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VOLUME 1/ISSUE 6 - MAY 2014
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Lip anatomy CPD Article
Sharon King discusses the anatomy and
physiology of the lower face for treatment of
the lips. CPD accredited article
Combination
treatments
Leading aesthetic
practitioners
discuss combination
treatments for body
contouring
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Data protection
SPF Debate
Dr Natalie Blakely
and Mandy Luckman
explore the legal
and ethical issues
with storing patient
data
Dr Tiina OrasmaeMeder and Deborah
Forsythe on the
benefits and
limitations of using
sunscreen
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Contents • May 2014
INSIDER
06News
The latest product and industry news
14On the Scene
Out and about in the industry this month
17 News Special: Anti-Aging Medicine World Congress
We report on the AMWC in Monaco, including the Allergan Medical Institute symposium
18News Special: American Academy of Dermatology Meeting
Dr Nick Lowe and Wendy Lewis share their thoughts on the 72nd CLINICAL PRACTICE
Lip augmentation Page 26
annual AAD meeting in Denver
CLINICAL PRACTICE
20Special Feature: Combination Treatments
A look at the best treatment combinations for body contouring
26CPD Clinical Article
Sharon King discusses the anatomy of the lower face for lip augmentation
32Treatment Focus
Dr Tiina Orasmae-Meder and Deborah Forsythe debate the benefits and limitations of using SPF sunscreen
38Clinical Focus
Leading practitioners discuss the best methods for treating pigmentation problems using skincare
44Techniques
Dr Carolyn Berry shares her experiences in treating caesarean scars and stretch marks
IN PRACTICE
Data protection Page 50
46Spotlight On
We learn more about Eternogen, the new collagen dermal filler portfolio coming to the UK
48Aesthetics Awards Special Focus
Clinical contributors
The latest news from the upcoming Aesthetics Awards 2014
Dr Nick Lowe is president of the BCDG, professor
of dermatology and a consultant dermatologist
with over 30 years of experience who practises in
London and California
IN PRACTICE
50Data Protection
Wendy Lewis has authored 11 books on anti-ageing
and cosmetic surgery, and regularly lectures internationally. She is the president of Wendy Lewis & Co Ltd
and founder/editor in chief of Beautyinthebag.com
Dr Natalie Blakely and Mandy Luckman on storing patient data legally and ethically
52Treatment Portfolio
Wendy Lewis explains why body shaping procedures will benefit your clinic
Sharon King is a director and clinical nurse specialist at the Cosmedic Skin Clinic, board member of the
British Association of Cosmetic Nurses and member
of the Aesthetic Complications Expert Group
56Marketing
John Castro on how using videos effectively can attract potential patients
Dr Tiina Orasmae-Meder is a dermatologist and
the founder of Meder Beauty Science, based in Switzerland, who also works at Iris Brand Vigilance
to guide cosmetic safety
60HR
John Sellers discusses the importance of nurturing your workforce
62In Profile
Deborah Forsythe is a medical aesthetic specialist
and member of the Allergan faculty responsible for
validating practitioners on injection techniques. She
specialises in non-surgical dermal facial rejuvenation
We speak to Mr Chris Inglefield about challenging the perception of aesthetic procedures
Dr Carolyn Berry is the founder and medical
director of the Firvale Clinic, and also practises as a
research fellow and general practitioner
64 The Last Word
Dr Darren McKeown promotes collaboration between surgeons and aesthetic professionals
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Editor’s letter
I am delighted to be taking over as Editor of
Aesthetics journal. Having been intricately
involved in medical aesthetics since it first
became a professional discipline, I have brought
this experience to my work with the Aesthetics
Amanda Cameron
Conference and Exhibition (ACE) and as part of
Editor
the journal Editorial Advisory Board. I now look
forward to leading the expanding editorial team and working closely
with our valued contributors and our Advisory Board, which this month
welcomes two new members; Dr Raj Acquilla and Mr Dalvi Humzah.
As the journal continues to move forward as the leading publication for
medical aesthetic professionals, we are honoured that two more highly
respected and experienced members of the profession have chosen
to join this select group. The knowledge, expertise and advice of both,
along with our other board members, will be invaluable in continuing our
work to create a safer and better industry for patients. In April, we were
pleased to be able to attend the Anti-Aging Medicine World Congress
in Monaco, where new products and treatments were showcased
alongside insightful and educational lectures and presentations from
international experts. Our report from this congress is featured on p. 17,
along with thoughts from Dr Nick Lowe and Wendy Lewis regarding
the American Academy of Dermatology meeting in Denver, which took
place in March.
This issue, our focus revolves around ‘The Sun’. For our special
feature, we spoke to practitioners about which treatments they use
in combination to produce the best bespoke solution for patients
seeking body contouring. Dr Carolyn Berry shares her advice on the
treatment of scars such as stretch marks and caesarean scars, which
are a particular concern to patients during the summer months. We also
feature a fascinating debate regarding the use of SPF, with Deborah
Forsythe supporting the use of sunscreen profusely, whilst Dr Tiina
Orasmae-Meder argues that it can be unnecessary in certain climates
and seasons. Aesthetic nurse Sharon King has provided our CPD article
for this month, which details the anatomy of the lip and perioral area in
relation to lip augmentation procedures. Our business development
articles this month include a guide from Wendy Lewis in building a body
shaping clinic and key advice from Dr Natalie Blakely and lawyer Mandy
Luckman regarding data protection. Our goal for the journal is to support
both established products and innovation through medical education.
We aim to provide impartial, credible and evidence based information to
support good clinical decisions. This also involves you, and we will work
hard to ensure that the journal continues to be a forum for expressing
quality opinions and mature debate in order to continue to raise the
standards in our industry. If you are interested in contributing to a future
edition of Aesthetics journal, or would like to share your thoughts and
comments on this issue, contact us on [email protected]
Editorial advisory board
We are honoured that a number of leading figures from the
medical aesthetic community have joined Aesthetics journal’s
editorial advisory board to help steer the direction of educational,
clinical and business content
Dr Sarah Tonks is an aesthetic doctor and previous
maxillofacial surgery trainee with dual qualifications in both
medicine and dentistry, who fell in love with the results
possible through minimally invasive methods. Now based
at Beyond Medispa in Harvey Nichols, she practises cosmetic
injectables and hormonal based therapies.
Dr Mike Comins is president and Fellow of the British
College of Aesthetic Medicine. He is part of the cosmetic
interventions working group, and is on the faculty for the
European College of Aesthetic Medicine. Dr Comins is also
an accredited trainer for advanced Vaser liposuction, having
performed over 3000 Vaser liposuction treatments.
