad Dermatol
1981; 5 (5): 533-4.
10. Pierini DO, Pierini AM. Keratosis pilaris atrophicans faciei (ulerythema ophryogenes): a cutaneous
marker in the Noonan syndrome. Br J Dermatol 1979; 100 (4): 409-16.
11. Borradori L, Blanchet-Bardon C. Skin manifestations of cardio-facio-cutaneous syndrome. J Am
Acad Dermatol 1993; 28: 815-9.
12. Sandilands A, O’Regan GM, Liao H et al, ‘Prevalent and rare mutations in the gene encoding
filaggrin cause ichthyosis vulgaris and predispose individuals to atopic dermatitis’, J Invest Dermatol
(8) (2006)126, p.1770-5.
13. Ichthyosis vulgaris: the filaggrin mutation disease, Br J Dermatol (6) (2013) 168, p.1155-66.
associated with the condition. Many early
studies demonstrated promising reductions in
erythema with the 595 nm pulsed dye laser.22
More recent studies report improvements in
skin texture with the 810 nm diode laser used
on three occasions four to five weeks apart23
and the combination of 595 nm pulsed
dye laser, long-pulsed 744 nm alexandrite
laser and microdermabrasion, with claims
of improved redness and texture and a
reduction in hyperpigmentation three months
after treatment.24
Conclusion
In addition to the more widely used treatments
outlined above, some parties have attempted
photodynamic therapy, chemical peels,
dermabrasion and microdermabrasion with
the hope of finding a better solution for those
with keratosis pilaris. To date, there is little
evidence to support their widespread uptake
although they may be considered in individual
cases where other methods have failed. The
mainstay of treatment remain as emollients,
keratolytic agents and topical retinoids. Whilst
many of those affected are not especially
troubled by their condition, others are more
disturbed by its appearance and it will be
both interesting and exciting to see which
techniques and treatments emerge in this
area over the next few years. At this time,
however, there are no new products or clinical
trials anticipated.
Dr Justine Kluk is a consultant
dermatologist based at London
North West Healthcare
NHS Trust and European
Dermatology London. Her
particular clinical interest is in skin cancer,
having undertaken a post-CCT fellowship in
cutaneous oncology, however her day-today practice encompasses all general adult
and paediatric dermatology.
14. ‘Cutaneous adverse effects of targeted therapies: Part II: Inhibitors of intracellular molecular
signalling pathways’. J Am Acad Dermatol (2) (2015), 72, p.221-36.
15. Yosipovitch G, DeVore A, Dawn A. Obesity and the skin: skin physiology and skin manifestations of
obesity. J Am Acad Dermatol 2007; 56 (6): 901-16.
16. ‘The prevalence of cutaneous manifestations in young patients with type 1 diabetes’. Pavlovic MD,
Milenkovic T, Dinic M et al. Diabetes Care (2007), p.1964-7.
17. ‘Practical management of widespread, atypical keratosis pilaris’. Novick NL. J Am Acad Dermatol
(11) (1984), p.305-6.
18. ‘Tazarotene 0.05% cream for the treatment of keratosis pilaris’. Bogle MA, Ali A, Bartel H. J Am
Acad Dermatol (50) (2004), (suppl 1), p.39.
19. ‘A comparative trial comparing the efficacy of tacrolimus 0.1% ointment with Aquaphor ointment for
the treatment of keratosis pilaris’. Breithaupt AD, Alio A, Friedlander SF. Pediatr Dermatol (28) (2011),
p.459-60.
20. Kraqballe K, Steijlen PM, Ibsen HH et al. Efficacy, tolerability, and safety of calcipotriol ointment
in disorders of keratinization. Results of a randomized, double-blind, vehicle-controlled, right/left
comparative study. Arch Dermatol 1995; 131 (5): 556-60.
21. ‘A case of ulerythema ophryogenes responding to isotretinoin’. Layton AM, Cunliffe WJ. Br J
Dermatol (129) (1993), p. 645-6.
22. ‘Successful treatment of severe keratosis pilaris rubra with a 595-nm pulsed dye laser;. Kaune KM,
Haas E, Emmet S et al. Dermatol Surg (35) (2009), p.1592-5.
23. ‘Treatment of keratosis pilaris with 810-nm diode laser: a randomized clinical trial’. Ibrahim O, Bolotin
D, Dubina M et al. JAMA Dermatol (2) (2015), 151, p.187-191.
24. ‘Combination of 595-nm pulsed dye laser, long-pulsed 755-nm alexandrite laser, and
microdermabrasion treatment for keratosis pilaris: retrospective analysis of 26 Korean patients’. J
Cosmet Laser Ther (3)c (2013), 15, p.150-4.
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Aesthetics Journal
Aesthetics
The Threepoint Facelift
Dr Beatriz Molina details her technique for
achieving a non-surgical facelift using cannulas
The role of volume augmentation for facial rejuvenation will continue to
progress as our knowledge and insight into facial anatomy, ageing, beauty
and aesthetic harmony continue to mature. Soft-tissue augmentation has been
used with positive results for some time,1 but the focus within the facial aesthetic
community as a whole on where to place volume has certainly changed and
expanded. With experience, practitioners recognise that filling just a wrinkle or
nasolabial fold, for example, can help or, better yet, appease a patient’s concern.
True facial rejuvenation, however, requires a more thoughtful scope of evaluation
and an expanded treatment philosophy in order to achieve facial harmony.
We are now moving a step further by using dermal fillers for a lifting effect. With the
cannula we can achieve this with only three points of access, making this treatment
extremely comfortable and requiring little-to-no downtime. In this article I will detail my
approach to achieving a non-surgical facelift using hyaluronic acid and a three-point
technique using cannulas.
Consultation
Careful patient selection and a detailed consultation are paramount for successful
outcomes in any aesthetic procedure, so I would advise practitioners to take their
time analysing the face and deciding which product to use, the amount of product
needed, and the number of sessions needed to achieve the best possible outcome
for your patient. In order to build trust with your patient, it is also imperative that they
understand why you have proposed this particular treatment protocol for them. Once
the patient has confirmed they are happy to go ahead with the procedure and has
signed the relevant consent forms, the next step for the practitioner is to decide how
they will be delivering this treatment; will they use needles or cannulas, or even a
combination of both?
Figure 1: Image demonstrates injection points for the 3-point facelift
Point 3
Point 1
Point 2
Treatment preparation
In my aesthetic practice, I have always looked for
ways to give the best outcome possible for my
patients, with minimal trauma and disruption to their
lives. Most of our patients want to continue their
busy routine with the least amount of downtime
possible. As such, I have aimed to perfect my
treatments with the cannula in order to deliver
these common patient requirements.
The reason I choose to use a cannula instead of
a needle for my three-point facelift treatment is
because it allows access to the whole face with
simply three small points of access or less. I also
believe that, as we are treating all areas of the
face, there are fewer risks associated with using a
cannula compared to a sharp needle.
The number of entry points (from one to three) for
the three-point facelift depends on the patient’s
age – they will need more or less lifting depending
The three-point
facelift treatment is
suitable for any man
or woman who starts
showing mild to
severe signs of ageing
on the amount of volume loss in their face. Younger
patients normally present with mild mid-facial
atrophy, while more mature patients often present
with volume loss in other areas such as the
lateral cheeks and temples. As we as aesthetic
practitioners all know, facial ageing is a complex
synergy of dynamic and cumulative effects of
skin textural changes and loss of facial volume,
combined effects of gravity, progressive bone
resorption, decreased tissue elasticity, and loss or
redistribution of subcutaneous fat.
For each point I use 0.1 ml of lidocaine 2% to
make the procedure more comfortable for the
patient, as it is important they are relaxed while
I am administering treatment. As well as this, if
the procedure is comfortable and your patient’s
experience was positive, they are more likely to
recommend your services to their friends and
family and come back to your clinic for future
treatments.
For the three-point facelift I use a 23G needle as
an access point for my cannula. I then use the
LIFT, CONTOUR &
REJUVENATE
with long-term collagen stimulation
The Lifting Filler
Call Merz Aesthetics Customer Services now
to find out more or to place an order
RAD144/0215/LD Date of preparation: February 2015
LESS
INTACT
COLLAGEN
S TO
P
LACK OF
STRUCTURAL
SUPPORT
REDUCED
COLLAGEN
SYNTHESIS
Tel: +44 (0) 333 200 4140
www.radiesse.co.uk
LOSS OF
FIBROBLAST
ACTIVITY
The Lifting Filler
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Figure 2
Aesthetics Journal
Aesthetics
Figure 3
Figure 4
Administration of treatment using a cannula
25G 60mm (2 inches) cannula as I find that this is the most comfortable to use.
The extrusion force this type of cannula provides is easier for depositing most
products, which gives me more control when administering treatment. In my
experience it also causes less bruising than smaller gauge cannulas, which
makes it beneficial to the patient as well. I normally use a fanning retrograde
linear threading technique, depositing about 0.1 to maximum 0.2mls of
hyaluronic acid per line.
Technique
The three-point facelift allows me to create a non-surgical facelift using the
vectors indicated in Figure 1, through replacing volume in the hollow areas
where there is volume loss. I would advise practitioners to think carefully about
the product they would use in each area and ask themselves what they are
trying to achieve from this treatment; does the patient need more volume
replacement or simply firmer skin texture? Practitioners should then adapt the
technique to suit the patient’s best interests.
• Point One
The first point is the most important entry point as this is the one that achieves
the most significant lifting effect, while providing mid-facial enhancement and
volumising the cheeks and cheekbones. From entry point one I am able to treat
a patient’s cheeks and cheekbones, including the tear through, and, if required,
the nasolabial folds and marionette lines.
• Point Two
For entry point two, an incision is made in the same method as entry point one,
but this time approximately half way along the jawline. In my opinion, this is
the perfect position for delivering the product on the mandibular line, creating
not just contouring but support, without accentuating the jowls. It also enables
the practitioner to replace volume loss on the lateral cheek, which will give an
additional lifting effect (on top of the lift already created by point one), which is
our main objective to achieving patient satisfaction.
From this point, we are also able to treat nasolabial lines if the patient’s
Before
After
nasolabial folds are still too deep, even after lifting
tissue medially and laterally. Caution is required in
this area and we must be gentle in our technique
due to the superficial location of the parotid gland.
• Point Three
The third entry point focuses on treating the
temples, our third area for lifting, and this is
particularly suited to more mature patients with
hollow temples (Figure 4). In addition, by using this
entry point we are also able to treat the tear trough
by leaving small deposits of hyaluronic acid, and of
course, in the cheeks and cheekbones. For those
patients in which the lost volume is more significant,
I would advise creating a crosshatch of the product,
firstly with point one and secondly with point three.
It is important to be gentle and to inject slowly
due to the risk of bruising in the temple area; the
transverse frontal branch of the superficial temporal
artery runs in the sleeves of the superficial
temporal fascia on the deep temporal fascia (which
is a continuation of the galea of the forehead),
along with a plexus of veins.2
Conclusion
The three-point facelift treatment is suitable for any
man or woman who starts showing mild to severe
signs of ageing. The technique demonstrates that
we can achieve a facelift with no surgery, simply
by placing between 4 and 6mls of hyaluronic acid
with just three points of access, a two-inch cannula
and minimal downtime. My patients appreciate the
technique as it enables them to leave the clinic
looking well, natural and fresh; allowing them to
continue with their busy lives.
Dr Beatriz Molina practised general
medicine for 12 years, before opening
her first aesthetic practice in Somerset in
2005. She is a member and the director
of conferences at the British College of
Aesthetic Medicine (BCAM), and teaches beginner
and advanced techniques in the use of botulinum
toxin and dermal fillers.
REFERENCES
1. Jean Carruthers and Alastair Carruthers,‘Soft Tissue Augmentation’,
Procedures in Cosmetic Dermatology Series, 3rd ed, edited by Jeffrey S.
Dover and Murad Alam (US: Saunders Elsevier, 2012)
2. Peter M. Prendergast, ‘Anatomy of the Face and Neck’, Cosmetic Surgery,
ed by Melvin A. Shiffman, and Alberto Di Giuseppe, (Berlin: Springer-Verlag
Berlin Heidelberg, 2013) pp. 29-35
@aestheticsgroup
Aesthetics Journal
Managing Inflammation
Dr Kathryn Taylor-Barnes examines how and why inflammation occurs,
while offering advice on how to manage it best for your patients
Introduction
The skin’s primary role is to protect our body. This protection is a
barrier to temperature changes and external trauma, as well as being
essential in maintaining homeostatic hydration.1 Our skin is on the ‘front
line’ and is a vital component in maintaining body harmony with the
outside world. Inflammation is a physical condition that can occur on
the skin as a result of both lifestyle choices and aesthetic procedures,
which can be irritating and painful to a patient. As such, this article
will aim to share advice on how inflammation can be managed
successfully with various treatments.
Lifestyle choices
When we neglect our health and lead a poor lifestyle, our skin can
deteriorate significantly. For instance, acne is made worse by eating
junk food and poor or inappropriate skincare efforts.2 Eczema
and psoriasis need external emollients and good levels of fluid
consumption to avoid the skin drying out, which can lead to flareups. In each of these conditions, flare-ups can appear as ‘islands’
of inflammation on the skin. As we already know, sun exposure
causes ageing and damage to the skin; solar damage generates
dangerous free radicals, which can also cause skin irritation and
ignite inflammation. As such, advising patients on the importance of a
healthy, balanced diet, staying hydrated and protecting their skin from
the sun can certainly play a role in reducing inflammation. In addition,
antioxidants, both ingested (polyphenols in green tea)3 and topical
(vitamin C),4 as well as physical and chemical sun protection barriers,
are key to opposing solar damage.
Inflammation following treatment: when, why and how
Aesthetic practices routinely advise patients that to achieve younger
looking skin, treatments should aim to smooth, refine, brighten
and build collagen. Various clinical skin treatments such as lasers,
skin peels, topical retinoid and alpha hydroxy acids (AHAs) do this
by increasing cellular turnover, excitation of fibroblasts, removal of
desiccated skin layers and deliberate stripping of the skin’s surface, in
addition to suppressing melanocytes by using topical hydroquinone
and tretinoin or retinol creams.5 These types of treatments cause
a more uniform and controlled degree of inflammation in the skin.
This is opposed to a more confined focus of inflammation caused
by injectable treatments, such as botulinum toxin and dermal fillers,
mesotherapy, cryotherapy and surgical skin excision. The treated
areas can leave inflammation that disrupts the harmony of surrounding
skin. This approach may be more damaging and ignite skin ageing
Figure 1; Infected eczema caused
by excessive sun exposure
Figure 2; Inflammation from lip filler
and ‘inflamm-ageing’, which is why controlling excessive inflammation
in these particular treatments may be of greater importance than we
might realise.
Dermal fillers: an inflammatory provoker
After injection, dermal fillers routinely require the practitioner to lightly
massage the area to conform to the contour of the surrounding
tissues.6 In doing so, the digital pressure can attract fluid causing
further inflammation to the hydrophilic HA filler ‘bed site’ and
encourage swelling and free radical escape. Having a good serum
concentration of anti-inflammatory in the blood at the time of treatment
may help slow down the filler-degradation rate and help improve filler
stability and longevity. We should be mindful that certain techniques
for injecting dermal fillers agitate the skin and increase inflammation.
These techniques are fanning injection, rapid bolus deposition and
injecting large volumes of product in one area in a single treatment
session.7 The larger needle/cannula gauge size may provoke more
inflammation. In regards to the common needle vs cannula debate,
while many chose to use a cannula to avoid traumatic bruising, I
would suggest that we might actually be causing more swelling
within the dermis due to more aggressive tissue dissection with our
implement. When looking at the array of dermal fillers on offer today,
polycaprolactone is different and this difference has an impact on
post-injection inflammation. It does not degrade, but instead gradually
resorbs without changing shape, and this preferred biologic activity
will help prevent the risk of secondary reactions. Dr Pierre Nicolau
has had extensive experience with polycaprolactone. He notes that,
“The advantage of bio stimulators such as Ellansé is that one has a
controlled reaction versus an uncontrolled and unwanted one such
as with hyaluronic acid and other dermal fillers. Ellansé disappears
without the risk of causing an inflammatory reaction, as proven in
histological studies. At the end of the bio resorption process, the
shorter polycaprolactone chains simply dissolve and are completely
removed from the body through normal metabolic processes.” Dr
Nicolau recommends only using dermal fillers that are resorbable
so that unwanted side effects can be avoided. BDDE is the crosslinked substance used in the majority of recognised HA fillers. After
reaction with HA, the epoxide groups of BDDE are PH neutralised
and there is a very small amount of unreacted BDDE that remains in
the product.8 This has historically been considered too insignificant to
create an inflammatory effect. In my opinion, however, this unreacted
portion could have more impact on inflammation than we may have
considered in the past. “It’s very difficult to know the exact amount
of BDDE that has been used in a given HA dermal filler, the
total amount of free-endings of the BDDE, or what is left once
the HA has disappeared from the tissues. These factors
represent an unknown measure of risk regarding potential
adverse events that may occur from using these products,”
says Dr Nicolau.9 Some new HA fillers, including Dermafill,
have reduced levels of BDDE compared to other HAs on the
market. Dermafill exceeds the stricter standards of the FDA
very low levels of BDDE controls, as stated in the product
guidance note. BDDE is found in all HA fillers but, as I have
already mentioned, I believe that the BDDE unreacted portion
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Aesthetics Journal
Aesthetics
to be true when injected slowly and without pre-mixed anaesthetic,
reducing the occurrence of patients looking red and swollen.