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).
Mr Dalvi Humzah is a consultant plastic, reconstructive and
Dr Nick Lowe is president of the BCDG and a consultant
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.
dermatologist with over 30 years of experience who practises
in London and California. Dr Lowe is Clinical Professor of
Dermatology at the UCLA School of Medicine in Los Angeles,
as well as director of a clinical research company specialising in
skin ageing.
PUBLISHED BY
EDITORIAL
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Amanda Cameron • Editor
T: 0207 148 1292 M: 07810 758 401
[email protected]
Sarah Dawood • Journalist
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DESIGN
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Chiara Mariani • Designer
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aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic
surgeon in the NHS for 15 years, and is currently a member of the
British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Mr Humzah lectures nationally and internationally.
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ARTICLE PDFs AND REPRO
Material may not be reproduced in any form without the
publisher’s written permission. For PDF file support please
contact Craig Christie; [email protected]
© Copyright 2013 Aesthetics. All rights reserved. Aesthetics
Journal is published by Synaptiq Ltd, which is registered
as a limited company in England; No 3766240
DISCLAIMER: The editor and the publishers do not necessarily agree with the views
expressed by contributors and advertisers nor do they accept responsibility for any errors in the
transmission of the subject matter in this publication. In all matters the editor’s decision is final.
Insider
News
Talk Aesthetics
What you’re talking about this month
#AMWC
Chytra V Anand / @drchytra
At #AMWC2014 the world anti ageing
congress @#monaco. My talk on
#radiofrequency for #skin tightening... —
at Forum Grimaldi.
#Stats
Aesthetic Source / @AestheticSource
How much do u spend on #skincare?
Women in their Sixties now splash out £235
a year!
#Bestpractice
Sharonbennettskin / @sharonbennettuk
@JAestheticNurse @aestheticsgroup @
Consulting_Room @CosmedicCoach
Who tells their patients which toxin they’re
administering? Always.
#Nutrition
Dr Nick Lowe / @DrNickLoweSkin
If you’re getting fewer than 20 grams of fat
a day, your body may not absorb enough
vitamin A, which can lead to premature
ageing.
#BJNawards
Emma Davies / @daviesemma5
@BJNursing @Nurse_A_Baker
@BACNurses fantastic night at BJN
awards. Congrats Adrian, well deserved
winner Aesthetic nurse of the year.
#SPF
Dermalogica UK / @DermalogicaUK1
Increases in #pollution levels can cause skin
ageing. Use an #SPF with #antioxidants to
combat both UV and free radical damage.
#dermalogica
#Research
Debi@cosmeticsupport /
@cosmeticsupport
If the NHS does not provide cosmetic
surgery, where will reliable scientific
evidence come from
#Treatment
Dr Sarah Shah / @DrSarahShah
#BeautyFact The non-surgical neck
rejuvenation is a great alternative to surgery.
Regain your youthful neck with #Botox and
dermal fillers.
To share your thoughts follow us on
Twitter @aestheticsgroup, or email us at
[email protected]
6
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
Editorial board
Mr Dalvi Humzah and Dr Raj
Acquilla join the Aesthetics
Editorial Board
Mr Dalvi Humzah and Dr Raj Acquilla are this month
welcomed as official members of the Aesthetics editorial
advisory board. Mr Humzah is a consultant plastic,
reconstructive and aesthetic surgeon based at the
Plastic Dermatological Surgery. A former NHS Consultant
Plastic Surgeon, Mr Humzah currently maintains a plastic
surgery private practice and is a key opinion leader for
Dr Raj Acquilla
several aesthetic companies.
Dr Acquilla is a cosmetic dermatologist with over 11
years experience in facial aesthetic medicine. He is UK
ambassador, global key opinion leader and masterclass
trainer in the cosmetic use of botulinum toxin and dermal
fillers. Of the appointment Dr Acquilla said, “I am delighted
to be joining the Aesthetics editorial advisory board at
such an exciting time for the journal. Leading Aesthetics
forward in its new clinical direction, my role will be to advise
Mr Dalvi Humzah
and support the publication in order to ensure that we
are delivering content of the highest quality and medical authority to our readers.
Aesthetics and its board members are at the forefront of developments within the
medical aesthetics industry, and I look forward to being a part of this journey.”
Industry
Sinclair IS Pharma acquires
global rights to Ellansé
Sinclair IS Pharma
announced that the
company has entered
into agreements
to acquire the
global rights to
Ellansé, a combined
dermal filler and
collagen stimulator
product range. The
international speciality
pharmaceutical
company acquires the global rights to Ellansé through the acquisition of AQTIS
Medical BV. The addition of the Ellansé brand will complement Perfectha,
Sinclair’s range of hyaluronic acid fillers, acquired in January 2014.
Chris Spooner, Sinclair CEO, commented, “Facial aesthetics is one of the
fastest growth segments in dermatology and creating a global presence is
a key strategic objective for Sinclair. We expect Ellansé’s innovative product
range and emerging market bias, in combination with our existing aesthetics
business, to add materially to Sinclair’s overall growth rate and market
presence in this exciting field.” This financial year, over one third of Sinclair’s
revenues are expected to come from aesthetics. The impact of recent
acquisitions including Ellansé means that this is expected to rise to around 50%
in the year ending 30 June 2015.
Aesthetics | May 2014
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
Insider
News
Acne
New website launched to provide post-acne support
A new acne scar resource website has
been launched for people suffering with
acne scarring. ascarfreeme.ca aims to help
people manage the emotional and physical
impacts of the aftermath of acne. “Beyond
the physical effects, acne scars can impact
self-esteem and self-confidence,” said a community manager for the site. “‘A Scar Free Me’
was started to support people, connecting
them with a community for advice and help.”
The website offers free online resources, from
articles on the latest treatments to blog posts
on improving self-esteem. “Millions of people
suffer from acne scars every day, often feeling
socially isolated and without hope,” said
dermatologist Dr. Ruth Tedaldi, member of the
Research
Clinical trial indicates
vitamin C makes skin 33%
firmer
A four-week placebo-controlled clinical trial conducted by Aspen
Clinical Research has demonstrated that liposomal vitamin C gel
Altrient C significantly improved skin elasticity. The trial included
60 participants with non-firm ageing skin aged between 31 and 65+.
50% took three sachets of Altrient C a day for four weeks and 50%
took a placebo. Skin elasticity and firmness were measured at three
points throughout the trial.