Regarding HA filler, the rare but dangerous inflammation-driven side
effect, Angioedema can occur within the first two weeks of injection
and the incidence is about one to five per 10000.6 Angioedema,
caused by IGE mediated immune response together with dermal filler
associated nephritis,15 further highlights the dangerous nature of the
extreme end of the inflammatory ladder.
Figure 3; TA-65 demonstrating how cells can divide over time, telomeres that protect the chromosome shorten and cell division eventually stopping. Image courtesy of T.A. Sciences USA .
may be a factor in inflammation caused by cosmetic injection with HA,
although research is needed to verify this.
Tools to reduce inflammation
I have been interested in oral supplements in the hope they may be
complementary to my aesthetic injection treatments and have the
added bonus of helping to reduce inflammation and ‘inflamm-ageing’.
Methyl sulphonyl methane (MSM) and omega 3 and 6 from flaxseed
work well in combination and may reduce the risk of an inflammatory
response. MSM inhibits the release of pro-inflammatory mediators,
such as nitric oxide and prostaglandin E2.10 These are released
in the skin after cosmetic injection treatments or facial and body
surgery, causing the area to become red, swollen and sore.Omega
3 from flaxseed inhibits the formulation of platelet-activating factors,
which increase the risk of inflammation when produced in excessive
amounts.11 It is also important to maximise dietary antioxidant intake
in the form of easily absorbed vitamin C (calcium ascorbate) and L
lysine. Nutraceuticals such as Skinade, which is a daily drink, contain
multiple naturally occurring ingredients together with the supplements
listed above to provide a significant anti-inflammatory effect. I have
observed that my patients’ skin tolerates procedures better and heals
quicker especially when they are already on a course of Skinade at
the time of treatment. In fact some plastic surgeons are now routinely
recommending their patients take nutraceuticals pre and post surgery
as they have observed improved healing rates. Oxidative stress and
excessive inflammation are common risk factors for a whole variety
of health problems. These inflamm-ageing associated problems
include development of insulin resistance, type 2 diabetes, asthma,
obesity and metabolic syndrome. Also chronic inflammation and
chronic oxidative stress are risk factors for cancer development (e.g.
breast, prostate, colon cancer and skin cancer).12 TA-65 is another
product that claims to repair damaged telomere ends and halt and
reverse biological ageing. A new study has just been released by T.
A. Sciences, USA. The TA-65 research group found that after taking
two capsules daily (250 units) over sixteen weeks, there was a decline
in the expression of inflammatory cytokines. In addition, interleukin 6
and interleukin 8 were found to decline by two-fold and seven-fold.
Also with up to seven-fold reduction in inflammation, this could have
a significant beneficial effect in treating dermatitis, eczema, psoriasis,
rosacea, acne and all the other inflammatory skin conditions.13 When
we consult with patients about having a dermal filler treatment, the
topic of downtime is always raised. Searching for the ‘holy grail’ I
have had extensive experience in my clinics with Stylage (Vivacy),
which contains mannitol and has anti-inflammatory benefits, claiming
to improve product longevity. A new filler from Italy, Algeness, is
composed of polysaccharide sugar gel derived from red algae.14
Algeness HD does not have the hydrophilic properties of its rival HA
and, as water is not encouraged into the injection bed, I have found
that there is less swelling and release of pro-inflammatory mediators. In
my early experience with this new product, I have observed its claims
Stem cells: the future?
Stem cells may play a significant role in reducing inflammation, allergic
reactions and promoting healing associated with aesthetic procedures.
Autologous fat transfer may help reduce the potential for allergic
reaction.16 Stem cells in fat are very powerful releasers of growth
factors that enhance tissue healing.17 There is, however, a lack of real
clinical data on aesthetic use and this needs to be carefully monitored
as more practitioners gather clinical observations and research data.
Conclusion
An opportunity is present to encourage a good anti-inflammatory,
skin-friendly diet, possibly including a nutraceutical, as well as
appropriate pre- and post-skincare regimes that will enhance what
our treatments are trying to achieve, and aim to stop inflammation
getting out of control. I would hope that the future will bring new
topical, injectable and ingested products and supplements that can
help to safely control the inflammatory process, while slowing the
ageing process and possibly assisting with skin cancer prevention in
our growing ageing population.
Dr Kathryn Taylor-Barnes is a general practitioner in
Richmond and founder of The Real You Clinics in Surrey,
established in 2004. Dr Taylor-Barnes has presented
her work at national and international conferences
and is currently completing a postgraduate Masters
qualification in botulinum toxin at the University of Bournemouth.
REFERENCES
1. J. Lademann ‘Determination of the thickness and structure of the skin barrier in vivo laser scanning
microscopy’. Laser Phys [2008]Lett 5[4] p 311-315
2. J. Jung ‘The influence of dietary pattern on acne vulgaris in Koreans. ’ European Journal of
Dermatology [2010] 20.6 p 768-72
3. N. Morley ‘The green tea polyphenol [epigallo catechin gallate] and green tea can
protect human cellular DNA from ultraviolet and visible radiation induced damage .’
Photodermatology,Photoimmunology and Photomedicine [2005] 21.1 p 15-22
4. D. Darr ‘Topical vitamin C protects porcine skin from ultraviolet radiation induced damage’ british
Journal of Dermatology [1992] 127 [3] p 247-253
5. Z. Draelos ‘Novel approach to the treatment of hyper pigmented and photo damaged skin’.,
Dermatological Surgery [2006] 21.s1 p 799-805
6. F. Brandt Hyaluronic acid gel filler in the management of facial ageing [2008] Clin Interv Ageing. 3 [1]
p 153-159
7. G.Monheit, R.J.R., ‘The nature of longer term filler and the risk of complications’. Dermatologic
Surgery 35(2) (2009), p.1598-1604.
8. K. De Boulle ‘A review of the metabolism of 1,4-butanediol diglycidyl ether-crosslinked hyaluronic acid
dermal fillers’, Dermatologic Surgery [2013] 39 p 1758-1766
9. P. Nicolau The European Aesthetic Guide Autumn (2012) (2) www.miinews.com
10. Y.Kim ‘The anti-inflammatory effects of methylsulfonylmethane on lipopolysaccharide induced
inflammation responses in murine macrophages.’ Biological and pharmaceutical Bulletin [2009] 32
No 4 p 651-656
11. 11. A.Simopoulos ‘Omega 3 fatty acids in inflammation and autoimmune disease’, Journal of the
American College of Nutrition (2002),vol 21 [6] p 495-505
12. A. Lasry, Y.B-N ’Senescence-associated inflammatory response; ageing and cancer perspectives.’,
Trends in Immunology 36 (4) (2015), p.217-228.
13. F. Stern ‘Demonstrated Improvement of Prematurely Aged Skin by Oral Intake of TA-65.’ study
commissioned by TA Sciences (2015).
14. P. Motolese, ‘Agarose gel long-lasting absorbable filler’ Data on file (Member of SIES and Prof. AMS
– Bologna)
15. J. Leonhardt, N.L., ’Angioedema -acute hypersensitivity reaction to injectable HA.’ Dermatologic
Surgery 31[5] (2005), p.577-579.
16. E. Gonzalez-Rey ‘Human Adipose-derived mesenchymal stem cells reduce inflammation and T cell
response and induces regulatory T cells in vitro in rheumatoid arthritis.’, Ann Rheum Dis [2010] 69 p
241-248
17. M. Murphy, K.M., ‘Mesenchymal stem cells: environmentally responsive therapeutics for regenerative
medicine.’, Experimental and Molecular Medicine online, 45 (2013).
Images courtesy of Dr Kathryn Taylor-Barnes. TA-65 diagram courtesy of T.A. Sciences USA.
Aesthetics Awards
Special Focus
@aestheticsgroup
Aesthetics Journal
Aesthetics
The finalists are
announced…
Following months of deliberation and discussion,
Aesthetics is delighted to announce the finalists for the
2015 Awards. With even greater numbers of entries received
this year and the standard of applications higher than ever, the
competition to get to the finalist stage was extremely tough. See
the full list of finalists in 23 categories revealed here or visit the
Aesthetics Awards website to vote today.
The voting and judging process is open from 1st September until the 30th October, with
winners announced at the Aesthetics Awards ceremony on 5th December at the Park
Plaza Westminster Bridge Hotel. Commended and Highly Commended finalists will be
honoured on the night, with Winners invited to the stage to be presented with their trophies
in front of 500 members of the medical aesthetics profession.
Tickets can be booked on the Aesthetics Awards website www.aestheticsawards.com
The judging panel…
An esteemed panel of 44 judges have been selected to consider all entries, with six assigned to
each category. These groups have been chosen specifically for their knowledge and expertise in
that area, as well as to ensure the avoidance of any conflicts of interest in the judging process.
The full list of judges can be found on the Aesthetics Awards website.
Have your say!
You can now vote for your winners on the Aesthetics Awards website. Readers of Aesthetics
journal should visit www.aestheticsawards.com to view all the finalists and use their Aesthetics
login or register today to cast their votes.
Select categories will be decided upon by reader votes and an esteemed judging panel, whilst
others will be decided by judges alone. Please see details under each category for clarification.
Voting and judging will close on 30th October 2015 and there will be no opportunity to vote after
this point. Voting is IP address monitored and each individual can only vote once. Multiple votes
under the same name will also be discounted from the final total. Multiple voting from within
finalists’ organisations will be monitored.
38
Aesthetics | September 2015
@aestheticsgroup
Aesthetics Journal
Aesthetics
Aesthetics Awards
Special Focus
The finalists…
Cosmeceutical Range/Product of the Year
Winner decided by: reader votes and judging panel
Equipment Supplier of the Year
IMAGE Skincare (Skin Geeks)
ZO Skin Health (Wigmore Medical Ltd)
NeoStrata® Skincare Range (AestheticSource)
Heliocare (AesthetiCare)
Epionce (Episciences Europe)
Jan Marini Skin Research (JMSR Europe Ltd)
Obagi Medical (Healthxchange Pharmacy)
SkinCeuticals Range (SkinCeuticals)
BTL Aesthetics
Syneron Candela UK
Lynton Lasers Ltd
ABC Lasers
Consulting Room Group
3D-lipo Ltd
Treatment of the Year
Distributor of the Year
Dermalux LED (Aesthetic Technology Ltd)
EndyMed (AesthetiCare)
Exilis Elite (BTL Aesthetics)
VelaOnce (Syneron Candela UK)
Dermapen (Naturastudios)
Harmony 4D ClearLift (ABC Lasers)
HydraFacial (HydraFacial UK)
3D-lipomed (3D-Lipo Ltd)
Wigmore Medical Ltd
Harpar Grace International for iS Clinical
Eden Aesthetics Distribution
AestheticSource
Church Pharmacy
Medical Aesthetic Supplies Limited
Healthxchange Pharmacy
Vida Aesthetics Ltd
The Sterimedix Award for
Juvéderm VOLIFT® with Lidocaine (Allergan)
TEOSYAL® PureSense Redensity [II] (Lifestyle Aesthetics)
Aqualyx (Healthxchange Pharmacy)
Belotero® (Merz Aesthetics)
Best Treatment Partner
NeoStrata® ProSystem Peels (AestheticSource)
iS Clinical SHEALD Recovery Balm (Harpar Grace
International for iS Clinical)
Dr Gabriela Aesthetic Line – Magic Beauty Face Lift Serum
and Advanced Molecular Mask (Dermagenica)
Oxygenetix (Medical Aesthetic Supplies Limited)
Skinade (Skinade)
MACOM Crystal Smooth (MACOM Medical)
39
Aesthetics Awards
Special Focus
@aestheticsgroup
Aesthetics Journal
Aesthetics
The 3D-lipomed Award for Best New Clinic,
UK and Ireland
lipomed
AestheticSource
AesthetiCare
BTL Aesthetics
Church Pharmacy
Lynton Lasers Ltd
Merz Aesthetics
Fat Reduction
Best Customer Service by
a Manufacturer or Supplier
Skin Tightening
A Powerful Three Dimensional Alternative to Liposuction
No other system offers this advanced combination of
technologies designed to target fat removal, cellulite
and skin tightening without the need to exercise
Winner decided by: judging panel
Dentelle
River Medical
Why choose 3D-lipomed?
S-Thetics
Facial Aesthetics NI
Perfect Skin Solutions
FAB Clinic
The Aesthetic MediSpa
Dr SW Clinics
A complete approach
to the problem
Face and Body skin
tightening
Prescriptive
Highly profitable
Multi-functional
No exercise required
Inch loss
National PR support
campaign
Cellulite
Clinician use only
Complete start up and support package
available from under £660 per month
The Janeé Parsons Award for Sales
Representative of the Year, supported by
Before
Treatment
of the Year
3D Lipomed
After
Before
Equipment Supplier
of the Year
3D Lipo Limited
Cellulite
This NEW advanced device is dedicated
exclusively to the clinical market
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Cavitation (Overall Circumference Reduction)
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
(Superficial Targeted Fat Removal)
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 advantages of this technology
are high treatment efficacy, no pain as less energy is
required, shorter treatment services and variable depths of
penetration.
After
The Pinnell Award for
Product Innovation
3D Lipomed
3D Dermology RF
(Cellulite Reduction)
The new 3D-lipomed incorporates 3D
Dermology RF with the stand alone benefits
of automated vacuum skin rolling and radio
frequency.
What the experts say...
‘As a Clinician I need to know that the treatments we offer are safe, effective,
scientifically based and fit in with our ethos of holistic care for our clients. 3D-Lipo
has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd
(Milton Keynes)
www.3d-lipo.co.uk
Best Clinic Scotland
@3Dlipo
Caroline Gwilliam (AestheticSource)
Belinda Aloisio (L’Oreal – SkinCeuticals)
Iveta Vinklerova (Boston Medical Group Ltd)
Louise Taylor (Aesthetic Technology Ltd)
Liz Robinson (Healthxchange Pharmacy)
Simon Ringer (Naturastudios)
Linda Wormald (Healthxchange Pharmacy)
Karen Smyth Gaffney (Merz Aesthetics)
The NeoCosmedix Award for Association/
Industry Body of the Year
Age Refined Medical Cosmetic Centre
Clinetix
Re-Nu Skin Clinic LTD
Face & Body
La Belle Forme Clinic
Temple Medical Ltd
dermalclinic
Grampian Cosmetic Clinic Ltd
The Epionce Award for
Best Clinic North England
British College of Aesthetic Medicine (BCAM)
Private Independent Aesthetic Practices Association (PIAPA)
British Association of Plastic, Reconstructive and Aesthetic
Surgeons (BAPRAS)
Treatments You Can Trust (Cosmetic Quality-Assurance Ltd)
Society of Mesotherapy of the United Kingdom (SoMUK)
40
Medizen Limited
Air Aesthetics Clinic
Mulberry House Clinic
Good Skin Days
Internal Beauty Clinic
Outline Clinic
CC Kat Aesthetics
face etc... medispa
3D-lipo
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The Dermalux Award for
Best Clinic South England
Aesthetics Awards
Special Focus
The Oxygenetix Award for Best Clinic London
EF MEDISPA
The Rejuvenation Clinic & Medispa
London Professional Aesthetics
PHI Clinic
The Glasshouse Clinic
Aesthetic Skin Centre
The Cadogan Clinic
Absolute Aesthetics
Radiance MediSpa
health + aesthetics
Medikas
Woodford Medical Ltd.
Riverbanks Clinic
The Skin to Love Clinic
Purity Bridge
Jill Zander Skin Rejuvenation Clinic
The Skinceuticals Award for Best Clinic Ireland
Best Clinic Wales
Cellite Clinic Limited
Peaches Bespoke Beauty & Aesthetics
Skinfinity
Cardiff Cosmetic Clinic
Specialist Skin Clinic
Dundrum Skin & Laser Clinic
Claudia McGloin Clinic
ClearSkin Clinic
The Laser and Skin Clinic
The DermaClinic
Faceworks
The AestheticSource Award for Best Clinic
Group UK and Ireland (3 clinics or more)
The Church Pharmacy Award for Clinic
Reception Team of the Year
EF MEDISPA
The Laser and Skin Clinic
The Private Clinic
Linia Cosmetic Surgery
Good Skin Days
Face & Body
La Belle Forme Clinic
Temple Medical Ltd
PHI Clinic
Dermalclinic
Riverbanks Clinic
Dr Leah’s Cosmetic Skin Clinics
The Swisscode Award for Best Clinic Group UK
and Ireland (10 clinics or more)
Courthouse Clinics
MYA Cosmetic Surgery
National Slimming & Cosmetic Clinics
sk:n Clinics
41
Aesthetics Awards
Special Focus
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Aesthetics Journal
Training Initiative of the Year
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The Institute Hyalual Award for
Aesthetic Nurse Practitioner of the Year
Dr Kate Goldie, Advanced Training and Masterclass (Medics
Direct, part of European Medical Aesthetics Ltd)
Allergan Medical Institute (Allergan)
RA Academy (Dr Raj Acquilla)
Dr Tapan Patel’s Aesthetic Masterclass (PHI Clinic)
Cosmetic Courses (Cosmetic Courses)
Mr Taimur Shoaib/Carolyn Fraser
(Inspired Cosmetic Training)
Facial Anatomy Teaching (Medicos-Rx)
Healthxchange Academy (Healthxchange Pharmacy)
Eve Bird
Helen Hannigan
Michelle McLean Demosthenous
Frances Turner Traill
Anna Baker
Alison Telfer
Jackie Partridge
Sharon Bennett
Product Innovation of the Year
Teosyal Pen (Lifestyle Aesthetics)
Fillerina (Medical Aesthetics Supplies Ltd)
Cynosure / PicoSure (Cynosure)
ResurFX by Lumenis (Lumenis)
Swisscode Bionic Stem Cell
Recovering Complex
(Pure Swiss Aesthetics)
Silhouette Soft (Sinclair Pharma)
ULTRAcel (Healthxchange Pharmacy)
PLEXR (Fusion GT LTD)
The Sinclair Pharma Award for Aesthetic
Medical Practitioner of the Year
The Schuco International Award
for Special Achievement
This award recognises the outstanding
achievements and significant contribution to
the profession and industry by an individual
with a distinguished career in medical
aesthetics. The Aesthetics’ judges will select the winner
and there will be no finalists for this category.
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Dr David Eccleston
Dr Kate Goldie
Mr Dalvi Humzah
Dr Beatriz Molina
Dr Raj Acquilla
Dr Victoria Dobbie
Mr Taimur Shoaib
Dr Tapan Patel
Dr Maria Gonzalez
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Aesthetics Journal
Aesthetics
Treating the
Décolletage
Dr Aamer Khan provides an overview
of the procedures available that aim to
improve the appearance of sun damage
and ageing on the chest
‘The décolletage is the upper part of a woman’s torso,
comprising her neck, shoulders, back and chest, that is
exposed by the neckline of her clothing’.1 While we could
refer to this area as the chest or the cleavage, the world of
aesthetics chooses to adopt the French approach and call
it the ‘décolletage’. Unfortunately whatever fanciful terms
we use, the décolletage presents a significant aesthetic
concern for many women. Whether women have chosen
to undergo anti-ageing treatment or simply employ the
use of moisturisers and make-up over the years, they
have long addressed the fine wrinkles, heavier lines,
and skin pigmentation issues that affect the face; only to
let the appearance of their chests give their age away.
A crepey décolletage can reveal a woman’s age just as
easily as her hands; think crinkly chests, lines between the
cleavage, and the dreaded age spots. Yet I am constantly
surprised by how many women we see in our clinic who
have neglected their décolleté and think skincare or sun
protection stops at the chin.
After the eye area, the décolletage is the most prone to
ageing on the body; more delicate than our complexion
as it doesn’t produce as much oil in women due to fewer
hair follicles, when compared with men,2 as well as being
the first place to develop wrinkles.3 This is because of the
stresses on the skin from movement, the weight of the
breasts, and exposure to UV damage.4
Cleavage wrinkles are deep, vertical creases that appear
as the skin becomes older and thinner. There are various
physical causes for them appearing more prominent.
These include hours spent sleeping on one’s side, where
gravity forces the top breast to droop further past the
body’s midline than it should, and by wearing sports
and push-up bras, which push the breasts together,
worsening the appearance of lines and wrinkles, similar
to those that occur on the face due to muscular tension
exerted on the skin.5
The skin covering the chest area tends to get a lot of sun
exposure too, and is thinner than that on the arms and
legs, making it extremely vulnerable to UV damage,6 resulting in sun spots,
and other signs of ageing. Once the collagen in the skin breaks down from
age and sun exposure, those wrinkles tend to linger and, thanks to gravity,
the generously endowed, whether naturally or surgically, tend to be more
affected.7 Throw in the volume loss that occurs naturally with ageing, as
well as pollution, smoking and repeated rapid weight changes; and the
chest quickly loses its youthful appearance.
As a result of hormonal changes relating to the menopause and
oestrogen deficiency, women in their 40s and 50s are also more prone to
ageing in this area. These changes result in an accelerated breakdown of
collagen and elastin, leading to skin thinning, dryness and other negative
changes referred to as ‘solar elastosis’ or ‘dermatosis’.8
Another problem with older skin is the risk of increased inflammation.
While usually not visible to the naked eye, photo-damaged and aged
skin can be more reactive and prone to inflammation due to higher
levels of inflammatory mediators (cytokines, prostaglandins and other
immune mediated factors such as histamine release) and abnormal
cellular activity immune system.9 Inflammation increases the production of
harmful super-oxidative species (free radicals) and leads to increased cell
damage, degradation of the skin matrix and rapid cell death, as well as an
increase in the risk of neoplastic change.10 In fact, the décolletage condition,
characterised by dilated vessels, red and brown spots, ruddiness, thin crepey
skin, and the ‘bubble wrap’ appearance, is referred to as ‘poikiloderma’,
derived from the neck condition ‘Poikiloderma of Civatte’.11 There are simple
ways of preventing and improving the appearance of the décolletage. Many of
the non-invasive procedures that make the face more youthful can also work
well on the décolletage. As such, I have detailed some of the most common
methods below, with information on how they should be used.
Combined CO2 resurfacing and PRP décolletage treatment
This 60-minute treatment uses fractional CO2 laser combined with Platelet
Rich Plasma (PRP) injections to treat the décolletage. The practitioner should
apply topical anesthetic to the entire cleavage area, before using a fractional
CO2 laser to encourage new collagen to form. The energy delivered has
to be relatively low as the skin in this area is thin, reactive and prone to
laser damage. The laser should also be adjusted to the patient’s skin type,
as skins of colour can be more reactive, and prone to post-inflammatory
hyperpigmentation.12
@aestheticsgroup
Aesthetics Journal
Peels are the backbone
of good skincare and
are often overlooked,
yet they can do much to
improve the quality of skin
including tone, texture and
elasticity for all skin types
The next stage of the treatment requires the practitioner to inject
50-60 small intra-dermal deposits of PRP,13 (this further stimulates
stem cell activity in the skin and hypodermis adipose layer)14 into
the décolletage. The skin will be red for approximately seven to
ten days, and peeling will occur. The results improve over the
next few months as the skin repairs and regenerates, and new
collagen is formed. It is essential to advise patients to moisturise
the treated area morning and night while the skin is healing. This
reduces inflammation and damage to the skin through the skin
cracking. While one treatment will see an improvement in texture,
tone and tightness, a course of three treatments is advised – one
to two months apart. It’s also important that patients use SPF50
on the treated area to protect against further sun damage. In
our experience results can last beyond three years. Histological
studies have shown that some of the effects of CO2 resurfacing
are permanent.15 Biomimetic mesotherapy
This 20-minute procedure will aim to treat sun-induced wrinkles
with no significant downtime. Biomimetic mesotherapy stimulates
the mesoderm (mid-dermis).16,17 First the décolletage is cleansed,
then a series of injections containing active ingredients including
hyaluronic acid, retinols and peptides, which aim to help boost
the collagen and elastin, are placed on the décolletage. The
treatment aims to help rejuvenate skin and soften fine lines and
wrinkles. Patients should see smoother skin within a couple of
weeks, but for best results, a course of three weekly sessions is
recommended. Side effects include small bumps and pinprick
bleeding, which settles within six to twelve hours. The limited injury from the mesotherapy starts a healing
response in the skin, with increased cellular activity and collagen
stimulation. The ‘biomimetic peptides’ mimic growth factors and
stimulate the repair activity even more.
Chemical peels
In my opinion, peels are the backbone of good skincare and are
often overlooked, yet they can do much to improve the quality of
skin including tone, texture and elasticity for all skin types.
A course of glycolic peels is particularly good for smoothing
fine lines on the décolletage, with minimal downtime. Glycolic
Aesthetics
peels are also known as ‘cellular peels’, and work at the cellular
level, causing cellular shock, and cells to shed, rather than
sheets of skin.18 The peeling process is slower, so often requires
six treatments. It is important to note that the skin has to be
pretreated with AHA skincare to condition the skin prior to these
peels, for at least two weeks, this helps to condition the skin and
reduces the risks of skin damage.19
The glycolic solution should be prepared to suit the patient’s
particular skin type and then brushed over the décolletage and
left on for approximately ten minutes. Following this, the solution
is rinsed off with water, and a moisturising lotion and sun block
is applied. A course of six peels, one a week, will produce best
results. This is because each peel can penetrate a little deeper,
addressing more fine lines and discoloration. This treatment will
also encourage dermal cellular activity,20 thereby giving the skin
a plumper and younger appearance. Results should last up to
a year and, in my clinic, we usually advise patients to continue
to use skincare that contains AHA for maintenance. For best
ongoing results we advise one peel every three months.
Stronger chemical peels that cause cellular necrosis and
shedding carry a higher risk,21 but can be useful in more severely
damaged skin. Newer formulations of combined chemicals are
proving safer and effective. Skin conditioning is recommended,
and maintenance is the mainstay of lasting results.22
Microneedling
As the microneedle roller is rolled over the skin, it creates pinpoint punctures in the dermis – the majority of which temporarily
push pores open. This reaction is perceived by the body as
damage, thus activating a wound healing response to regenerate
the skin and boost collagen levels. As a result, thin skin thickens
and fine lines, scars, and uneven skin tone are targeted.23
The skin is then cleansed, a peptide serum is usually massaged in
and the roller is gently rolled over the skin several times, allowing
the peptide serum to penetrate into the skins layers. Antioxidant
serums are then applied.
There may be a temporary reddening of the skin for an hour
after treatment, and a course of six treatments once every foursix weeks is recommended. The natural healing process lasts
for several months in which time skin will carry on improving.24
Maintenance is then advised every three to six months,
depending on the age and condition of the skin. Improved results
can be gained when this technique is combined with red light and
IPL treatments.25
Dermal filler injections and botulinum toxin treatment
Hyaluronic acid: As the décolletage is an area of thin skin, I would
advise using a hyaluronic acid based filler, which can be finely
injected with greater control, to avoid the appearance of unsightly
lumps and bumps. The hyaluronic acid should be injected into the
skin with lots of tiny microinjections, aiming to replenish moisture
and reduce the appearance of fine lines while plumping skin,
without the risk of leaving bumps, caused by larger deposits of
product. While treating the face with fillers might require a syringe
or two, the décolletage could require as many as ten syringes
over three sessions to achieve best results. This is because of the
large surface area, and the need to minimise the risk of leaving a
bumpy outcome. The action of injecting will also contribute to the
skin remodeling, as with microneedling.
Treatment Focus
Décolletage
@aestheticsgroup
Avoid using permanent fillers such as silicone, as well as any
filler that is long lasting and may result in nodules, which can
be difficult to manage. In our experience, the results from
hyaluronic acid used in this way should last up to a year. The
maintenance with good skin care and SPF protection will give
even longer lasting results.
Poly-L-lactic acid (PLLA): Diluted PLLA should be administered
sub-dermally in small injections, and then massaged into
the décolletage. Three to five sessions, a month apart, are
advised to get a result that will last up to four years.26 I would
advise one maintenance treatment every 18 months in order
to maintain the results, as involution of the effects starts about
then.27
Botulinum toxin: Small doses of diluted botulinum toxin type-A,
injected into the dermis 1 to 2cm apart, also have a smoothing
effect on the décolletage. The mediation of this effect is
unclear, but may relate to a relaxation of fibres or cells in the
dermis, that may have some contractile function. This is a safe
treatment with minimal risks, and results can last three to five
months.
Radiofrequency
Non-ablative: A non-ablative radiofrequency skin tightening
treatment can help tighten crinkly décolletage skin by
stimulating collagen production. A conductive gel is applied
to the décolletage, before the radiofrequency device delivers
constant gradual energy to the skin, causing heat to build up
where the skin and fat layers meet.
The increasing heat modifies the collagen bundles deep
inside the skin causing them to contract, thus stimulating the
production of new collagen over time. Most patients notice
a tightening of the skin after one treatment, with ongoing
improvements over the following four to six months as
new collagen is formed.28,29 For best results a course of six
treatments, two weeks apart, is recommended. The procedure
should give lasting effects with one maintenance treatment
a month. This gives rise to the best results through tissue
remodeling.30
Ablative: Ablative radiofrequency devices, with coated
or uncoated pins that create holes in the skin and tissue
coagulation, can also be very effective. We do, however, have
to be careful not to use very high-energy settings, as the skin
in this area is very thin and prone to scarring. Three sessions,
six weeks apart with annual maintenance are advised.31
Photodynamic therapy (PDT)
PDT is an established method for treating some non-melanoma
forms of skin cancer, while also having the added benefits of
being a highly effective treatment for rejuvenating the skin and
treating pigmentation and sun-damaged chests.32,33 It’s a simple
procedure but time consuming, and can be painful for the patient.
To begin, an exfoliating mask is used to slough off dead skin cells
and prepare the skin for treatment. A cream containing a lightsensitising chemical, 5-aminolaevulinic acid (ALA), is applied to
the sun-damaged skin. The treated area will then be covered for
up to three hours to allow the cream to penetrate into the sun-
Aesthetics Journal
The décolletage is a greatly
ignored area of the body
when it comes to antiageing and protection.
It is a vulnerable area
predisposed to photoageing and the effects
of shearing forces,
particularly in women who
have very few hair follicles
on their chests
damaged skin cells. The damaged cells, through active amino
acid uptake channels, preferentially take up the 5-ALA, which
makes the damaged skin cells very sensitive to the PDT light.34,35
A red LED laser is then used to target the photosensitised cells
for ten minutes. The light will target the damaged cells, but not the
normal cells. The body then repairs and replaces the damaged
cells with new healthy skin cells. After the treatment, patients may
notice some redness, blistering, peeling and milia formation for up
to two weeks. Advise patients to keep the treated area covered
and moisturised for 36 hours.
Intense Pulsed Light (IPL)
Despite the latest state of the art treatments, there’s something
to be said about the tried and tested treatments such as IPL. The
light-based device is used to reduce discoloration, sun damage,
and broken capillaries. IPL is also successfully used for treating
age spots as it targets melanin in the skin and, with four to six
treatments, a significant improvement can be seen.36
There is little downtime, though treated skin may be red for a few
hours, and the pigmented areas appear darker before scaling off.
This treatment targets both pigmented areas and the vascular
elements of the photodamaged skin.
In practice, IPL is ‘fired’ at the area to be treated. Photo-filters
are used at specific wavelengths to target a specific pigment.
This releases low levels of energy into the skin, which then
stimulates regeneration of the cells, and also boosts collagen
so skin becomes tighter and plumper. High-energy absorption
into the target pigment causes photo-coagulation of the tissues,
which are then repaired and replaced by the body. Lower levels
of energy released also have an anti-inflammatory effect on the
@aestheticsgroup
Aesthetics Journal
healthy tissues. Patients often report that the treatment feels like
an elastic band is being pinged against the skin, especially in
the areas where the target pigment is at its greatest. A few days
post treatment, the treated areas become darker before they
fade. Patients may need up to six treatments and the results are
likely to last up to 18 months. I recommend patients undergo this
treatment in the autumn or winter when they will not be exposed
to a sunny climate, as treated areas can burn or become darker
when exposed to UV light. As always, I advise my patients use an
SPF50 to protect their skin following treatment.
Polydioxanone (PDO) sutures and dermaroller in combination
The latest weapon in our fight against the aged and
damaged décolletage is the use of PDO sutures inserted
sub-dermally to form a structural matrix, followed by rolling a
3mm dermaroller over the surface and PRP application.37 This
treatment is performed under topical local anaesthesia. 30G
Knotless PDO sutures are positioned in the hypodermis in a crisscross fashion to form a matrix. As they dissolve, they stimulate
cellular activity and collagen production. The sutures provide the
extra-cellular matrix upon which the collagen is structured and
laid down. A 3mm dermaroller is used to produce microneedling
trauma to the tissues, in order to increase the cellular activity
and healing.38,39 This combined treatment can give excellent skin
rejuvenation, which, judging by my experience, can last for more
than two years. In my clinic, we are seeing excellent results with
this technique. It is also helpful in improving the appearance of
stretch marks around the décolletage and breasts.
REFERENCES
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2. Prost-Squarcioni C. [Histology of skin and hair follicle]. Med Sci (Paris). 2006 Feb. 22(2): pp.131-7.
[Medline].
3. Burns DA, Breathnach SM, Cox N, Griffiths CE, eds. Rook’s Textbook of Dermatology. 7th ed. Malden,
Mass: Blackwell Science; 2004
4. Rabe JH, Mamelak AJ, McElgunn PJ, Morison WL, Sauder DN. Photoaging: mechanisms and repair. J
Am Acad Dermatol. 2006 Jul. 55(1): pp.1-19.[Medline]
5. Fongo A, Ferraris E, Bocca M. Skin tension lines and wrinkles. Anatomoclinical observations. Minerva
Chir. 1966. 21(13): pp.627-30.