Results presented that participants using Altrient C showed
improvement in skin firmness and elasticity compared to participants
taking the placebo. Those who took Altrient C showed an increase
in skin firmness of 32.7% after four weeks. Following the four weeks,
100% of participants who consumed Altrient C also reported an
overall improvement in their skin, 50% of which noted greater
hydration, 43% thought they looked younger and 33% thought their
skin appeared more nourished. “This research has demonstrated a
clear link between the skin ageing process and vitamin C via dietary
American Academy of Dermatology and a
contributor to ascarfreeme.ca. “The first step
in treating acne scars is to understand the
skin condition, and through ascarfreeme.ca,
visitors can quickly get information on how
these scars occur, what to expect at your first
acne scar consultation and access to many
other resources,” she said.
supplements,” said
Jonathan Orchard,
director of Abundance
& Health, distributors of
the product. “However,
up to 85% of the
vitamin C contained in
tablets and powders
is destroyed in the
digestive system. Altrient C vitamin C is encased in a tiny bubble
of protective fatty acids. This safeguards the vitamin through the
harsh digestive system and the body’s absorption barriers, into
the bloodstream, where it is transported through the body.” Danny
McCamlie, lead clinical scientist and principal investigator at Aspen
Clinical, said, “With an increase of 15.1% and 32.7% in skin firmness,
following two and four weeks respectively, Altrient C achieved results
that, in our experience, some topically applied creams fail to achieve
following eight weeks of use.”
“Formation of free oxygen radicals is widely accepted as a pivotal
mechanism leading to skin ageing, and the production of free radicals
increases with ageing,” said Dr Sanjay Rajpara, dermatologist and
cosmetic skin doctor. “Vitamin C is an important part of the body’s antioxidative defence mechanism. This product has a potential to become
one of the first line products for anti-ageing.”
Awards
Sponsors announced for the Aesthetics Awards 2014
The first sponsors for the Aesthetics
Awards 2014 categories have been
announced. 3D Aesthetics will present
the 3D-lipomed Award for Best New
Clinic, UK and Ireland; Dermalux will
present the award for Best Clinic South
England; Church Pharmacy will present
the award for Best Clinic North England;
Institute Hyalual will present the award
for Aesthetic Nurse Practitioner of the
Year; Aesthetic Source will present the
prestigious Lifetime Achievement award
whilst Healthxchange Pharmacy will
present The Janeé Parsons Award for
Sales Representative of the Year.
Roydon Cowley, managing director of
3D Aesthetics said, “3D-Aesthetics are
Aesthetics | May 2014
delighted to sponsor the Aesthetics
Awards 2014. We will be thrilled to present
the 3D-lipomed Award for Best New Clinic
to the deserving winner.” Of The Janeé
Parsons Award for Sales Representative
of the Year, chairman of Healthxchange
Pharmacy Dr John Curran said, “Sales
and marketing people are the backbone
of any good business; great staff make
great businesses work. Janeé was an
exceptional example of a colleague
who gave her all. Each one of you need
recognition and we at the Healthxchange
would like to honour the very best
amongst you. Good Luck!” Details of how
to enter the Awards are found on pages
48 and 49 of the journal.
7
Insider
News
@aestheticsgroup
White paper
Aesthetics Journal
Aesthetics
aestheticsjournal.com
Industry
National Special Procedures
Register proposed in Wales
The Welsh government has put forward a proposal for a
mandatory register for practitioners offering cosmetic piercing,
tattooing, semi-permanent skin colouring, acupuncture and
electrolysis. The National Special Procedures Register would require
practitioners and businesses in Wales to meet specified standards
to obtain registration, and then practice to specific standards to
maintain this registration.
Part of the requirements to achieve this would include a standardised
pre-and post-consultation with patients and the maintenance of
records. Pre- and post-consultation at a minimum would include
whether the person receiving treatment had any medical problems
that would put them at greater risk resulting from treatment, how the
treatment would be carried out, including potential complications, and
how to look after any wounds in order to prevent infection occurring.
Other points in the proposal include all practitioners and businesses
being required to register in order to practice, practitioners and
businesses being required to pay a fee to register and the inclusion
of a specified ‘fit and proper’ person test for all practitioners and
businesses. There would also be cleanliness standards based on
infection control advice and industry best practice. A practitioner or
business could also be removed from the register for a specified
period of time and would be unable to practice in that time period for
offences such as failing to meet cleanliness standards or not following
pre-and post-consultation requirements.
A Welsh Government spokesperson said, “Over the last decade,
cosmetic procedures such as body piercing and tattooing have
become increasingly popular. However, there are known health risks
connected to these procedures if they are carried out in an unhygienic
fashion. It is therefore important that practitioners have safe working
practices, and that good infection control practices are followed at all
times, so that customers are protected. Some people taking up these
procedures are often more vulnerable than others, which is why we’re
proposing to make it compulsory for consultation with customers
which would include, for example, a requirement to check whether
the person has any health problems that may put them at greater
risk as a result of the procedure.” The proposal, released on April 2,
was published in a White Paper entitled, ‘Listening to you: Your health
matters. Consultation on proposals for a Public Health Bill’. The Welsh
Government is currently inviting responses to the proposal, which
should be submitted by June 24.
Winner announced for BJN
Aesthetic Nurse of the Year
Oxfordshire aesthetic nurse Adrian Baker has won Aesthetic
Nurse of the Year at the British Journal of Nursing Awards
2014. The awards ceremony, which took place on March 21 in
London, was set up to celebrate the contribution of individual
nurses to the development of the profession as a whole. Nurses
from across the country were in attendance.
Mr Baker, who qualified as a nurse six years ago, became an
independent nurse in 2011 and immediately started training to
become an aesthetic nurse specialist. He then trained for an
independent nurse prescribing qualification and now works
as an aesthetic nurse at the MBNS and Qutis Skin clinics in
Oxfordshire. “I was incredibly honoured to have been nominated
in the first place,” said Mr Baker. “To have won the award was
simply breath taking. The best part about this award is that it is
demonstrating a recognition of aesthetic nursing as a profession,
whilst celebrating excellence within all nursing specialisms.”
Industry
Aesthetics journal team
welcomes new contributors
The Aesthetics journal is proud to welcome new members to
its contributing editorial team. Ruth Donnelly started her writing
career on Brand New You, a consumer magazine focused on
cosmetic enhancement.