6. Rabe JH, Mamelak AJ, McElgunn PJ, Morison WL, Sauder DN. Photoaging: mechanisms and repair. J
Am Acad Dermatol. 2006 Jul. 55(1): pp.1-19.[Medline]
7. Fongo A, Ferraris E, Bocca M. Skin tension lines and wrinkles. Anatomoclinical observations. Minerva
Chir. 1966. 21(13): pp.627-30.
8. Borg M; Brincat S; Camilleri G; Schembri-Wismayer P; Brincat M; Calleja-Agius J. The role of cytokines
in skin aging, Climacteric the journal of the International Menopause Society, 2013; 16(5); pp.514-21.
9. Borg M; Brincat S; Camilleri G; Schembri-Wismayer P; Brincat M; Calleja-Agius J. The role of cytokines
in skin aging, Climacteric the journal of the International Menopause Society, 2013; 16(5); pp.514-21.
10. Baumann L, Department of Dermatology, University of Miami, Miami Beach, FL, USA’ The role of
cytokines in skin aging; The Journal of Pathology 2007; 211(2): pp.241-51.
11. ‘Scattone L, de Avelar Alchorne MM, Michalany N, Miot HA, Higashi VS. Histopathologic changes
induced by intense pulsed light in the treatment of poikiloderma of Civatte. Dermatol Surg. 2012 Jul.
38(7.1): pp.1010-6. [Medline]
12. The Use of Lasers in Darker Skin Types Eliot F. Battle, Jr, MD. Seminars in CutaneousMedicin and
Surgery.2009, 28: pp.130-140
13. Freymiller EG. Platelet-rich plasma: evidence to support its use. J. OralMaxillofac. Surg. 62(8),
pp.1047–1048 (2004).
14. Kakudo N, Minakata T, Mitsui T et al. Proliferation-promoting effect of platelet-rich plasma on human
adipose-derived stem cells and human dermal fibroblasts. Plast. Reconstr. Surg. 122(5), pp.1352–1360
(2008).
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and histopathologic evaluation. Berlin AL; Hussain M; Phelps R; Goldberg D. dermatologic Surgery
2009; 35(2): pp.222-8
16. Lacarrubba F, Tedeschi A, Nardone B, Micali G. Mesotherapy for skin rejuvenation: assessment of the
subepidermal low-echogenic band by ultrasound evaluation with cross-sectional B-mode scanning.
Dermatol. Ther. 21(Suppl. 3), S1–S5 (2008).
17. El-Domyati M, El-Ammawi TS, Moawad O et al. Efficacy of mesotherapy in facial rejuvenation: a
histological and immunohistochemical evaluation. Int. J.Dermatol. 51(8), pp.913–919 (2012).
18. Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I, Wang B. Evidence and considerations in the
application of chemical peels in skin disorders and aesthetic resurfacing. J Clin Aesthet Dermatol.
2010 Jul. 3 (7): pp.32-43.
19. Briden ME. Alpha-hydroxyacid chemical peeling agents: case studies and rationale for safe and
effective use. Cutis. 2004 Feb. 73 (2 Suppl): pp.18-24.
20. Goldman A, Wollina U. Facial rejuvenation for middle-aged women: a combined approach with
minimally invasive procedures. Clin Interv Aging. 2010 Sep 23.5: pp.293-9.
Aesthetics
Treatment Focus
Décolletage
Conclusion
In addition to the treatments listed above, I advocate the use of skincare
packed with antioxidants such as peptides and vitamins to protect,
repair and hydrate the décolletage. Vitamin C is a fantastic ingredient
for treating this area as it builds collagen (which plumps the skin) and
treats, as well as helps prevent, pigmentation.40 Products containing
vitamin A are also suitable for use on the décolletage as they will
help repair sun damage.41 In conclusion, the décolletage is a greatly
ignored area of the body when it comes to anti-ageing and protection.
It is a vulnerable area predisposed to photo-ageing and the effects of
shearing forces, particularly in women who have very few hair follicles
on their chests. The treatments that work on the face also have benefits
on the décolletage, however the skin here is slower to heal, and
easier to damage. The practice of preparation with skin care including
retinoids and vitamin C, with, or without hydroquinone (in Fitzpatrick skin
types IV-VI) is always prudent. Experience has taught us that combining
treatments can help us to attain better results, with fewer risks and side
effects. My advice to practitioners is to use the treatments they already
use on the face, but with greater care on the décolletage. There is no
right or wrong, as long as we ensure patient safety and effectiveness
in achieving expected results. This puts great emphasis on managing
patient expectations, and the informed consenting process. All of this
starts with the consultation and listening to the patients.
Dr Aamer Khan is an aesthetic practitioner specialising
in non-invasive treatments of the face and neck. He
graduated from The University of Birmingham in 1986
and has dedicated the past 15 years to perfecting antiageing skin treatments. He is also co-founder of The
Harley Street Skin Clinic.
21. Nikalji N, Godse K, Sakhiya J, Patil S, Nadkarni N. Complications of medium depth and deep chemical
peels. J Cutan Aesthet Surg. 2012 Oct. 5 (4): pp.254-60.
22. Glogau RG, Matarasso SL. Chemical peels. Trichloroacetic acid and phenol. Dermatol Clin. 1995 Apr.
13 (2): pp.263-76.’
23. Doddaballapur S. Microneedling with dermaroller. J. Clin. Aesthet. Dermatol. 2(2), pp.110–111 (2009).’
24. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin.
Dermatol. 26(2), pp.192–199 (2008).
25. Clementoni MT, Broscher M, Munavalli GS. Photodynamic photorejuvenation of the face with a
combination of microneedling, red light, and broadband pulsed light. Lasers Surg.Med. 42(2),
pp.150–159 (2010).
26. Grippaudo FR, Mattei M. High-frequency sonography of temporary and permanent dermal fillers. Skin
Res. Technol. 16(3), pp.265–269 (2010).
27. Grippaudo FR, Mattei M. High-frequency sonography of temporary and permanent dermal fillers. Skin
Res. Technol. 16(3), pp.265–269 (2010).
28. El-Domyati M, El-Ammawi TS, Medhat W et al. Radiofrequency facial rejuvenation: evidence-based
effect. J. Am. Acad.Dermatol. 64(3), pp.524–535 (2011).
29. Jay A. Burns thermage: monopolar radiofrequency. Aesth. Surg. J. 25(2), pp.638–642 (2005).
30. ‘Alster TS, Lupton JR. Nonablative cutaneous remodeling using radiofrequency devices. Clin.
Dermatol. 25(5), pp.487–491 (2007).’
31. Reddy BY, Hantash BM. Emerging technologies in aesthetic medicine. Dermatol. Clin. 27(4),
pp.521–527 (2009).
32. Shamban AT. Current and new treatments of photodamaged skin. Facial Plast. Surg. 25(5),
pp.337–346 (2009).’
33. Gold MH. Photodynamic therapy for cosmetic uses on the skin: an update 2010. G. Ital. Dermatol.
Venereol. 145(4), pp.525–541 (2010).
34. Freymiller EG. Platelet-rich plasma: evidence to support its use. J. OralMaxillofac. Surg. 62(8),
pp.1047–1048 (2004).
35. ‘Kakudo N, Minakata T, Mitsui T et al. Proliferation-promoting effect of platelet-rich plasma on human
adipose-derived stem cells and human dermal fibroblasts. Plast. Reconstr. Surg. 122(5), pp.1352–1360
(2008).
36. Scattone L, de Avelar Alchorne MM, Michalany N, Miot HA, Higashi VS. Histopathologic changes
induced by intense pulsed light in the treatment of poikiloderma of Civatte. Dermatol Surg. 2012 Jul.
38(7.1): pp.1010-6. [Medline]
37. Suh DH; Jang HW; Lee SJ; Lee WS; Ryu HJ. Outcomes of polydioxanone knotless thread lifting for
facial rejuvenation, Dermatologic Surgery 2015; 41(6): pp.720-5
38. Doddaballapur S. Microneedling with dermaroller. J. Clin. Aesthet. Dermatol. 2(2), pp.110–111 (2009).
39. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin.
Dermatol. 26(2), pp.192–199 (2008).
40. R. Darlenski; C. Surber; J.W. Fluhr. Topical Retinoids in the Management of Photodamaged
Skin: From Theory to Evidence-based Practical Approach. The British Journal of
Dermatology. 2010;163(6):pp.1157-1165.
41. R. Darlenski; C. Surber; J.W. Fluhr. Topical Retinoids in the Management of Photodamaged
Skin: From Theory to Evidence-based Practical Approach. The British Journal of
Dermatology. 2010;163(6):pp.1157-1165.
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Aesthetics Journal
Aesthetics
Glutathione
Dr David Jack details the efficacy and
clinical uses of the glutathione antioxidant
Over the past few years there has been a surge of interest in antioxidants for
both general health and in skincare. Almost every new serum or cream released
seems to contain reference, at least, to the anti-ageing benefits of antioxidants. One
of the molecules responsible for much of the excitement in this field, and in medicine
in general, is glutathione – a thiol tripeptide present in every cell of most animal
species, as well as in some plants.1
From my experience and personal observation, there is interest in glutathione in the
skincare arena for two reasons: its strong antioxidant activity and its reputed ability to
reduce hyperpigmentation and lighten skin. The Japanese skincare industry is awash
with glutathione soaps, creams and oral supplements to fulfil the latter purpose.
Closer to home, there has been growing interest in glutathione as a supplement
in topical skincare, as well as an intravenous or intramuscular supplement for
its numerous supposed health benefits. Given the negative press that the
depigmentation agent hydroquinone has received recently, (albeit in my opinion
on fairly shaky evidence)2 there may be a place in the market for a new means of
tackling hyperpigmentation. Does glutathione fill this gap? In this article I outline the
basics of glutathione, its clinical uses, evidence so far for its use, and information on
the way it has been introduced to the western skincare market.
What is glutathione?
In humans, glutathione is probably the most important endogenous antioxidant.3
It is produced from the conjugation of glutamate, cysteine and glycine in all cells,
however it is found in greatest concentration in the liver, which also acts as a
reservoir for glutathione. It exists in two forms: reduced, L-glutathione (GSH), or an
oxidised form (GSSH), the former comprising 90% of the total pool of glutathione.
In the oxidised state, glutathione is able to non-enzymatically reduce free radical
species and reactive oxygen and nitrile compounds, acting as a substrate for
conjugation and reduction reactions by virtue of the thiol group of the cysteine
amino acid. Glutathione acts alone and in synergy with other antioxidants, such
as L-ascorbic acid and alpha-tocopherol to neutralise these damaging molecules
throughout the body. It is also involved in various cytochrome P450 reactions,
DNA synthesis and repair, amino acid transport, iron metabolism, nitric oxide cycle
regulation, protein synthesis, prostaglandin, leukotriene synthesis and many other
intracellular processes. Thus, should glutathione levels be depleted or inadequate,
a variety of systems and cell types may dysfunction as
a result.4
The emerging importance of the role of oxidative
stress in a substantial number of disease processes
has resulted in a surge of interest in the use of
supplementary antioxidants as an alternative or
additive treatment in a variety of conditions as
diverse as Parkinson’s disease, conjugation autistic
spectrum disorders, various cancers, chronic fatigue
syndrome, chronic obstructive pulmonary disease
(COPD) and diabetes.5,6,7 It has also been reported
that glutathione levels generally decrease with
age, possibly contributing to the pathogenesis of
Alzheimer’s disease.8
In the cosmetic industry, there has been some
interest in the ability of glutathione to alter melanin
production and thus be used as a skin lightening
treatment, particularly in the Philippines and Japan, as
mentioned earlier. The mechanism of this interaction
is at present unclear, however, several mechanisms
have been proposed. These include: the direct
inactivation of melanocyte tyrosinase activity and
transport, interruption of L-DOPA function, and
mediation of a switch in melanin production from
eumelanin production (which does not require GSH)
in favour of the colourless pheomelanin, found in
paler skin types.9,10 Thus, when GSH is found at high
concentrations, production of colourless pheomelanin
tend to be higher and at lower concentrations,
eumelanin predominate.11
Methods of delivery
Although glutathione is a ‘non-essential nutrient’ in
humans, (as it is synthesised by all normal cells from
the raw amino acid components), there is evidence
that a wide variety of wasting conditions including HIV,
various cancers, chronic fatigue syndrome, sepsis
and Crohn’s disease, among others,12 are associated
with reduced levels of GSH (and presumably
increased oxidative stress). As a result, glutathione
supplementation has been proposed as a novel way
of treating many of these conditions.
Given the fact that glutathione is a tripeptide, there has
been much scepticism that it can be taken orally and
absorbed without being completely broken down into
its constituent amino acids. Witschi et al13 found that
following oral ingestion, very little glutathione actually
reaches the systemic circulation. They reported that
the majority of the ingested glutathione is thought to
remain in gut luminal cells or is rapidly hydrolysed in
the circulation by extracellular membrane gammaglutamyl transpeptidases.
There is very little evidence to the contrary, however,
one non-randomised study indicated a rise in
blood (but not liver) levels of GSH following oral
supplementation in animal models.14 Given the lack
of evidence, at present, parenteral administration
of glutathione is considered the gold standard for
delivery of glutathione systemically.
In Western Europe and the US, many oncology centres
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offer glutathione as intramuscular and intravenous supplements
to patients undergoing chemotherapy, with evidence that it may
increase length of survival, improve tumour responses and reduce
neurotoxicity associated with platinum-based chemotherapy regimens,
without reducing the efficacy of the treatments.15 Similarly, in the US,
glutathione has been used as an intravenous supplement to attempt
to reduce motor symptoms in idiopathic Parkinson’s disease,
where reduced GSH levels associated with increased oxidative
stress are heavily implicated in its pathogenesis.16 There has been
some evidence of a mild improvement in those suffering from this
condition in terms of motor symptoms.17 Inhaled glutathione has
also been used in COPD and other lung conditions, however this
use is not commonplace in the UK.18 In almost every study I am
aware of, there seems to be no toxic dose or effects experienced
with any form of glutathione.
With regard to skincare, there is very little evidence for any particular
form of administration over another for the purpose of anti-ageing
or skin lightening. The belief, however, that oral administration is less
favourable than parenteral and topical approaches has led to the
development of a few products that can be delivered in these ways.
Glutathione in skincare
Japan, Thailand and the Philippines lead the market with glutathionebased skincare, with relatively few products available in the UK. The
numerous putative benefits of glutathione, including the antioxidant
benefits on sun-damaged skin and reduction of hyperpigmentation via
its effects on melanin production make it a potentially ideal constituent
of anti-ageing skincare products, particularly for patients concerned
with using products such as hydroquinone for hyperpigmentation.
The current problem is establishing the ideal topical dosage that
can result in a similar outcome to other established treatments of
hyperpigmentation for this purpose. As far as I have found, there have
been no studies to elucidate this ideal dosage and none comparing
glutathione to hydroquinone, for example, in the treatment of melasma
or other forms of hyperpigmentation.
Medik8’s CE-Thione is one of a small number of glutathione-containing
products in the mainstream cosmeceutical market in the UK. This
fairly advanced product combines optimal topical doses of vitamins
C & E with the chirally correct L-glutathione in an easy-to-use serum.
Perricone MD produces a similar treatment, Acyl-Glutathione. Other
products containing glutathione such as ARCONA Desert Mist and
Paula’s Choice Resist Super Antioxidant Concentrate Serum claim to
have anti-ageing and hydrating benefits for the skin, but as with other
products of this kind, there have not been any controlled trials as yet to
prove their effectiveness.
In the UK, other mechanisms of delivery of glutathione to the skin
are as part of combination peel treatments, most notably The
Perfect Peel. The product was developed in the US, aiming to
combine various peeling agents with glutathione to resurface the
dermis and homogenise skin tone. The developers suggest that the
combination of a self-neutralising mid-to-deep peel, combined with
glutathione, would result in ideal penetrance of glutathione to the
stratum basale and spinosum where the melanocytes are located.
In my own experience, this is one of the most effective peels for
hyperpigmentation that I have used so far – it is extremely simple to
use and the results I have seen are relatively impressive.
Parenteral administration (IV/IM) of liquid or reconstituted powdered
glutathione for hyperpigmentation is a much discussed and debated
topic at present. However, there is little, if any, substantial evidence
regarding the efficacy of this as a mode of delivery, as well as no
Aesthetics Journal
explicit approval for this purpose existing in the UK.
Glutathione is available in the UK to administer intravenously and
intramuscularly as a supplement, however, ideal dosage and dosage
frequency have not yet been established and only one supplier (TAD)
is approved by the MHRA. To date, there is only one, relatively limited,
randomised controlled trial from Thailand showing an association
between the use of exogenous oral glutathione and reduction
in skin pigmentation. No randomised controlled trials supporting
parenteral administration for reduction of hyperpigmentation has been
undertaken as yet.19
Conclusion
Significantly more evidence is required before the use of
glutathione can be convincingly marketed as an agent to reduce
hyperpigmentation, particularly in relation to means of administration,
dosage, dosage frequency and potential outcome measures. It does
however, show significant potential as there does not seem to be any
documented side effects to this treatment, and circumstantial and
early evidence does indicate its effectiveness. In addition, the multiple,
documented health benefits to this treatment add to the appeal of
glutathione over other depigmentation products in my practice. I am
sure there will be many interesting developments over the next few
years, with this seemingly versatile molecule used in both skincare and
in general medical supplementation.