In 2009 she moved to The Cosmetic Surgery and Aesthetics
Magazine (later to become The Cosmetic Surgery Guide), before
becoming editor in early 2010. More recently, she has been
contributing as a health writer for a number of publications. Also
joining the team are Suzi Lewis-Barned and David Jacobs. Suzi
is a freelance writer, editor, researcher and healthcare journalist
with more than 20 years experience. Producing commissioned
content across all print and digital media, Suzi’s expertise is
also in demand for the fourth year running as a judge at the
2014 Communiqué Awards for Writing Excellence. David is the
senior copywriter and a partner at Lewis-Barned & Associates.
A published author and report writer and editor, he also trains
others to improve their writing skills.
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Aesthetics | May
2014
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BEL093/0314/FS Date of preparation: March 2014
@aestheticsgroup
Aesthetics Journal
Aesthetics
Insider
News
aestheticsjournal.com
Vital Statistics
Training
Dr Raj Acquilla launches online
training academy
Dr Raj Acquilla is set to launch his new
online facial injectables training academy,
the RA Academy, in May 2014. The website
will comprise a series of video masterclasses
demonstrating various facial injectable techniques,
from common procedures such as frown lines to more advanced strategies,
including some of Dr Acquilla’s signature techniques.
The RA Academy has been set up as both a training tool and a reference
for practitioners to call upon during their day-to-day practice. As well as the
online masterclasses, members will be offered the opportunity to attend an
annual live symposium. Dr Acquilla said, “Through continuing to learn and
constantly updating our knowledge and technical application we can deliver
safe, consistent and exceptional results that will delight our patients and help
to grow our practices.”
There are over 4000
aesthetic nurses in
the UK
4000+
British Association of Cosmetic Nurses
10%
Over
of women
surveyed said stretch marks
were their biggest skin dislike
Syneron-Candela, Censuswide survey
Conference
ACE 2015 is announced
The American Society for
Aesthetic Plastic Surgery (ASAPS)
The Aesthetics Conference and Exhibition 2015 will take place on
Saturday 7 and Sunday 8 March 2015 at the Business Design Centre,
London. This follows the success of ACE 2014, where packed lectures,
clinical demonstrations and business workshops provided helpful guidance
to practitioners in best practice, new innovations and business development.
Post-event feedback further confirmed the popularity of the conference
as a vital learning tool for practitioners. One delegate said, “The event had
wonderful lectures aimed at the right level, and a great environment to learn
from colleagues.” Another delegate praised the exhibition, saying it was a
“great opportunity to meet some truly interesting suppliers who were very
helpful.” Based on the feedback, work has already begun on an even larger
educational programme, featuring more masterclasses and expert clinic
demonstrations. With over 90% of delegates from this year’s event interested
in attending again, and key suppliers already requesting exhibition stand
space, ACE is set to be the major conference for aesthetic professionals in
2015. Registration will open later this year.
Injectables
TSK Laboratories launch new
syringe for botulinum toxin
injections
TSK Laboratory Europe BV has launched the 3dose syringe, the
company’s new instrument for use in botulinum toxin injections. The
product was launched at the AMWC 2014 meeting, Monaco, and is
expected to be commercially available in May 2014.
The 3dose syringe has an adjustable clicker system, which provides a
precise dose injection of 0.025ml, 0.04ml or 0.05ml. TSK claim that this
precision means that there is no risk of over- or under-injection, allowing
practitioners to administer small doses accurately and consistently. Each
syringe comes packed with two 33G 13mm needles, which are 22% thinner
than a standard 30G needle and aim to reduce discomfort for patients.
Aesthetics | May 2014
non-surgical
cosmetic
procedures
were carried
out in the US
in 2013
More than five billion dollars was
spent on non-surgical procedures in the
US in 2013
The American Society for Aesthetic Plastic Surgery (ASAPS)
One in 20 patients
who undergo nonsurgical treatments
self-administer
Transform Cosmetic Surgery Group,
Botox Survey
Over 14% of people surveyed do not
want anyone to know they have had line
and wrinkle smoothing treatments
Transform Cosmetic Surgery Group, UK Wrinkle Smoothing Survey
40% of men have
noticeable hair loss by
age 35 The Belgravia Centre
Non-surgical facial rejuvenation
procedures are the fastest growing
segment in cosmetics, up almost 6%
annually
Iovera Beauty, London Beauty Survey
9
Insider
News
@aestheticsgroup
Events diary
20th September 2014
British College of Aesthetic Medicine BCAM Conference 2014, London
www.bcam.ac.uk
25th - 26th September 2014
The British Association of Aesthetic Plastic
Surgeons - BAAPS Meeting 2014, London
www.baaps.meetings.org.uk
3rd October 2014
British Association of Cosmetic Nurses BACN Meeting 2014, London
www.cosmeticnurses.org
6th December 2014
The Aesthetics Awards 2014, London
www.aestheticsawards.com
Radiofrequency
Syneron’s Sublative
technology gains CE
mark clearance for
stretch marks and
acne scars
Syneron Medical Ltd has announced that its
Sublative technology has received a CE mark,
clearing it for the treatment of stretch marks and
acne scarring. Promoted as an anti-ageing treatment,
Sublative uses fractionated bi-polar radiofrequency
to generate deep dermal heating and elicit a woundhealing response, with the aim of tightening and
rejuvenating the skin.
With stretch marks affecting an estimated 95% of
women and up to 85% of adolescents suffering from
acne, the company expects that the new treatment
protocols, which will be available on all of the Sublative
compatible systems, will expand the appeal of the
technology to a wider market.
“We have received very positive physician and
patient feedback on the Sublative technology
since its introduction in 2009,” said Amit Meridor,
CEO of Syneron. “This patented fractional bi-polar
radiofrequency technology delivers excellent
outcomes with little to no downtime and is a safe and
more effective treatment alternative for all skin tones.”
The typical Sublative protocol consists of three to five
treatments, spaced four to six weeks apart.
10
Aesthetics Journal
Aesthetics
aestheticsjournal.com
Injectables
Galderma launches new syringes
Galderma has launched two new syringe delivery
systems for their Restylane range. Launched at the
Anti-Ageing Medicine World Congress in April, the
Restylane Filler Syringe and Restylane SkinBoosters
Syringe have been designed with the aim of offering
greater precision, comfort and control as well as
incorporating new safety measures.
The new Restylane Filler Syringe has been
designed in consultation with practitioners
and has a new grip and thumb rest to provide
greater comfort. Safety measures include a
new tamper-proof seal and a Luer lock. The
Restylane SkinBoosters Syringe uses the
SmartClick system to provide built-in dosage
control, dispensing ~10 μL microdroplets.