Dr David Jack is an aesthetic practitioner based
between his clinics in Harley Street in London and
Scotland. He graduated from the University of Glasgow
and later became a member of the Royal College of
Surgeons of Edinburgh. Dr Jack trained in the NHS until
2014, mostly in plastic surgery, before leaving to establish his nonsurgical aesthetic practice, having worked in this sector part-time for
almost seven years.
REFERENCES
1. Aw TY, Wierzbicka G and Jones DP ‘Oral glutathione increases tissue glutathione in vivo’ Chem Biol
Interact 80(1) (1991) pp.89-97
2. Patel T, Williams S, ‘Skin: Pigmentation’ Aesthetic Medicine August 2014 www.aestheticmed.co.uk/skinpigmentation/
3. Mari M, Morales A, Colell A, Garcia-Ruiz C and Fernandez-Checa JC Mitochondrial Glutathione, a Key
Survival Antioxidant, Antioxid Redox Signal (2009) 11(11) pp. 2685-2700 4. Scholz, RW, Graham KS, Gumpricht E, Reddy CC, Mechanism of interaction of vitamin E and glutathione
in the protection against membrane lipid peroxidation Ann NY Acad Sci (1989) 570 pp.514–517
5. Droge W and Holm E, ‘Role of cysteine and glutathione in HIV infection and other diseases associated
with muscle wasting and immunological dysfunction’ FASEB J, 11(13) (1997) pp.1077-1089
6. Block KI, Koch AC, Mead MN, Tothy PK, Newman RA, Gyllenhaal C, ‘Impact of antioxidant
supplementation on chemotherapeutic efficacy: A systematic review of the evidence from
randomized controlled trials’ Cancer Treatment Reviews 33 (2007) pp.407– 418
7. Lamson D, Brignall M, The Use of Nebulized Glutathione in the Treatment of Emphysema: a Case
Report Altern Med Review 5(5) (2000) pp.429-431
8. Pocernich CB and Butterfield DA, ‘iElevation of glutathione as a therapeutic strategy in Alzheimer
disease’ Biochimica et Biophysica Acta, 1822 (2012) pp.625.
9. Villarama CD and Maibach HI, ‘Glutathione as a depigmenting agent: an overview’, Int J Cosmet Sci,
27(3) (2005), pp.147-153.
10. Matsuki M, Watanabe T Ogasawara A, Mikami T and Matsumoto T, ‘Therapeutic strategy’,Yakugaky
Zasshi, 128 (8) (2008) pp.1203-1207.
11. Galvan I, Alonso-Alvarez, C and Negro JJ, ‘ Relationships between hair melanization, Glutathione
Levels, and Senescence in Wild Boars’, Physiological and Biochemical Zoology, 85(4) (2012), pp.332347.
12. Droge W and Holm E, ‘Role of cysteine and glutathione in HIV infection and other diseases
associated with muscle wasting and immunology dysfunction’ FASEB J, 11(13) (1997) pp.1077-1089.
13. Witschi A, Reddy S, Stofer B and Lauterburg BH, ‘The systemic availability of oral glutathione’ Eur J
Clin Pharmacol, 43 (1992), pp.667-669.
14. Aw TY, Wierzbicka G and Jones DP, ‘Oral glutathione increases tissue glutathione in viv’, Biol Interact,
80(1) (1991), pp.89-97.
15. Block KI, Koch AC, Mead MN, Tothy PK, Newman RA, Gyllenhaal C, ‘Impact of antioxidant
supplementation on chemotherapeutic efficacy: a systematic review of the evidence from
randomized controlled trials’, Cancer Treatment Reviews, 33 (2007) p.407.
16. Martin HL and Teismann P, ‘Glutathione – a review on its role and significance in Parkinson’s disease’,
The FASEB Journal, 23(10) (2009), pp.3263-3272.
17. Hauser RA, Lyons KE, McClain T, Carter S and Perlmutter D, ‘Randomized, double-blind, pilot
evaluation of intravenous glutathione in Parkinson’s disease’ Mov Disord. 24(7) (2009), pp.979-983.
18. Lamson D, Brignall M, The Use of Nebulized Glutathione in the Treatment of Emphysema: a Case
Report Altern Med Review 5(5) (2000) pp.429-431
19. Arjinpathana N and Asawanonda P, ‘Glutathione as an oral whitening agent: a randomized, doubleblind, placebo-controlled study’, J Dermatolog Treat 23 (2012), pp.97-102.
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Aesthetics Journal
Aesthetics
Treating Sunspots
Consultant dermatologist Dr Daron
Seukeran details the occurrence of
photoageing and discusses treatment
options for solar lentigos
Photoageing refers to skin damage and skin ageing caused by
intense and chronic exposure to sunlight, specifically ultraviolet
A (UVA) and ultraviolet B (UVB) rays.1 Accounting for the majority
of age-associated changes in the appearance of the skin, it is
the superposition of chronic UV-induced damage on natural
ageing.2 The photoageing process is caused by receptor-initiated
signalling, mitochondrial damage, protein oxidation and telomerebased DNA damage responses, displaying as variable epidermal
thickness, dermal elastosis, decreased/fragmented collagen,
increased matrix-degrading metalloproteinases, inflammatory
infiltrates and vessel ectasia.2 It can be characterised clinically by
the skin’s coarseness, wrinkling, mottled pigmentation, skin laxity,
telangiectasia, and premalignant and malignant neoplasms.3
One visible sign of photoageing is through the development
of solar lentigines, more commonly known as ‘sunspots’. Solar
lentigines are considered one of the earliest signs of photoageing
and are a common aesthetic complaint.4 Most frequently found in
sun-exposed sites, they are regularly seen in areas such as the
face, shoulders and the backs of the hands, and usually have a
uniform shade of brown, often seen in older fair-skinned patients
who have had excessive sun exposure.5
The pathological features of a solar lentigo consist of a linear
increase in melanocytes at the dermal-epidermal junction, but no
cytological atypia of these melanocytes, and no budding down
of these cells into the underlying dermis. There is frequently
associated actinic damage to the adjacent dermal collagen.6
Diagnosis
It is essential that a definitive diagnosis is made, indicating that
these pigmented flat lesions on the hands and face are harmless
and are not showing any signs of progression to skin cancer, such
as lentigo maligna.4
The features of a simple lentigo are usually of a uniformly brown
flat macule, most often on the face or on the dorsum of the hands.
Benign solar lentigos tend to be uniform in colour with welldefined margins and no history of change within them. A history of
there being any change in shape, size or colour associated with a
pigmented lesion should lead to concern that this lesion may not
be benign or may require further investigation. There needs to be
a low index of suspicion as to whether further investigations, such
as excision and submission to histology, is required.
However, a clinical diagnosis can be made more difficult to
ascertain due to pigmented actinic keratosis, lichen planus-like
keratosis and lentigo maligna, which each may appear in similar
forms.7 It is only when one is confident that a pigmented lesion
is benign that one can then consider the best form of treatment.
Although successful removal of these lesions can be achieved,
as will be discussed below, the ability to distinguish a benign
pigmented lesion from a malignant lesion is very important and
requires appropriate training. Stankiewicz et al reported three
cases of pigmented lesions that had been referred to a clinic for
laser removal of these lesions on the face, and fortunately were
recognised to be suspicious and diagnosed as melanomas.4
A French study further found that multiple solar lentigines on
the upper back and shoulders of adults could serve as clinical
markers of previous severe sunburn, and indicated that it may be
used to identify those at a higher risk of developing cutaneous
melanoma.8
Prevention
The application of sunscreen helps decrease the rate of
appearance and the darkening of solar lentigines, and limiting
one’s exposure to sun tanning and the use of artificial sources
of UV light may help prevent them. The application of a liberal
quantity of sunscreen has been shown to be by far the most
important factor for effectiveness of the sunscreen, followed by the
uniformity of application and the specific absorption spectrum of
the agent used.9
Topical Treatment
It was suggested that first line therapy in terms of physical
treatment for solar lentigines was ablative therapy with cryotherapy,
and the occasional use of topical treatments with substances
such as retinoids (Adapalene and Tretinoin) have been suggested
to provide lightening of lentigines.10 Studies have indicated that
a topical agent containing a combination of a retinoid, phenol
agent and an antioxidant, was well tolerated and showed a
significant improvement in the depigmentation of solar lentigines.11
A triple combination cream with fluocinolone acetonide 0.01%,
hydroquinone 4%, and tretinoin 0.05% as adjuvant to cryotherapy
for solar lentigines on the dorsal hands was also found to be
effective.12 Finally, the effect of a bleaching solution containing
2% mequinol (4-hydroxyanisole, 4HA) and 0.01% tretinoin (Solagé)
applied twice daily for three months, on solar lentigines which
were present on the back of one hand, demonstrated a significant
lightening effect after two months of treatment, and was maintained
at least two months after stopping treatment.13
Cryotherapy
Some patients, particularly with darker skin types, can experience
hypopigmentation or a recurrence of pigment.14
Many consider the first-line therapy for solar lentigines to be
@aestheticsgroup
ablative therapy with cryotherapy.10 This procedure is often
successful because of the susceptibility of melanocytes to
freezing with liquid nitrogen; while squamous cells resist injury at
-20°C, melanocytes freeze at -4 to -7°C.10 In one study, the efficacy
and safety of cryotherapy and trichloroacetic acid (TCA) were
compared. It was found that cryotherapy showed more positive
results than the TCA 33% solution for treatment of sunspots
on the back of the hands, and this was particularly effective in
lighter-complexioned individuals. It was suggested that for darker
complexions, TCA 33% may be preferred. However, it was further
stressed that post-inflammatory hyperpigmentation remains a risk
for both modalities.15
Lasers and intense pulsed light (IPL) systems:
IPL treatment:
Intense pulsed light (IPL) devices emit polychromatic light in
broad ranges of wavelengths and are selectively filtered to target
specific chromophores. Kawada et al confirmed that a broadband
(non-coherent in terms of pulsed light) source also led to over
50% improvement in lentigines, though while the smaller solar
lentigines responded well, the larger patches showed lack of
response. Ephelides or freckles responded very well with 75% of
patients showing more than a 50% response.16 In another study
of 22 pigmented lesions, a marked improvement was obtained
in 17 cases, with a moderate improvement showing in four cases
and a slight improvement in one case. It further claimed that no
undesirable effects were observed.17
Laser treatment:
Various lasers produce beams of light that emit specific wavelengths,
which are then absorbed by melanin, the chromophore found in
solar lentigines, and converted to heat.18
The development of short-pulsed, pigment-specific lasers to
selectively destroy the pigment within the solar lentigo has led to
significant clinical improvement, a low risk of high patient acceptance
and adverse effects.19 Various studies have shown lasers to be one of
the most effective forms of treatment for this indication. Schoenewolf
et al noted that the Q-switched ruby laser has been highly effective
in the treatment of lentigines on the dorsum of the hands, which is
the site where many individuals seek treatment.20 Todd et al7 also
found that the frequency doubled in the Q-switched Nd:YAG laser
was most likely to provide significant lightening with the fewest
adverse effects. It highlighted that out of 27 patients, 25 preferred
laser therapy to cryotherapy.21
Laser resurfacing:
An alternative approach to removing these solar lentigines
has been by laser ablation using erbium-YAG or pulsed CO2
lasers. These lasers remove microns of tissues accurately and
thereby often remove the epidermis, down to the reticular
dermis. Following this, a new layer of skin forms which is no
longer pigmented.20 Fractionated lasers are some of the newest
technology in laser rejuvenation. This is where the light is broken
up and delivered in neat individual columns, which allow for
quicker healing. The new fractionated ablative systems have also
been very helpful in this area, leading to less downtime with a
good response to treatment.20 A study using a non-ablative
1927 nm fractional resurfacing laser indicated that, after two
treatments, it had produced moderate to marked improvement
Aesthetics Journal
in the overall appearance of facial pigmentation with high patient
satisfaction. It further indicated that response to treatment was
maintained at one and three months follow up, suggesting this to be
an effective technique for treating solar lentigines.22
Conclusion
The ‘sunspot’ or solar lentigo is a commonly acquired pigmented
lesion most often seen on the sun-exposed areas such as the face
and the dorsum of the hands, and is a key sign of photoageing.
However, before any treatment is confirmed, the practitioner
considering administering treatment must be well-trained in the
diagnosis and treatment of pigmented lesions, as skin cancers can
be missed and treated inappropriately.
Once an appropriate diagnosis of a benign solar lentigo has been
made, there are then various options of treatment as outlined in
this article that can be considered. Laser treatment has significantly
improved the outcome of these treatments and is safe and effective
in appropriately trained hands.19,20,21
Dr Daron Seukeran is a consultant dermatologist at
the James Cook University Hospital in Middlesbrough
and previously worked at the Royal Berkshire Hospital.
He undertakes general dermatology and dermatological
surgery, however his main interest is laser surgery.
REFERENCES
1. C Battie, S Jitsukawa, F Bernerd, S Del Bino, C Marionnet, M Verschoore. ‘New insights in
photoaging, UVA induced damage and skin types’, Exp Dermatol, 23(1) (2014) pp. 7-12
2. M Yaar, BA Gilchrest, ‘Photoageing: mechanism, prevention and therapy’, Br J Dermatol,
157(5) (2007) pp. 874-87
3. JJ Leyden, ‘Clinical features of ageing skin’, Br J Dermatol, 122(35) (1990) pp. 1-3
4. K Stankiewicz, G Chuang, M Avram, ‘Lentigines, laser, and melanoma; case series and
discussion’ Lasers Surg Med, 44(2) (2012) pp.112-6
5. S Monestier, C Gaudey, J Gouvernet et al, ‘Multiple senile lentigos of the face, a skin ageing
pattern resulting from a lofe of intermittent sun exposure in dark skinned caucasions: a case
control study’, Br J Dermatol, 154 (2006), pp. 438-44
6. JA Newton Bishop, ‘Lentigos, Melanocyte Naevi and Melanoma’, in Rooks Textbook of
Dermatology, ed. by T Burns, S Breathnach, N Cox, C Griffiths (West Sussex: Wiley-Blackwell,
2010) pp. 54.3 -54.5
7. A Lallas, G Argenziano, E Moscarella, C Longo, V Simonetti, I Zalaudek, ‘Diagnosis and
management of facial pigmented macules’, Clin Dermatol, 32(1) (2014), pp.94-100
8. C Derancourt, E Bourdon-Lanoy, JJ Grob, JC Guillaume, P Bernard, S Bastuji-Garin, ‘Multiple
large solar lentigos on the upper back as clinical markers of past severe sunburn: a casecontrol study’, Dermatology, 214(1) (2007), pp. 25-31
9. S Lautenschlager, HC Wulf, MD Pittelkow, ‘Photoprotection, Lancet, 370(9586)(2007), pp.
528-37
10. JP Ortonne, AGLui H Panday et al, ‘Treatment of solar lentigines’, J Am acad dermatol, 54(5,2)
(2006), pp. 262-71
11. Camelin et al, ‘The clinical and instrumental evaluation of the efficacy of a new depigmenting
agent containing a combination of a retinoid, phenol agent, and an anti-oxidant for the
treatment of solar lentigines’, Dermatology, 230(4) (2015) pp. 360-6
12. D Hexsel, C Hexsel, MD Porto, C Siega, ‘Triple combination as adjuvant to cryotherapy in
the treatment of solar lentigines: investigator-blinded, randomized clinical trial’, J Eur Acad
Dermatol Venereol, (2014)
13. C Pierard-Franchimont, F Henry, P Quatresooz, V Vroome, GE Pierard, ‘Analytic quantification
of the bleaching effect of a 4-hydroxyanisole-tretinoin combination on actinic lentigines’, J
Drugs Dermatol, 7(9) (2008), pp. 873-8
14. D Leroy, A Dompmartin, A Dubreuil, S Louvet, ‘Cryotherapy of PUVA lentigines’, Br J Dermatol.
135(6) (1996) pp. 988-90
15. M Raziee, K Balighi, H Shabanzadeh-Dehkordi, RM Robati, ‘Efficacy and safety of cryotherapy
vs. trichloroacetic acid in the treatment of solar lentigo’, J Eur Acad Dermatol Venereol, 22(3)
(2008) pp. 316-9
16. A Kawada et al, ‘Clinic improvement of solar lentigines and ephelides with an intense pulsed
light source’, Dermatologic Surgery, 28(6) (2002), pp. 504-508
17. P Campolmi, P Bonan, G Cannarozzo et al, ‘Intense pulsed light in the treatment of nonaesthetic facial and neck vascular lesions: report of 85 cases’, J Eur Acad Dermatol Venereol,
25(1) (2011), pp. 68-73
18. KD Polder, JM Landau, IJ Vergilis-Kalner, LH Goldberg, PM Friedman, S Bruce, ‘Laser
eradication of pigmented lesions: a review’, Dermatol Surg, 37(5) (2011), pp.572-95
19. MZ Bukvic et al, ‘Laser therapy for solar lentigonies: review of the literature and case report’,
Acta Dermatoveneral Croat, 14(2) 2006, pp. 81-5
20. NL Schoenewolf, J Hafenr, R Dummer, ‘al laser treatment of solar lentigines on dorsum of
hands: QS Ruby laser versus ablated CO2 fractionated laser – randomised controlled trial’,
Eur J Dermatol, (2015)
21. MM Todd et al, ‘A comparison of three lasers and liquid nitrogen in the treatment of solar
lentiginies: a randomised controlled comparative trial’, Arch Dermato,l 2000 136(7) (2000), pp.
841-6
22. JA Brauer, DH McDaniel, BS Bloom, KK Reddy, LJ Bernstein, RG Geronemus, ‘Nonablative
1927 nm fractional resurfacing for the treatment of facial photopigmentation’, J Drugs
Dermatol, 13(11) (2014), pp.1317-22
@aestheticsgroup
Aesthetics Journal
Aesthetics
A summary of the latest
clinical studies
Title: Botulinum toxin injections for the treatment of hemifacial
spasm over 16 years
Authors: Sorgun MH, Yilmaz R, Akin YA, Mercan FN,
Akbostanci MC
Published: Elsevier Ltd, August 2015
Keywords: Botulinum toxin, Dysport, Hemifacial spasm
Abstract: The aim of this study was to investigate the efficacy and
side effects of botulinum toxin (BTX) in the treatment of hemifacial
spasm (HFS). We also focused on the divergence between different
injection techniques and commercial forms. We retrospectively
evaluated 470 sessions of BTX injections administered to 68
patients with HFS. The initial time of improvement, duration and
degree of improvement, and frequency and duration of adverse
effects were analysed. Pretarsal and preseptal injections, Botox
and Dysport brands were compared in terms of efficacy and side
effects, accompanied by a review of papers which reported BTX
treatment of HFS. An average of 34.5 units was used per patient.
The first improvement was felt after 8 days and lasted for 14.8weeks.
Patients experienced a 73.7% improvement. In 79.7% of injections,
no adverse effect was reported, in 4.9% erythema, ecchymosis, and
swelling in the injection area, in 3.6% facial asymmetry, in 3.4%
ptosis, in 3.2% diplopia, and in 2.3% difficulty of eye closure was
detected. Patients reported 75% improvement on average after 314
sessions of pretarsal injections and 72.7% improvement after 156
sessions of preseptal injections (p=0.001). The efficacy and side
effects of Botox and Dysport were similar.
Title: Laser Resurfacing for Latin Skins: The Experience with
665 Cases
Authors: Triana L, Cuadros SC, Triana C, Barbato C, Zambrano M
Published: Springer US, August 2015
Keywords: Laser, resurfacing, CO2, microfractionated
Abstract: CO2 resurfacing and CO2 microfractionated laser systems are reliable tools to improve different facial pathologic skin conditions, but are associated with a high rate of complications specially
in Fitzpatrick III, IV, and V skin phototypes, predominant in the Latin population, which has pushed many surgeons to change technologies and abandon its use. The study aims to compare patient results
with the CO2 resurfacing laser and microfractionated CO2 laser resurfacing in all skin types and show similar results to those obtained
worldwide in patients with phototypes III, IV, and V. Standardized
review of medical records from a database of private practice patients
treated since January 1998 to July 2012 with SlimE30 MiXto SX(®)
CO2 laser. Evaluation of outcomes, complications, and satisfaction
of three different modalities of treatment was made. A total of 665
treated patients were included. Ablative CO2 was applied to 80.3 %,
CO2 microfractionated to 15.1 %, and mixed treatment to 4.5 % of
cases. Globally, hyperpigmentation rates were 30.4 % in the CO2
resurfacing group, 16.3 % when a combination of modalities was
applied and 11 % in microfractionated CO2 cases. A steady increase
of these rates is shown as the phototype becomes higher. Satisfaction
rates were high for all groups: 86.7 % in the mixed group, 82.2 % in
the microfractionated CO2, and 79.6 % in the CO2 ablative.
Title: Phototherapy in the elderly
Authors: Powell JB, Gach JE
Published: British Association of Dermatologists, August 2015
Keywords: Phototherapy, ultraviolet, dermatoses, elderly
Abstract: Elderly patients present with a unique spectrum of
dermatoses that pose particular management opportunities and
challenges. The skin of elderly patients differs from that of younger
patients, not only in appearance but also in structure, physiology and
response to ultraviolet (UV) radiation. In January 2014, we analysed
all patients recently referred for, currently receiving or recently
having completed a course of phototherapy at a university teaching
hospital in England (UK). 249 patients were identified; 37 (15%) were
over the age of 65 years (the WHO definition of an elderly or older
person). The dermatoses being treated were psoriasis (51%), eczema
(11%), nodular prurigo (11%), pruritus (11%), Grover disease (5%)
and others (11%). One patient with dementia was deemed not safe
to embark on phototherapy, and five patients were yet to start. The
remaining 31 elderly patients received 739 individual phototherapy
treatments: 88% narrowband (NB)-UVB and 12% systemic, bath and
hand/foot psoralen UVA (PUVA). The acute adverse event (AE) rate
was 1.89%, all occurring in those receiving NB-UVB. No severe acute
AEs occurred. Of those who completed their course of phototherapy,
80% achieved a clear/near clear or moderate response, while just two
patients (8%) had minimal response and two (8%) had worsening
of the disease during treatment. Of those receiving NB-UVB for
psoriasis, 91% achieved a clear or near-clear response.
Title: Prevalence of foot eczema and associated occupational and
non-occupational factors in patients with hand eczema
Authors: Brans R, Hübner A, Gediga G, John SM
Published: Contact Dermatitis, August 2015
Keywords: Foot eczema, irritant contact dermatitis, occupational,
tobacco smoking
Abstract: Foot eczema often occurs in combination with hand
eczema. However, in contrast to the situation with hand eczema,
knowledge about foot eczema is scarce, especially in occupational
settings. This study aims to evaluate the prevalence of foot eczema
and associated factors in patients with hand eczema taking part in
a tertiary individual prevention programme for occupational skin
diseases. The medical records of 843 patients taking part in the
tertiary individual prevention programme were evaluated. Seven
hundred and twenty-three patients (85.8%) suffered from hand
eczema. Among these, 201 patients (27.8%) had concomitant foot
eczema, mainly atopic foot eczema (60.4%). An occupational irritant
component was possible in 38 patients with foot eczema (18.9%).
In the majority of patients, the same morphological features were
found on the hands and feet (71.1%). The presence of foot eczema
was significantly associated with male sex [odds ratio (OR) 1.78, 95%
confidence interval (CI) 1.29-2.49], atopic hand eczema (OR 1.60,
95%CI: 1.15-2.22), hyperhidrosis (OR 1.73, 95%CI: 1.33-2.43), and
the wearing of safety shoes/boots at work (OR 2.04, 95%CI: 1.462.87). Tobacco smoking was associated with foot eczema (OR 1.79,
95%CI: 1.25-2.57), in particular with the vesicular subtype.
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Aesthetics Journal
Aesthetics
vaginal rejuvenation topics such as labiaplasty has
increased 41% year-on-year. In the past three months
alone, half a million consumers have conducted
research on RealSelf and, in the past year, consumers
have viewed 3.8 million pages of content on this topic.
Labiaplasty is the most important topic, representing
68% of visits to this subject matter.” The numbers
of procedures are increasing every year as vaginal
rejuvenation has become accepted as mainstream.
Once a procedure that was considered a dirty little
secret, women are now actively searching online for
practitioners, joining forums to discuss their concerns
with other women, and doing research on all of the
options available. While some women undergo these
procedures to improve their comfort, many also want
to improve their self-confidence.
Vaginal
Rejuvenation
Wendy lewis investigates the
incorporation of women’s health
treatments into aesthetic practices
Frustrated with endless Kegel exercises, hormone creams and adult nappies,
more women are turning to procedures that address both their functional
problems and the changes that accompany childbirth and ageing.
Surgery to reshape the labia and other aspects of the vagina is on the rise.
According to the American Society for Aesthetic Plastic Surgery (ASAPS), in 2014,
the procedures that showed the largest growth in volume on a year-over-year
basis included labiaplasty, which rose by 49%. A visit to RealSelf.com reveals a
94% ‘Worth It’ rating for labiaplasty from 388 posted reviews. According to Tom
Seery, CEO of RealSelf, “Consumer satisfaction with labiaplasty has increased over
the years, and suggests that women are very satisfied with the outcomes. Traffic to
What women want
Many practitioners I have spoken to say that while some women
opt for surgery because their labia has caused them physical
discomfort, there is also a growing segment of patients seeking
treatments who are being encouraged by their partners.
According to these practitioners, women are also requesting
procedures because they feel self-conscious about their
anatomy post-childbirth.
Aesthetic concerns
1. Large, hanging, wrinkled or uneven labia minora
2. Unhappy with their appearance due to length, dark
pigmentation, asymmetries
3. Pain, discomfort or irritation from exercise or sports
4. Unable to wear certain clothes, lingerie, bikinis, tight jeans
5. Hygiene or odour issues
6. Stress incontinence
7. Multi-directional urine stream
8. Feeling self-conscious or embarrassed by their anatomy,
camel toe appearance
9. Inhibited from sexual activity, decreased sensation or friction
during intercourse, feeling of loose or wide vagina
10. Unable to participate in routine activities
Functional female issues
While more and more women seek vaginal rejuvenation treatments
for aesthetic concerns, many others simply undergo treatment for
Business opportunities
Many of the clinics I work with are reporting dramatic
increases in the number of women seeking labiaplasty
and vaginal tightening treatments over the last few
years. Some members of the medical community
attribute this rise to the proliferation of pornography
and the establishment of a ‘new normal’ for women’s
private parts. It can also be attributed to the fact that
there are more available options to women today that
are safer, less invasive, less expensive and with less
down-time. The increasing numbers of practitioners
adding these treatments to their menu of services
and honing their skills, coupled with patient referrals
health-related issues. According to the American Urogynecologic
Society (AUGS), one in three women will experience a pelvic floor
disorder (PFD) in her lifetime.3 These may occur when women
have weakened pelvic muscles or tears in the connective tissue,
which may cause pelvic organ prolapse, bladder and bowel control
problems. These symptoms are more common as women get
older, and childbirth is definitely a contributing factor. Vaginal births
double the rate of pelvic floor disorders compared to caesarean
deliveries or women who have never given birth. Today there is
a growing number of non-surgical and surgical treatment options
available to address these concerns. Aside from prescription
medications for incontinence, an overactive bladder (OAB) can be
treated with botulinum toxin injections. Botulinum toxin is injected
into the bladder muscle and used to treat OAB symptoms such as
a strong need to urinate with leaking (urge urinary incontinence),
a strong need to urinate (urgency), and urinating often (frequency).
Many women suffer from painful intercourse due to vaginal atrophy,
an uncomfortable condition that causes changes in the structure
and function of the vagina. It can be caused by hormonal changes
associated with menopause, or by a slowdown in oestrogen
production, such as after chemotherapy or radiotherapy for cancer
or removal of ovaries. This drop in hormone levels can result in a
thinning and loss of elasticity of vaginal tissues. The blood supply
is reduced and the vagina loses some of its natural lubrication,
which can cause itching, burning, dryness, incontinence, laxity and
prolapse. Not surprisingly, these symptoms can have a devastating
effect on a woman’s self-esteem and relationships.
@aestheticsgroup
from practitioner colleagues, demonstrate that the desire for vaginal
rejuvenation has become a topic of interest in popular culture. This
newfound acceptance of procedures that enhance the beauty
of an area once considered off limits can translate into growth
opportunities for aesthetic clinics. Practitioners who are marketing
vaginal cosmetic procedures are getting in on the ground floor of
this new frontier in cosmetic medicine and surgery. As our culture
continuously puts pressure on women to measure up to a certain
ideal image, the popularity of this category of procedures is likely to
continue to flourish.
The art of vaginal reshaping
Labiaplasty, as well as other vaginal augmentation procedures,
are getting a lot of attention lately. By all accounts, labia reduction
appears to be the most popular form of vaginal cosmetic surgery,
although that is just where the list of options begins. According
to practitioners offering these treatments, vaginal rejuvenation,
vaginoplasty, hymenoplasty (revirgination), clitoral hood reduction
(clitoral unhooding), labial fat injections, and G-spot enhancement are
becoming more commonly requested. For women who are unhappy
with the appearance of their vagina, but are reluctant to undergo
surgery, there are new and exciting non-surgical alternatives. There
has been a recent rise in injectable fillers specifically designed for
enhancing women’s anatomy. For example, Desiral by Vivacy is
an antioxidant hyaluronic acid based gel formulated to preserve
women’s intimate health. Cindy Barshop, founder of the Completely
Bare laser hair removal clinics that were later sold and rebranded
as Spruce & Bond, has jumped on this trend. She founded VSpot
on New York’s Fifth Avenue as the first vaginal rejuvenation spa
in the US and is carving out a new niche in the world of beauty.
“Until recently, the only option for women who suffered from
incontinence, dryness, and painful sex, was invasive surgery with
horrific side effects. It’s time to take control of our bodies, our
sexuality and our vaginal health. VSpot is literally life changing for
so many women,” she says. Although the number of procedures
being performed seems to be steadily climbing, not every woman
is comfortable telling her practitioner about her concerns. Such
hesitation in speaking to medical professionals, however, will likely
change as more women’s health clinic models such as VSpot arise,
new technologies are developed and more aesthetic clinics add
vaginal rejuvenation procedures to their treatment offering. The rise
in the specialty of urogynecology, which focuses on the treatment
of pelvic floor disorders, is also significant. According to the
International Urogynecological Association (IUGA), it has more than
2,900 members from 90 countries, and is affiliated with 29 national
societies including the British Society of Urogynaecology (BSUG).
There are more practitioners entering the market offering some
aspect of women’s health services, from gynaecologists, plastic
surgeons, and dermatologists, to aesthetic practitioners.
Emerging non-surgical technologies
The newest entries into this category include devices using
radiofrequency or CO2 fractional energy to promote the recovery of
genital mucosa by stimulating the production of collagen and restoring
blood flow. Energy may be delivered externally to address tissue laxity,
and internally to improve the functional aspects of the vagina.
‘Vontouring,’ short for vaginal contouring, is a new term coined by BTL
Aesthetics for their Protege Intimo system (Exilis Protégé in the US). This
system uses radiofrequency energy to heat the collagen and stimulate
the production of new collagen fibres.
Aesthetics Journal
The range of women’s lasers
•
•
•
•
•
•
•
•
Mona Lisa Touch – Cynosure
Viveve Treatment – Viveve Medical
ThermiVa – Thermi Aesthetics
Pelleve RF – Ellman, a Cynosure Company
Femilift – Alma Lasers
IntimaLase - Fotona
Protégé Intima – BTL Aesthetics
C02RE Intima – Syneron-Candela
The beauty of these systems from a business model perspective is
that the procedures are typically performed in a clinic environment,
take 15-30 minutes usually without the need for an anaesthetic,
and there is minimal to no discomfort, side effects or downtime for
the patient. In most cases, it also involves a course of treatment
sessions, so patients will be returning to your clinic periodically and
for maintenance sessions, leaving an opportunity to introduce them
to other treatments on offer. These treatments can also dovetail into
other non-surgical cosmetic procedures, including injectables, laser
resurfacing and light-based treatments. As more companies enter
this space, we can expect to see direct-to-consumer marketing
campaigns that will ultimately raise awareness of treatments that
address the symptoms that may already be on the minds of women
of all ages. This area of practice may still be in its infancy, but
everything we have seen so far points to it becoming a big growth
market. According to Dr Bruce E Katz, board-certified dermatologist
and director of the Juva Skin & Laser Center in New York, “Over the
past few years, media attention has given rise to consumer awareness
of the options available to women both from a functional standpoint
as well as aesthetics. We began offering FemiLift in our practice this
year because we see a need for women’s procedures that address
incontinence. Most women first notice urine leakage after they have
given birth, though it can happen with ageing as well. FemiLift is a
30-minute, minimally invasive therapy that uses a CO2 laser to deliver
fractional laser energy that strengthens the walls of the vagina.”
Building a women’s clinic
Establishing a centre for women’s health takes careful planning,
investigation, and some marketing muscle. It requires more effort than
just buying a laser and putting out some brochures in the waiting room
to generate interest. Here are some pointers to help you get started:
• Investigate the various systems on the market, carefully read the
clinical data to support the claims being made, and ask colleagues
whom you trust for their recommendations.
• Visit the company website to see if there is a clinic finder so that
patients seeking these procedures can find you.
• Look at how many units of the system you are interested in are
currently being used in your general area; if there is a system
around every corner then the market may be oversaturated for the
current state of consumer demand. There is surely a marketing
advantage to being the first in your postcode to offer an innovative
technology.
• Inquire about what the company offers in terms of training or
preceptorships to bring the clinic staff up to speed quickly on how
to treat patients.
• Finally, ask about the availability of marketing programmes and
public relations support to help you spread the word.
@aestheticsgroup
Aesthetics Journal
The question on the minds of some practitioners interested in
adding vaginal rejuvenation technology to their armamentarium
is how to start the conversation with new and existing patients.