The idea is to allow practitioners to focus
on technique, rather than the amount being
injected. The feature can also be turned off if
required. The Restylane SkinBoosters Syringe
also incorporates the same safety precautions
as the Restylane Filler Syringe. Both syringes
are compatible with thin walled needles and
pix’L flexible microcannulas.
Hair removal
Soprano ICE introduces diode
laser alexandrite technology
The Soprano ICE hair removal system
has now expanded its usage to offer
removal for fine hair that aims to be
pain-free, using a diode laser based
on an alexandrite wavelength.
The system, created by ABC Lasers,
incorporates a wavelength of 755nm,
to provide better energy absorption
by the melanin chromophore. Soprano
ICE cools the skin with an encircled
sapphire tip, preventing surface
burns while maintaining heat within
the dermis. This high fluency delivery
system aims to provide a comfortable
and fast treatment with improved
results for light-coloured and thin hair.
Soprano ICE now also has a lighter
and improved ergonomic design,
meaning it can be used to treat
smaller and difficult-to-target areas
such as the eyebrows, nose and ears.
This provides a more comfortable
treatment experience for the
practitioner, as well as the patient.
The manufacturers claim that the new,
more powerful energy absorption
Aesthetics | May 2014
combined with contact cooling,
treatment coverage, comfort and low
maintenance of the solid-state laser
provides a solution for a wide range
of hair types and colours using one
platform.
@aestheticsgroup
Aesthetics Journal
Fat reduction
Insider
News
aestheticsjournal.com
Aesthetics
Skin tightening
Zeltiq launches new
CoolSmooth head
Zeltiq Aesthetics Inc has
launched its CoolSmooth
applicator for noninvasive fat reduction
on the outer thighs. The
latest addition to the
CoolSculpting range of
applicators, CoolSmooth is
to be used in conjunction
with the CoolFit applicator,
designed to treat the
inner thigh, now allowing
practitioners to treat
the entire thigh area.
“The introduction of the
CoolSmooth applicator
provides a new solution
to individuals who struggle to reduce fat in the thigh
area, a difficult-to-treat part of the body,” said Mark
Foley, president and chief executive officer of Zeltiq.
“Through our newest applicator, we are excited by
the opportunity to expand our current offerings to
physicians and, ultimately, the individuals who may
benefit from our unique technology. Results achieved
with CoolSmooth add to the growing body of evidence
demonstrating the safety, efficacy and long-lasting
results of the CoolSculpting procedure.”
Study demonstrates single
treatment tightening effect with
ThermiAesthetics device
Temperature controlled
radiofrequency system ThermiRF
has demonstrated effective skin
tightening in a single treatment,
according to a study published in the
Journal of Drugs in Dermatology. The
18-person study, which was carried
out by board-certified dermatologist
Dr Douglas Key, showed statistically
significant results in reducing skin
laxity on the face and neck after just
one treatment.
Patients reported no pain during or after
the ThermiTight procedure, and any
redness or swelling subsided within a
few hours. No pigmentary alterations or
scarring occurred during the trial.
“This is the future of skin tightening,”
said Dr. Key. “Previous radiofrequency
devices have required multiple
treatments and offered unpredictable
results. ThermiRF delivers
radiofrequency heat energy in
conjunction with Thermal Image
Monitoring. This advanced infrared
imaging allows medical professionals
to see and direct heat at all three layers
of the skin, achieving optimal skin
tightening results in a single treatment.”
As a safety measure, the ThermiRF
device contains an auto shut off feature
that is triggered when temperatures rise
above predetermined levels. A number
of further studies are planned and
underway to demonstrate the use of
ThermiRF for conditions such as axillary
hyperhidrosis, cellulite, snoring and postchild-bearing vaginal laxity.
Botulinum toxin
Johnson & Johnson to terminate neurotoxin programme
Pharma giant Johnson & Johnson
has revealed that it will discontinue
developments of PurTox, a neurotoxin
widely referred to as a potential rival for
Allergan’s Botox.
Johnson & Johnson acquired PurTox in 2009,
following the acquisition of breast implant
maker, Mentor. The company has now
expressed a desire to focus on its core breast
surgery business. The termination of the
PurTox programme will lead to a small number
of job losses in the US. “We are winding down
the neurotoxin program in a responsible
manner,” said Tom Sanford, vice president
of communications at Johnson & Johnson.
“Regrettably, this involves the elimination of
a small number of positions in the United
States. Mentor has long been a leader in the
breast surgery market, both in augmentation
and reconstruction, and we are committed to
maintaining our leadership,” he said.
“Focusing on our core breast surgery
business will allow us to expand successful
programs, as well as increase our investments
to develop additional new products to meet
the needs of patients and the surgeons who
care for them.”
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Aesthetics | May 2014
11
Insider
News
@aestheticsgroup
Aesthetics Journal
aestheticsjournal.com
News in Brief
Radiofrequency
PelleFirm receives FDA
clearance for tissue heating and
cellulite reduction
The new PelleFirm RF
body treatment system
has received FDA
510(K) clearance for
tissue heating and for
temporary reduction
in the appearance of
cellulite. Its distributor
Ellman International,
Inc. has also received
FDA clearance to market the system. The PelleFirm is CE marked for
body skin tightening and cellulite reduction. The system is a non-invasive
radiofrequency treatment for the body, which aims to produce firmer skin
and impermanent reduction in the appearance of cellulite. PelleFirm has two
large diameter handpieces, which elevate tissue temperature up to 45°C,
and mechanical massage heads to treat areas with cellulite, and particularly
focuses on problem zones such as the abdomen, arms, thighs and buttocks.
“We have been working with physicians around the world to develop
PelleFirm and are excited to bring this innovative RF body treatment system
to market,” said Ellman International CEO and president Frank D’Amelio. “It
addresses the need for an effective, non-invasive body solution. With two
different sized handpieces, PelleFirm can address almost every area of
the body.” Dermatologist Josephine Hernandez said, “Many of my patients
request treatment for sagging skin in their arms, hands, abdomen, thighs
and gluteal area. The results with the PelleFirm system are outstanding and
superior to any of the many body contouring or skin tightening devices we
have used in our practice. I have seen PelleFirm results in as little as a few
treatments. We are very satisfied users.”
Research
C-Tetra found to be effective
against photo-ageing
An independent study carried out by researchers at Prefectural
Hiroshima University, Japan, has established that Tetrahexadecyl
Ascorbate, otherwise known as C-Tetra, is more effective at preventing
photo-ageing than standard vitamin C. C-Tetra, a vitamin C derivative
used in the Medik8 cosmeceutical range, was also found to increase
collagen synthesis.