Addressing these intensely personal concerns with women who
are feeling vulnerable, especially if you are not a gynaecologist
or obstetrician, can be a challenge in the beginning. Some
practitioners may not have the requisite bedside manner or
temperament for it. Recruiting the right staff is a critical first step.
“The consultation process can be a challenge for some
practitioners. My advice is to enlist a female nurse or practitioner’s
assistant to talk to patients about their needs and goals. We have
found that it helps to have a woman who is knowledgeable and
comes from a place of credibility speak to patients about these
delicate issues. It helps to put them at ease,” says Dr Katz. Plastic
surgeon Dr Christine Hamori has the advantage of being one of
only a handful of female surgeons performing vaginal rejuvenation
procedures in her practice location of Duxbury, Massachusetts.
“As a woman, I can speak to female patients from a different
perspective. With men, it may sometimes be more difficult. It also
helps that I have become known as a specialist in the field so
women are coming to our clinic already interested in having these
procedures done,” she says.
In general, Dr Hamori has found that labiaplasty is the most
requested and straightforward procedure. She also performs the
‘labial puff’ with fat grafts to the labia majora for more volume or
uses Juvederm Ultra Plus. “When I perform liposuction on the
inner thighs, patients will often ask about where they can use the
fat. They usually want the fat injected into their facial areas. In
some cases, I will gently suggest that we use it to plump up the
labia majora,” she says.
Practicing in the conservative market of New England, Dr Hamori
sees a lot of menopausal women who are most concerned about
vaginal dryness. “These women are the perfect patients for
these treatments,” she says. Having used the Pelleve RF system
successfully, she recently added ThermiVa to her device collection.
“ThermiVa works for vaginal tightening and reduces stress
incontinence. It is a series of three treatments spaced one month
apart. The probe delivers controlled thermal energy externally to
the labia and internally for tightening,” says Dr Hamori.
Marketing to women
Promoting vaginal rejuvenation services requires a lighter touch
than some of the tactics aesthetic clinics typically use. Whereas
more women today are open to sharing their experiences with
injectables and skin lasers with friends and family, this is a far more
private decision that doesn’t necessarily lend itself to dinnertime
conversation. Taking an aggressive approach is more likely to elicit
a negative reaction on the part of many prospective patients and
could turn them off. Try to put yourself in the position of a woman
seeking intimate treatments and be extra sensitive to her concerns
for privacy and professionalism. Having informative patient materials,
a website landing page, blog content, and a selection of before
and after photographs available are important to make patients feel
comfortable and to educate them on what they can expect.
If you are serious about building this area of your clinic, a microsite is
a good investment. A microsite is a smaller website incorporated into
a main website, which aims to give specific information on a particular
subject. The benefit of creating an educational microsite on women’s
health issues could be, for example, that it helps position your clinic
for expertise in this category of treatments. It may be beneficial to use
Aesthetics
a different domain name for the site entirely and spend some of your
marketing budget on search engine optimisation (SEO). There is a lot
of misinformation and widely inflated claims online about how some
of these treatments work, the results that can be achieved, and if and
when surgery may be indicated. A microsite offers an opportunity to
inform consumers about your special expertise and approach to this
sensitive area of practice, and answer their questions.
Your clinic also needs to be visible to women who are searching for
these procedures online, rather than solely by personal referral. Think
about the terminology they may be using to search, and invest in the
most common keywords in your area. For example, common search
terms include; vaginal rejuvenation, vaginal tightening, vaginoplasty,
labiaplasty, labial reduction, vaginal reshaping, G-spot enhancement,
laser vaginal rejuvenation, vaginal cosmetic surgery, vagina lift, and
cosmetic vaginal procedures. Consider where you may be able to
get referrals. For example, other medical professionals who have
large populations of female patients who are of child-bearing age or
peri-menopausal, and who do not already offer similar services, may
be ideal targets. Aestheticians, massage therapists, yoga instructors,
midwives, and personal trainers may also be worthwhile to tap into.
Conclusion
Like men who suffer with erectile dysfunction, women are beginning
to feel more empowered to take steps to improve their confidence
and their sex lives. Dr Hamori believes that Viagra-like drugs for
women will go far to advance awareness of women’s health and
sexual well-being treatments. At the moment, a pink pill, developed
by Sprout Pharmaceuticals, is pending FDA approval to treat
Hypoactive Sexual Desire Disorder (HSDD) in women. In addition,
at-home devices that mimic the vaginal tissue tightening effects of
clinical treatments are currently under development and may be
available to consumers by early next year.
Wendy Lewis is president of Wendy Lewis & Co Ltd,
Global Aesthetics Consultancy. Lewis is an international
figure in the field of medical aesthetics, and is a frequent
presenter at national and international conferences. In
2008, she founded Beautyinthebag.com and has served
as editor in chief. The author of eleven books, her next, Aesthetic Clinic
Marketing in the Digital Age, will be published in the winter of 2015.
REFERENCES
1. The American Society for Aesthetic Plastic Surgery Reports Americans Spent More Than 12
Billion in 2014; Procedures for Men Up 43% Over Five Year Period (New York: The American
Society for Aesthetic Plastic Surgery, 2015) <http://www.surgery.org/media/news-releases/theamerican-society-for-aesthetic-plastic-surgery-reports-americans-spent-more-than-12-billionin-2014--pro>
2. Search results for “labiaplasty” (US: Realself, 2015) <http://www.realself.com/search/results?gsc.
q=labiaplasty>
3. PFD 101: Fact or Fiction (Washington, DC: American Urogynecologic Society, 2015) <http://www.
voicesforpfd.org/p/cm/ld/fid=134>
4. BOTOX® (onabotulinumtoxinA) Important Information (Irvine, CA: Allergan, 2015) <https://www.
botoxforoab.com/>
5. Vaginal dryness and vaginal atrophy (US, MedicineNet.com, 2015) <http://www.medicinenet.
com/vaginal_dryness_and_vaginal_atrophy/article.htm>
6. IUGA, What is urogynaecology? (IUGA, 2015) <http://c.ymcdn.com/sites/www.iuga.org/resource/
resmgr/press_packet/what_is_urogynecology.pdf>
7. Marcarelli R, ‘Female Viagra’ resubmitted for FDA approval by Sprout Pharmaceuticals (US,
HNGN, 2015) <http://www.hngn.com/articles/70077/20150217/female-viagra-resubmitted-forfda-approval-by-sprout-pharmaceuticals.htm>
FURTHER READING
Jillian Lloyd, Naomi S. Crouch, Catherine L. Minto, Lih-Mei Liao, Sarah M. Creighton, ‘Female genital
appearance: ‘normality’ unfolds’, BJOG: An International Journal of Obstetrics & Gynaecology, 112
(2005) p. 643-646.
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Aesthetics
Seasonal
Marketing:
Getting
Winter-ready
Charlotte Moreso talks winter marketing
and how to keep your patients coming
back in the darker months
Autumn and winter is traditionally a time, aside from party
preparation treatments, that business can take a dip. There
are multiple reasons why this can occur. In the autumn, reasons
include a shortage of money following patients’ annual summer
escapes, and often the chillier weather can deter people from
leaving the comfort of their homes. Over the Christmas period,
many are simply too busy to fit in appointments and, in many
cases, the financial strain of saving up for Christmas means that
treatments tend to go to the bottom of priority lists. However, if
you make treatments alluring enough and allow the names to
resonate with patient’s own skin or body issues, you are sure to
lure traffic into your clinic.
To fill your clinics with a steady stream of patients it is helpful to
divide this season’s marketing into three segments, all of which
are real call-to-action opportunities.
1. Autumn post-holiday skin repair and treatments suitable for
Autumn/Winter – September/October
2. Festive party-season preparation for late October/November/
December
3. Christmas gifting for mid-November/December
Autumn Post-Holiday Repair
Before you do anything, look at your treatments and list what your patients will be thinking about during this time. Patients’
thoughts, particularly women’s, will turn to the damage the sun may have had on their skin during the summer. As well as
worries about wrinkles, this is the time when pigmentation and sunspots may be visible. This is, therefore, the perfect opportunity to target
patients with pigmentation treatments and products, facial peels and laser treatments. Once you have your definitive treatment list, it’s
time to get creative. You need to stand-out from the other clinics and capture the attention of the consumer. The simplest way to do this is
through package names and creatively-named treatments. For example, why not create:
1. The Sundowner Package
• Pigmentation Peel – peel away pigmentation in just three treatments
• Sunspot SOS Treatment – zap away sunspots with just three laser treatments
• Squinting Wrinkle Treatment – wipe away the sun squints around the eyes with our light-based therapies
Timing: Promotion to go out the second week of September
Other autumn promotional ideas include:
2. Winter Glow/Slough Off the Summer Treatments
Take advantage of patients’ lower moods by offering the perfect pick-me-up to return a glow to their cheeks. This is a great time of year for
promoting and even discounting any glow-getting treatments. Offer treatments that slough off the summer to reveal healthy, radiant skin.
Peels, microdermabrasion and similar treatments can be included in your menu.
Timing: Promotion to go out middle/end of September
3. Laser Loves Winter
Most lasers can only be used during colder months when sun exposure is at a low and active tans don’t interfere with successful
and safe treatments. Create a ‘Laser Loves Winter’ menu, which incorporates facial and body treatments. This is the time to promote
laser hair removal to the maximum so that your patients are hair free by spring. Six treatments spaced four to six weeks apart means
they need to start their course in September.
Timing: Promotion to go out October when tans have faded
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Party Season Preparation
The festive season over Christmas and New Year is
a huge opportunity for your business. Party season
starts in November, so you have two months to capitalise on this
segment. The key areas of focus should incorporate both the face
and the body:
Face: Treatments that contour the face and leave skin radiant
Body: Treatments that target the areas on show in the little
black dress
Create a menu of suitable treatments, that could include:
• Bingo Wing Blaster: Dance without dread in your strappy dress
(radiofrequency, infrared light, ultrasound, fat freezing)
• Little Black Dress Lovely Legs Treatment: Tone and shape your
legs and get dance floor ready! (radiofrequency, fat freezing,
ultrasound)
• Decollate Renewal Treatment: Eliminate crepiness and sun
damage in this zone (lasers, peels etc)
Festive Face Treatments:
• Christmas Glow Facial: (microdermabrasion, radiofrequency,
infrared light)
• Party Peel: A lighter peel to reveal clear, glowing skin with a
more even skin tone
• Festive Lift Treatment: Firm and lift the skin on the face
(radiofrequency, mircocurrent)
Christmas Party Ready Open Day
Now is the ideal time to showcase all of your festive
treatments. I have witnessed immense success from open
days, with patients queueing to pay for bookings – but only if
you get them right.
Here’s the festive formula for filling the diary with bookings:
What: Open up your clinic for a day, or afternoon and evening to
all your patients and potential new patients, offering free taster
treatments from your Little Black Dress Ready and Festive Face
treatment menu. It’s a good idea to ensure you have a few ‘models’
to demo on in quieter spells, as this often draws an audience.
When conducting these trials, leave treatment doors open so that
people can see what is going on inside.
When: Late October or early November is a good time, but avoid
half-term, as many of your potential patients may have children and,
therefore, other commitments.
Deals: Create good value package offerings, redeemable only if
they book on the day. This ensures you get the booking right there
and then without the risk of losing their interest once they have
walked away.
Goody Bag: Contact the suppliers of your brands to donate some
mini-samples to the goody bag – everyone loves a freebie!
Adding Luxury: Serve Christmas themed canapés, sparkling wine
and healthy juices.
Showcase: Promote your Christmas gift offering.
Christmas Gifting
Although a smaller part of your winter campaign, Christmas
gifting is a good opportunity to take advantage of.
Understandably, your product offerings are likely to be more scientific
brands than pampering high-street products, but there may be some
Aesthetics Journal
How: Create a post-card sized flyer with the details and treatment
menu on the reverse that can be mailed out via the Post Office to
homes in your local area. Buy a beautiful stock shot of ladies in their
little black dresses at a Christmas party to use on the front.
• Invitation to preview/experience the festive treatments at your clinic
• Menu of complementary taster treatments
• When and where
• Times
• Special offers
• Goody bag for every attendee
• RSVP to reserve your place
Special Offers:
Great value package offers are a strategic way of attracting
bookings but it’s essential that you adhere to Keogh’s
recommendations when marketing these offers. The Keogh
Review stated, “advertising and marketing practices should not
trivialise the seriousness of procedures or encourage people to
undergo them hastily.” Avoid offering ‘buy one get one free’, ‘refer
a friend’ or doing competitions for cosmetic treatments and steer
away from time-limited deals and financial inducements.1
The Science:
You may respond to the intricacies of the technology, but the
average woman will not. She wants to know if the treatment works,
how long until she will see results, will it hurt and how much will it
cost? So don’t blind her with science and keep your chats on this
subject short and snappy, explaining the key information and, of
course, any potential risks.
Create a Consistent Campaign
Create the strapline for your festive treatment campaign and stick
to it. Use this throughout all communication. PR and marketing tools
could comprise:
• Window sticker
• Posters
• Leaflets with the treatment menu
• Roll-up banners
• Press releases
Press Release and Reviews:
Press releases to journalists: When sending out your press release,
include the aforementioned treatment menu to offer journalists
the chance to try a treatment from the festive menu. First-hand
reviews are very powerful. Journalists must be offered the full-length
treatment in order to be able to write a decent and balanced story.
Timing:
Timing is critical to capture business. You need to reach patients
with your messaging and offers in late October when they are
starting to think about the Christmas festive period. With regards
to your press release, this must go to your local press in October.
Email and post the release then follow-up a few days later to ask
them if they wanted to book in to review a treatment.
products that could be grouped together as a gift, such as a cleanser,
moisturiser and mask. Three products usually suffice for skincare gifts.
Purchase some tasteful red/gold/silver gift bags and tissue paper
so that these sets are gift wrapped and ready to go. Display one
set in front of the bag in reception. The other Christmas gift worth
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Aesthetics Journal
considering is vouchers for treatments. It may be worth contacting your
local printer to produce some simple gift voucher cards with spaces
left blank for the monetary amount or the treatment.
Timing:
Ensure you create an e-blast with these items on and send it out mid
November with a reminder in December for ‘last minute gift ideas’.
Use what you have….
Use any press coverage you receive to best effect. Consumers love
to see your name in magazines or newspapers, so scan it and post on
Facebook, Twitter and your website, or, if the piece is particularly good,
produce an email flyer and send to your patient list. Many clinics also
produce coverage books or create montages of their coverage as a
Aesthetics
poster or postcard which can be displayed in reception. Finally, it is also
worth seeing what support the PR agencies for the aesthetic device
companies you work with can offer you. They may have press releases
you can use or ideas on how to market the treatment to patients.
Charlotte Moreso is managing director of True Grace PR.
She has worked as a PR and marketing consultant in the
health and beauty industry for more than 20 years, running
highly successful campaigns for global commercial brands,
smaller UK beauty brands and in more recent years,
creating news for the UK’s leading aesthetic treatments, doctors and
clinics. Her work has won several industry awards.
REFERENCES
1. Department of Health, Review of the Regulation of Cosmetic Interventions (England: Gov.uk, 2013) <
www.gov.uk/government/publications/regulation-of-cosmetic-interventions-government-response>
In Practice
“We start to think about the New Year as autumn approaches and decide on what we want to celebrate. We host a client event
to thank our current patients for visiting us and introduce them to what’s new and what to expect next year. It’s a champagne
affair where clients can openly ask questions they have been keen to but haven’t yet, or see treatments happening that they
haven’t yet experienced. It’s an open door policy in the clinic, so everyone gets to see inside rooms. Winter equals caring and
sharing for Karidis.” Lucy Alice Martin, PR and marketing manager of Karidis MediSpa
“Winter; the point where the summer glow and holiday memories wear off and Christmas looms large. It’s a dull time of year
and rejuvenation to prepare for party season is just what the doctor ordered. I send seasonal emails to my mailing list and
target promotions aimed at getting party and photo-op ready. It’s a timely reminder for existing clients and brings the clinic back
into the mind of previous enquirers. Timing is everything and a little incentive pre-xmas is always welcome.”
Dr Renee Hoenderkamp, founder of The Non-Surgical Clinic
Plastic Surgeons
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Aesthetics Journal
to remember every detail about each one.
Ensure that either you, or another member of
staff, are adding key notes to the patient file
that can be checked before appointments, to
show that you have taken an interest in them.
Staying Positive
Plastic surgeon Mrs Elena Prousskaia highlights her
key tips for building a happy working environment
Like all practitioners, even undergoing
training requires tremendous dedication
and years of hard work, often leaving one
with little time for anything else other than
studying and working. Once you achieve
the keenly desired training post, it takes
approximately 10 years before you become
a consultant. At that point, it’s fairly common
for people to look back and reflect on all that
they’ve missed. This is not to bemoan my
position: I love my job and consider myself
extremely privileged to be able to conduct this
work. But it’s worth setting the record straight
about the road we all take to get here, and the
ways we try to stay on track once we’ve done
so. For myself, I’m careful to spend time doing
a number of things to stay happy and healthy
so that I continue to enjoy the profession that
I spent so long training for. In this article I will
briefly outline some methods that you can
employ to try to maintain a positive approach
to work.