It was found that by administering 10-50 microM of Tetrahexadecyl
Ascorbate to human fibroblasts and then irradiating them with UVA, the
cells were protected from UV damage. The tests used several markers to
evaluate the performance of C-Tetra, including the successful repression
of MMPs and the repression of p53 gene expression, a hallmark of UVinduced damage.
Pharmacologist and Medik8 founder Elliot Isaacs, said, “We are extremely
satisfied with the conclusions of this respected Japanese scientific group
whose findings corroborate and in fact exceed our own research data into
the activity of Tetrahexadecyl Ascorbate.”
12
Aesthetics
Aesthetics | May 2014
Murad reveal new Essential-C Sun Balm
This month Murad will launch its portable sun stick,
Essential-C Balm Broad Spectrum SPF 35 PA+++.
The balm provides protection against UVA and
UVB rays and incorporates the use of the branded
MuraSol Antioxidant Defence: a blend of antioxidants
designed to penetrate the skin to create a protective
barrier of encapsulated free radical neutralisers.
Dr Carl Thornfeldt to present Epionce
workshop
Dr Carl Thornfeldt, CEO and founder of Episciences
Inc., will present a workshop at this year’s FACE
conference. He will explain the science behind the
Epionce line, offer practical demonstrations and
launch the Epionce MelanoLyte Pigment Perfecting
Serum to the European market. “I am pleased to have
the opportunity to share some pearls from my years
of clinical practice and research with the attendees,”
said Dr Thornfeldt. The workshop will take place on
June 21.
Aneva Nutraceuticals introduce new antiageing skin drink
Aneva Nutraceuticals have launched new skin
health drink Aneva Derma. The product’s formula
includes bio absorbable collagen and hyaluronic
acids, promoting collagen synthesis and skin
health. Dr Diane Keith, based in Harley Street
said, “Aneva Derma differs from other collagen
drinks by addressing crosslinking problems with
antioxidants. It also provides exceptional collagen
and hydration skin support due to the high level of
hyaluronic acid and hydrolysed collagen peptides.”
Cambridge Biotech Ltd launch
Uma Jeunesse Ultra
Cambridge Medical Aesthetics/Cambridge Biotech
Ltd have announced the launch of Uma Jeunesse
Ultra, the latest addition to the Uma Jeunesse
range of dermal fillers. Uma Jeunesse dermal
fillers are monophasic, hyaluronic acid (HA)based and cross-linked with butanediol diglycidyl
ether (BDDE). Uma Jeunesse Ultra also contains
lidocaine, which aims to make the procedure
more comfortable for patients without the need for
topical anaesthesia.
Medik8 launch new skin ageing kit
Medik8 has launched a new Skin Ageing Essential
Kit, aimed at women and men aged 40+. The kit
is suitable for normal to dry skin and contains
both Vitamin C and Vitamin A skin serums and
moisturisers for day and night. The edited collection
treats skin ageing concerns including lines and
wrinkles, dull complexion, uneven skin tone and
sun damage.
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Contact us on Tel: 0845 1707788
[email protected] | www.abclasers.co.uk
Insider
On the Scene
Enerjet
demonstration,
London
Dr Tapan Patel played host to an intimate
presentation on Enerjet on Monday March 24 at 102
Harley Street, speaking to an audience of doctors
and aesthetic practitioners, including Apprentice
winner Dr Leah Totton. A dermal remodelling system
that pneumatically introduces a jet of Hyaluronic Acid
(HA), Enerjet works to remodel skin, repair scars and
lift facial tissue. Described as a non-surgical facelift
using HA, Enerjet is a skin remodelling treatment in
which strong, controlled volumetric injury induces
collagen regeneration. As the first practitioner to
introduce this treatment to the UK, Dr Patel shared
his experience of the system before performing live
demonstrations. This saw Dr Patel administer powerful
pneumatic injections into the model’s skin in order to
create intentional wounds, triggering a natural healing
process that generates production of new collagen,
skin thickening and tightening.
ARTAS Workshop,
Manchester
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
The Future of Harley Street,
London
A live debate on the future of the famous
medical destination Harley Street took
place on March 27, at the Royal Society of
Medicine.
The event was host to over 200 attendees,
including Harley Street doctors and
surgeons, practice managers, property
owners and advisors, patients and health
journalists, and was opened by Keith Pollard,
managing director of harleystreet.com.
The debate, chaired by medical journalist
and former ITV News medical correspondent
Sue Saville, allowed attendees to vote on
a number of issues. The results of the votes included that 75% believe there is
additional potential in the Harley Street brand that is yet to be exploited, whilst
50% believe that Harley Street is the place to go for the best doctors, dentists
and healthcare professionals. Other issues discussed included the lack of
representation of the UK and Harley Street at international medical tourism events,
and lack of central marketing support promoting UK clinics to those overseas who
wish to visit the UK for aesthetic treatment. Pollard said, “As a result of Thursday’s
events, we already have a number of people interested in joining a steering
committee, who will look at forming a formal Harley Street Partnership, to maximise
the Harley Street brand both in this country and overseas.”
Attendee Darren Rowe, managing director at Harley Street Cancer Concierge, said,
“I was keen to attend this event as I felt it was important to support what I consider
to be a very worthwhile initiative. We’ve known for some time that Harley Street
as a brand isn’t keeping up with other parts of the world and the data presented
at the meeting highlighted this,” he said. “The fragmented nature of Harley Street
can make it quite difficult for patients, and with no cohesive marketing plan, our
voice on the international stage is drowned out. I was encouraged that the survey
indicated a desire to do something collectively. I hope we can maintain momentum
and start to work towards a common goal of increasing patient volumes and
providing an outstanding level of customer service to go with the outstanding level
of patient care.”
Sculptra Open Day, London
Europe’s only live
robotic hair transplant
surgery workshop took
place at the Farjo Hair
Institute on Friday 28
and Saturday 29 March.
Each day included
a morning seminar
followed by a live
demonstration of new
technology, the ARTAS
Robotic System.
The system uses a robotic arm to identify follicles for
harvest and extract the donor hairs and surrounding
tissue. Performing up to 1,000 follicular extractions
per hour, the ARTAS Robotic System uses advanced
imaging technology to locate the densest areas of
donor hair before harvesting an evenly distributed
selection of donor grafts.
A Sculptra open day was held at The
Cadogan Clinic in London on March
27, to demonstrate the effectiveness
of the CanuSculpt technique to
guests. As part of the open day,
consultant oculoplastic and aesthetic
specialist, Dr Maryam Zamani,
completed a full facial analysis on a
model and treated half her face with
Sculptra using the cannula technique.
Dr Maryam illustrated how this procedure leaves minimal or no marks, makes
the procedure more comfortable for the patient and decreases the risk of
bruising.
Sculptra aesthetic account manager Claire Williams said, “This type of exclusive
open event with a small group of clients is a very effective way to demonstrate
the benefits of Sculptra using the cannula technique. It was a great success
with a high level of interest from all the guests.”
14
Aesthetics | May 2014
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Insider
News Special
12th Anti-Aging Medicine World Congress
On the 3 -5 April the annual AMWC meeting was held in Monaco.
We look back on the event and report on the Allergan Medical Institute
eye symposium
With delegates
attending from over
120 countries, the 12th
Anti-Aging Medicine
World Congress was
an opportunity for
international peers and colleagues to learn from
experts in their field and see the vast number of new
products available. This year, the emphasis was on
looking forward, with the congress’s overall concept
labelled, ‘Be ready for the future’. Dr Chytra V Anand,
a cosmetic dermatologist based in India, presented
several sessions during the three days. She said of
the event, “As faculty, what I love is that not only do I
get to share my knowledge but I am also able to learn
from other masters, which is very important in order to
stay updated.”
The importance of expert collaboration to enhance
learning was also highlighted by Dr Ravi Jain, who
said, “I was privileged to be part of the Galderma
symposium on achieving patient satisfaction, using
optimised injection strategies with Dr Philip Levy and
Dr Colette Carmansch from Switzerland.”
Dr Anand also emphasised the independent nature
of the presentations as a key draw for practitioners
looking for information on best practice, new products
and clinical excellence; she said,, “I enjoy lecturing
at this event as the organisers are keen on keeping
the lectures devoid of commercialisation, and ask
speakers to be open with their disclosures.” With
more than 250 companies exhibiting over four
floors, there was plenty of opportunity for delegates
to speak to suppliers and distributors and find out
more about exciting products and treatments being
showcased. “I spent my time mainly looking at a
few new machines as I am currently expanding my
clinics”, said Dr Johanna Ward “I spoke with several
leading dermatologists in France who use the Tri
Wings LED system and they highly recommended
it for the kind of dermatology work that I do.”
Delegates at the congress were provided with a
comprehensive educational programme and a vast
range of exhibitors, reflecting the congress’ focus on
preparing practitioners to meet with and embrace the
challenges of the ever-changing world of anti-ageing
medicine. “It’s a good opportunity to understand
what is currently trending in the rest of Europe
and liaise with our European colleagues,” said
chair of the British Association of Cosmetic Nurses
Sharon Bennett. “I was particularly interested in the
workshops on periorbital and perioral areas as this
is so relevant to the type of patients I see in my clinic
on a day-to-day basis, and who are always wanting
to know what’s new.”
Editor Amanda Cameron reports on the Allergan symposium: “An eye for
detail: a progressive approach to periorbital revitalisation”
The Allergan Medical Institute symposium at AMWC, designed to both educate
and entertain, comprised a full day programme with a mixture of talks, live
demonstrations and debates, focused on the periorbital region. A panel of experts
were in attendance to cover the topics of relevant anatomy, patient assessment,
new clinical data and recommended injection technique.
Dr Koenraad De Boulle, chairing the day with Dr Lakhdar Belhaouari, introduced
the symposium with insightful photography, demonstrating the role that the
periorbital region has in conveying emotions and communicating feelings. This
presentation highlighted the complexity of the area and thus its treatment.
The first formal session of the day saw plastic surgeon Mauricio De Maio
emphasising the importance of patient assessment. Thorough consultation and
assessment, he reminded us, allows the practitioner to make an informed decision
as to the most appropriate treatment, or combination, for each patient. He advised
that the strategy for periorbital treatment should be dependent on the analysis of a
number of key anatomical issues including: skin excess; muscle laxity; cheek ptosis;
skin laxity; volume loss and excess fat.
Dr De Maio then spoke in detail on patient perception and expectation, stating
that patients will not be satisfied with just filling lines, as often the impact of these
outcomes are too minor in terms of what observers (partners, friends) will notice.
His discussion also included an explanation of the stark differences between how
a patient perceives their own face, and how a practitioner views the patient’s face.
Patients, he explained, tend to view their face in units (small areas) whereas
the practitioner will consider the face in its entirety and get the ‘full picture’. His
recommendation was for practitioners to discuss the patient’s face with them in
facial thirds, either horizontally or vertically, as it is easier to take sections and look
at minor details of the patient without the distraction of the full face.
Professor Hee-Jin Kim continued with an informative session on anatomy,
focusing particularly on the need to study the anatomy of the nerves and vessels,
highlighting the delicate nature of the skin around the eye and its anatomical
complexity. In his presentation on treating the tear trough, Dr Hervé Raspaldo
concurred with this, emphasising that in his opinion, the tear trough is an area for
experienced injectors only, and that it took him 20 years before he felt confident
enough to inject in that region. Delegates were then shown the new app from the
Allergan Medical Institute, which allows practitioners to analyse exactly where they
are injecting whilst performing a procedure. This technology further underlined
the importance of a firm and detailed grasp of anatomy when performing
aesthetic treatments, a recurrent theme of the symposium, along with the role
that technology can play in assisting practitioners to achieve increasingly precise
and aesthetically pleasing results. The symposium provided a wealth of learning
for attendees, and not only demonstrated advanced injection techniques in the
periorbital area but also provided delegates with expert and useful advice that
could be easily applied elsewhere in medical aesthetic practice.
Aesthetics | May 2014
17
Insider
News
@aestheticsgroup
Aesthetics Journal
American Academy
of Dermatology
Annual Meeting
Dr Nick Lowe, Aesthetics editorial advisory board
member, professor of dermatology and president of
British Cosmetic Dermatology Group, discusses the
highlights of the recent AAD meeting
With more than 350 sessions
and attracting over 16,000
delegates and exhibitors,
the 72nd Annual Meeting of
the American Academy of
Dermatology, which was held in Denver Colorado between March 21 and 25, is the
largest and most prestigious dermatology conference in the world.
This was the 30th consecutive AAD meeting I have attended. This year, I was invited
by the Academy to be guest presenter at two sessions on injectables and facial
rejuvenation.
The protocol I described and demonstrated was the use of different volumising
fillers and neurotoxins for synergistic improvement of the facial lines and ageing.