Passion for your vocation
I believe that the best people in any
profession are the ones who emote pride and
professionalism and really love what they are
doing. If you’re doing what you love, there’s no
need to look at the clock; you’re completely in
the moment and focused on the task at hand.
One of the great things about the medical
profession is that many people share this
sense of a greater purpose. We’re here
because we want to be – so that puts all the
hard work into perspective. Various issues
can, however, affect motivation for your job;
from working too much, to problems at home
– these issues can stretch from simply a
difficult day, to a long period of disillusionment
with your profession.
If you are struggling to maintain passion in
your work, think about the aspects of your
job that give you greatest pleasure and
try to set aside time to ensure that you are
regularly able to enjoy these. For instance,
if you see one of your most loyal patients
will be visiting your clinic, you may wish
to schedule in an extra 10 minutes to the
appointment so that you can catch-up before
the treatment. This works to both remind them
how important they are to you, and to allow
yourself dedicated time to enjoy a less formal
interaction with a valued customer who truly
appreciates your time and skill.
Have a genuine interest in your patients
When I started my career, I was very
technical during conversations with patients.
Retrospectively, that seems like a very
sensible approach, but can come across as
cold. Past medical history, examination, and
treatment plans are obviously crucial topics
of discussion and we are all limited in our
time as clinics can regularly be overbooked.
The more I’ve adopted this approach,
and engaged my patients as real human
beings, the more rewarding I’ve found these
professional relationships.
For instance, when my breast cancer patients
come for their first consultation to discuss
reconstruction, they are understandably
very stressed. Asking about their interests
is as important in some respects as asking
about their medical history. I enquire about
their favourite hobby, if they love cinema or
gardening. Suddenly, the atmosphere in the
clinic changes; it feels human and enjoyable,
and makes the working day a little more
interesting. Of course with many patients
on your client list you cannot be expected
Surround yourself with positive influences
This can be difficult, but this is crucial in order
to create a working environment that is as
stress-free as possible. Consider arranging a
short staff meeting each Friday to share good
news; perhaps you’ve hit a sales target, a
member of staff has been promoted, or a new
treatment has been proving popular within
clinic. Make it one person’s responsibility to
collate any patient feedback from the week
and to share this with the rest of the team. I’d
suggest checking this yourself first for any
complaints or issues that are best dealt with
on a private basis. Not only will these meetings
help you to appreciate the achievements of
your business, but by encouraging the whole
team to share in these successes, you will
help to boost team morale.
Delegate and teach
Learning how to get the best out of every
member of the team and how to delegate
and teach can bring enormous joy to daily
life in the clinic.
It’s also important to remember that delegating
tasks can save you time in the long run to
concentrate on other aspects of your practice.
It is certainly not about working less; teaching
is hard and stressful. Of course it involves
enormous responsibility, and that is why
when you reach a senior position, you have
to be capable of taking this responsibility and
dealing with it appropriately. The best part
of my day can be when I teach a technique
to someone and feel their gratitude and
appreciation. Think about the particular
strengths of each member of your team and
discuss with him or her whether there are
aspects of their role or the wider business that
they would like to explore further. Then come
up with a plan to make this happen, including
a realistic time frame based on your availability
and achievable goals.
Compete only with yourself
Most people would recognise that my
specialty is highly competitive. My personal
rule is that if I compete, it is only with myself.
Consider the following; how can I become
better tomorrow than I was today? How can
I perform this complex procedure with even
better outcomes for my patients? Constantly
comparing yourself to others within your
specialty can lead to a great deal of anxiety,
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which can easily leak into home life if it is not
handled properly. Benchmarking success is
about seeing a big picture and enjoying the
view rather than looking at what others are
doing. I am a strong believer that if you are
good at what you do, no matter how many
people there are doing the same, there will be
a place for you in the market.
Whether you work alone or in a team, it’s
important to look outside of your practice
to build a wider support network within
the industry. Being able to call upon the
expertise of other practitioners in a similar
position to yourself, can provide a great
deal of support in good times and bad.
Attending professional meetings and joining
membership associations are good ways to
create key contacts.
Spend a lot of time on education
Throughout your career you should
continue to prioritise education, training and
professional development and consider; how
can I become the best I can be? What new
skills, including non-clinical ones, are going
to enhance my practice, the way I work with
others and the way I approach day-to-day
Aesthetics Journal
Aesthetics
tasks? Learning a new skill will not only help
your business to continue to grow, but can
also serve to re-ignite passion in your work.
Handling difficult situations
Having to manage a patient complaint or deal
with a tricky situation with a member of staff
can be extremely stressful. To me, dealing
with a difficult situation is about honesty and
respect. The capacity to work well with others
is not about being weak or keeping your head
down. It is about being there when problems
occur, talking to people and being humble
enough to apologise if it is your fault.
People will like you because they feel safe
with you, because they know they can count
on you and feel that you care. Building this
type of reputation can be extremely difficult in
our highly stressful and demanding jobs, but
once you get there, you suddenly find yourself
surrounded by people who smile and say
thank you for your hard work.
Keep levels of care to the highest standards
This final rule is simple and crucial; be fully
present in the task that you are doing at
each moment. We all have busy lives and
having a million worries on your mind is
human. When I am with a patient, however,
I obligate myself to forget about outside
concerns and try to concentrate on doing
my best right here, right now. I always
advise my juniors that there are no small
details in our profession. Acute attention to
every single detail before, during and after
treatment is key not only to a good result,
but also to having a happy patient. And what
else can make your day better than a patient
attending the follow-up with a huge smile,
expressing their appreciation for your care
and the treatment that has changed their
life? High levels of care can also reduce the
risk (and stress) of complications, and ensure
the patient comes back time and time again.
Mrs Elena Prousskaia is
a board certified consultant
plastic, cosmetic and
reconstructive surgeon,
a member of the British
Association of Plastic Surgeons (BAPRAS),
Royal College of Surgeons, London (FRCS
Plast) and European Board of Plastic
Surgeons (EBOPRAS). Mrs Prousskaia runs a
cosmetic surgery practice in the South East
of England.
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Aesthetics Journal
“My drive for coming
to work is producing
incredible results and
making someone feel
amazing about themself”
Dr Kuldeep Minocha details his journey from GP
partner to successful aesthetic practitioner
With more than 3,500 current patients over four clinics and a fourweek waiting list, Dr Kuldeep Minocha is one of many in-demand
aesthetic practitioners. Yet, unlike those who have dedicated their
entire medical career to aesthetics, his love and devotion to the
specialty only began in 2006. “I’d been a GP partner for 16 years after
studying medicine at Southampton University in 1986. But working for
the NHS was changing a lot,” Dr Minocha says. “It wasn’t about the
doctor/patient relationship anymore or providing the best standard
of care for the person sitting in front of you – things were changing,
it became more about rationing care.” As such, Dr Minocha tried
to divert his expertise into something else and find a new vocation
within medicine. “I did some work with Paul McKenna, I was one of
his weight-loss consultants. I also became a diabetic specialist. I did
things I could devote my time and energy to,” he explains. It wasn’t
until he began a botulinum toxin and dermal filler course in 2006,
however, that he found his niche. “I instantly thought ‘wow!’ this is
interesting. After a three-hour course on each, though, I didn’t have
the confidence to go out and inject someone,” he says. Instead Dr
Minocha started attending Q-Med’s (now Galderma) injectable courses
and, in that first year, turned up to approximately 20 training sessions.
“One of the trainers even joked, ‘Do you know that you could actually
give these courses yourself now? Why are you here?’” he laughs,
adding, “I told her, ‘Because I want to be the best I can be, I want to
learn as much as possible.’”After building his confidence, Dr Minocha
began decreasing his time spent in general practice and focused
more on establishing his aesthetic practice. Three years ago he
joined Absolute Aesthetics, and as a result of that, was exposed to the
world of public relations. “I built-up my client base on word-of-mouth
recommendations and never needed to do any sort of promotion,”
Dr Minocha explains, adding, “I’m a very old-fashioned GP at heart;
I’m not a business man or entrepreneur and before I joined Absolute
Aesthetics I didn’t even have a business card! I warned the team,
‘Don’t expect me to be doing this and that (promotion), just give me
my patient and I’ll do my best for them.’” Ethics are very important
to Dr Minocha and, he claims, no amount of money or prestige can
persuade him to treat patients who don’t need it. “I once had a lady
who came from Abu Dhabi, jumped straight on the couch and said,
‘I’ve come for my Botox! I’ve just flown over as my daughter’s getting
married in six weeks and I want to look my best.’” He explains that
he had only treated her ten weeks ago and felt it was too soon for
her to undergo more treatment, as she simply did not need it. “I sat
the patient down, we looked at her mirror reflection together, as
well as before and after photographs from her last treatment. I then
reassured the patient that the treatment was working and it would be
unnecessary for her to have any more treatment so soon after. She
respected my honesty and joked, ‘Oh, you and your ethics!’ Patients
often lose perspective quickly so when an opportunity such as this
presents itself, it’s important for practitioners to act appropriately and
do what is best for the patient.” Dr Minocha enthuses that taking part
in the Galderma Proof in Real Life Campaign, which aims to build
consumer trust in aesthetics, has been his greatest achievement. The
campaign involved ten identical twins, with one sibling from each pair
been treated with either Restylane and Restylane Skinboosters, or just
one of the products, with the aim of demonstrating the natural-looking
results that can be achieved through aesthetic treatment. “It was an
amazing, emotional journey. Actually seeing people in real-life, in threedimension, with their untreated twin next to them, getting an idea of
the quality and texture of their skin – that was remarkable!” Reflecting
on his career, Dr Minocha says he wouldn’t do anything differently,
“Since the age of seven, all I wanted to be was a doctor. I loved what
I did within the NHS, but now I get to see people who choose to see
me, I get to help them feel great about themselves. I’m not driven by
money; my drive for coming to work is producing incredible results
and making someone feel amazing about themself. If I get paid or not, I
don’t really care. It’s very much about what we’re doing for the patient.”
Do you have an ethos or motto that you work by?
Always be true to yourself and try to be as objective as
possible. Always have the strength to say ‘no!’
Do you have an industry pet hate?
Huge lips!
Do you have any words of advice for people who are
looking to get into the industry?
Master one or two skills, rather than trying to be a jack-ofall-trades.
What aspects of the industry do you enjoy the
most?
Being involved in a journey that is able to help someone’s
self confidence and how he or she feels about themselves
is so rewarding. Most of my patients are women, most are in
their 40s and most of them are going through a phase in life
where they’re trying to redefine themselves as to who they
are. Being in this industry creates such positive energy; you
do a treatment for somebody and when they come back for
their review they look amazing and they feel amazing.
COMPOSED • CONFIDENT • MY CHOICE
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Now approved for
crow’s feet lines
Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product
Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU 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) and lateral periorbital lines seen at maximum smile
(crow’s feet 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. Glabellar Frown Lines: 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. Injections near the levator palpebrae superioris and
into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular
injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL
(4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus
major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over
65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to
any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton
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. Should not be used during breastfeeding. 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). Glabellar Frown
Lines: 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, 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). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema,
dry eye. General disorders and administration site conditions; Common: injection site haemotoma.
Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema
(also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness
have been reported. 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: August 2014. Further information
available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire
WD6 3SR.Tel: +44 (0) 333 200 4143
Adverse events should be reported. Reporting forms and information can be found at
www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at
the address above or by email to [email protected] or on +44 (0) 333 200 4143.
1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from:
URL: http://www.medicines. org.uk/emc/medicine/23251.
2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the
treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in
Aging 2013; 8: 449-456.
3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared
with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010;
36: 2146-2154.
4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily
practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58.
5. Data on File: BOC-DOF-11-001_01
Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA.
1182/BOC/OCT/2014/LD Date of preparation: October 2014
PURIFIED1• SATISFYING2,3,4 • CONVENIENT5
Botulinum toxin type A
free from complexing proteins
@aestheticsgroup
Aesthetics Journal
The Last Word
Dr Martin Godfrey discusses the need
for clinical trials in aesthetic medicine
Rightly so, regulatory requirements for testing new pharmaceutical products
are rigid. They must be assessed using strict quality standards and require a
significant investment of time and money.
Of course there are very good reasons why pharmaceuticals are so tightly
regulated. Since the early 1960s, newspapers have been filled with hundreds of
apparent panaceas that have failed to transpire. Many pharmaceutical companies
are becoming hesitant to develop new products from the expense and fear that, if
they get something wrong, there is a chance they could conjure a new thalidomide
epidemic. For cosmetic companies, on the other hand, probably the worst thing that
could happen is that somebody develops a nasty rash to one of its new skincare
products. As such, we see new cosmetic products on the market almost every day,
with many manufacturers appearing to take very little regard to the importance
of clinical trials. They claim their product can treat all sorts of aesthetic concerns,
with little or no proven scientific evidence to support them. Many will use ‘sciencesounding’ terms and a bucket load of anecdotes to convince consumers that their
products are worthy of their hard-earned cash. Not only do some companies market
such products with unsubstantiated claims, they also often advertise them as having
no side effects or downtime, which is not always strictly the case.
In addition to this, more and more cosmetic products are being developed that claim
to have medicinal properties and significant health benefits. As their name suggests,
the categories of ‘cosmeceuticals’ and ‘nutraceuticals’ are prime examples of this.
By definition, nutraceuticals are a ‘food or part of a food that allegedly provides
medicinal or health benefits, including the prevention and treatment of disease’.1
In addition, the dictionary definition also states that a nutraceutical may be a naturally
nutrient-rich or medicinally active food, such as collagen, garlic or soybeans.2 Then
there are cosmeceuticals; marketed as cosmetics but as the definition states, they
are, ‘A cosmetic product claimed to have medicinal or drug-like benefits’.3
As such, this leads me to ask questions; if these products really do deliver health
benefits, then, like drugs, shouldn’t they be subject to the same rigorous testing
that pharmaceuticals have to go through? If they exhibit such powerful properties
like drugs, won’t they have side effects like drugs? And, as a result, shouldn’t they
be prevented from being advertised to the public? Well, for me, the answer is no.
Nutraceuticals are, after all, just foods. When was the last time your evening meal had
to go through a randomised controlled trial? Have you ever seen a health warning
on your daily fruit and veg? There has to be a line drawn between what is a drug and
what is a food and, for the moment, nutraceuticals sit on the non-drug, less-regulated
side of the fence. But that should not mean that their manufacturers can relax into the
soft world of the cosmetics industry and just tip their hat to the clinical trial process.
We are all aware of the limp attempts (or non-attempts) that a great deal of
companies in the cosmetic field make to support their claims for efficacy.
They partake in tiny trials – often including less than a
dozen users; employ purely subjective testing – such
as simply filling out a questionnaire with vague or
non-existent end points; and include questionable
photographic ‘evidence’ of success in their marketing
campaigns. I am not trying to argue that nutraceuticals
should be made to undergo the sorts of testing that
drugs are made to go through. More that if they are
ingested, and if they do contain biologically active
molecules, then surely the manufacturers have a duty
to their customers to test them rigorously?
In my opinion, companies that take research and
development (R&D) seriously in the world of ‘nutracosmeceuticals’ are few and far between. Even wellknown, household name companies (including pharma
companies) have realised the enormous potential that
these foods represent in generating profit within the
aesthetic market and, as a result, should be taking their
research responsibilities seriously. Simply conducting
a search on PubMed or other scientific databases will
show that only a small number of trials are listed.
This situation cannot and hopefully will not continue.
The regulators are finally waking up to the fact that
they need to protect the public and, as such, are
demanding marketing claims are substantiated with
statistically robust studies. Maybe the best example is
the ASA and the US Federal Trade Commission (FTC).
There is some suggestion that these organisations
are now looking closely at claims made by
nutraceutical and cosmeceutical companies and are
no longer accepting six-patient, questionnaire-driven
studies as proof of an effect.4 While the companies
should focus on sharing honest marketing claims,
and regulators should take their monitoring duties
seriously, we as practitioners should also take some
responsibility for the widespread problem. Rather
than just reading the marketing hype and watching
some spurious, animated, mechanism-of-action
video, we need to dig below the surface. We have
to ask; what trial evidence supports the claims being
made? How can the company prove the product
it’s distributing is safe and effective? We need to do
our own due diligence to protect our patients from
being misled by over-exaggerated or false marketing
claims. And, as healthcare professionals, if the
products don’t have the research to back them up,
we shouldn’t be using them.
Dr Martin Godfrey is head of research
and development at MINERVA Research
Labs. A trained medical practitioner,
Martin has a wealth of expertise
in health and nutritional product
marketing. His main responsibilities are gaining
scientific verification for Minerva’s products through
overseeing clinical trials and obtaining the support of
medical professionals.
REFERENCES
1. www.medicinenet.com/script/main/art.asp?articlekey=9474
4. mthink.com/intersection-authority-fda-ftc-nutraceutical-regulation/
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Dr. Catalin Calinoiu
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Experience all the benefits of VYCROSS™ technology.
Treat various areas of the face using only 3 products.
It’s that versatile.
Instructions and directions for use are available on request.
Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK
Date of Preparation: August 2014 UK/0880/2014

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