This is achieved by using hyaluronic fillers such as Voluma or SubQ as lifting and
filling injections, administered to the zygomatic area and mid-face.
To correct volume loss caused by age, weight loss or post-acne scarring, Sculptra
can be administered to the mid face following these hyaluronic filler injections.
Combining Sculptra with hyaluronic fillers creates the optimum lifting and filling
effect, and one that improves over time and with subsequent Sculptra treatments.
Some patients also benefit from injection of botulinum toxin to the depressor
angulae oris, the jawline and platysma, with small doses of neurotoxins. During
the live demonstrations, a simultaneous cadaver dissection showed the relevant
anatomy, and key areas to avoid or be cautious with, such as the periocular nasal
and lower facial areas, because of their vascularity.
Serious complications of injecting filler into the blood vessels and causing blindness
or skin necrosis when treating these areas with fillers were discussed at length. The
consensus view of the dermatologists was that injections into these areas should
be classed as high risk interventional procedures and should only be administered
by specialist physicians with additional training. If signs of ischemia appear, such
as pain or blanching, we can immediately inject Hyalase to dissolve the filler, apply
nitroglycerin paste to the affected area and consider other treatments to increase
vascularity, such as oral niacinamide. Any visual disturbances should be treated as
an ophthalmologic emergency.
There were interesting sessions on body contouring. Systems such as Venus
Freeze, Venus Legacy and ThermiRF administer radiofrequency plus magnetic
Dr Nick Lowe is president of the
BCDG, professor of dermatology and
a consultant dermatologist with over
30 years of experience who practises
in London and California
18
Aesthetics | May 2014
Aesthetics
aestheticsjournal.com
resonance and can achieve a steady state deep
tissue temperature of 48-50°C, providing collagen
tightening, and refining body contour. For cryolipolysis,
the Zeltiq system was considered at present the most
reliable and fully tested system. Fat necrosis has been
described with other systems. The key to success
for all body contouring treatments is to be realistic in
patient selection and evaluation. For example, it may
be necessary to suggest weight loss before treatment,
and patients with significant excess skin should be
referred for abdominoplasty if they desire. Cynosure’s
new Nd:YAG vascular laser presented an alternative
treatment for facial redness. Unlike pulsed dye lasers,
it did not result in several days of bruising, and patchy,
irregular improvement.
There were interesting presentations on combination
scar treatments, showing how needle-driven RF
systems such as Intracel or fractional CO2 lasers
deliver microscopic channels into hypertrophic or
keloid scars, reducing vascular supply and scar
density. Megapotent cortisone creams can then be
applied, which penetrate deeper into the scar tissue,
reducing scar thickness. Patients can also apply
Haelan tape overnight to the scars. Any scar erythema
can then be reduced with vascular lasers. Several
treatment sessions may be required depending on
scar size and density. Recent topical treatments were
also discussed for rosacea; in addition to Galderma’s
recent Mirvaso (Brimonidine gel) for facial redness,
which has been available in the USA for several
months, there was an interesting new treatment of
rosacea papules and pustules with Ivermectin (a
drug used to treat headlice) delivered as a gel. The
mechanism of action is not known but may involve a
reduction in dermadex population in rosacea lesions.
One of the most exciting products discussed at the
meeting was a new biologic drug developed for adult
atopic eczema. Patients treated with Dupilumab, an
antibody drug targeting the cytokine interleukin 4,
saw disease activity decline significantly. About 85%
of patients treated with Dupilumab had at least 50%
improvement in Eczema Activity and Severity Index
(EASI-50) after 12 weeks, compared with 35% of the
placebo-treated patients. We have several active
biologic drugs for psoriasis but Dupilumab is a first to
be active in atopic eczema.
AAD also named its contact allergens of the year,
which are causing frequent contact dermatitis. This
year one was benzophenone-3, the sunscreen
ingredient better known as Oxybenzone. The other
key allergen discussed was methylisothiazolinone (MI),
a widely used preservative in shampoos; particularly
when used every day, it can be a significant
contributor to facial and neck dermatitis. Attending
and listening to the presentations reminded me of
the vital role dermatologists and skin specialists hold
as ‘dermatology detective’; identifying causative
factors in skin diseases and being the specialist for
all diseases and treatments of skin, hair and nails, as
well as having the optimum knowledge for aesthetic
treatments. This was an excellent conference from which delegates
learned much new information and I brought back to the UK many
ideas to refine our dermatology and aesthetic practices at the
Cranley Clinic.
Wendy Lewis discusses the role of
professional skin care at the American
Academy of Dermatology Conference
According to the IMCAS Tribune, the global market for
cosmeceuticals (referred to by the French as cosmeceutiques
or cosmetique active) is valued at $1.05 billion for 2014 and
is projected to grow to $1.38 billion by 2018 (imcas.org). This
represents an average annual growth rate of +7.4%. Unsurprisingly,
the principal zones, in descending order, were the US, Asia, Latin
America, and Europe. Nowhere was this trend more apparent than
at the 72nd annual American Academy of Dermatology Conference
where, although the anti-ageing category captured the lion’s share
of attention, acne, scars, stretchmarks, sensitive skin, sun protection,
and pigmentation solutions all had a strong presence.
Elizabeth Arden entered the physician channel with the Elizabeth
Arden Rx collection featuring Triple Protection Factor Broad
Spectrum Sunscreen SPF 50+, based on a combination of of three
protective and restorative ingredients - DNA Enzyme Complex,
Antioxidant Complex and broad-spectrum SPF 50+ sun protection
in a moisturising base. Another new launch into the physician
distributed skincare arena was GMC Medical, from G.M.Collin, a
25-year-old Montreal based spa brand. This comprehensive line of
a dozen products addresses acne, skin ageing, sun damage, and
pre- and post-medical aesthetic procedures. L’Oreal put forth new
entries from some of its active cosmetics brands, while SkinCeuticals
captured attention by featuring an impressive total of 13 scientific
publications, and the debut of Resveratrol B E Antioxidant Night
Concentrate. La Roche Posay showcased the new Anthelios 60
Ultra Light Lotion Spray with Cell-OX Shield, which boasts new micro
shield technology to protect skin during intense UV conditions and in
water. Also launched at the meeting was NeoStrata’s new Skin Active
Triple Firming Neck Cream, which targets the neck and décolleté
areas with Swiss Apple Stem Cell Extract and an array of proprietary
ingredients. Exuviance Age Reverse HydraFirm, a luxurious cream
that targets the visible signs of ageing and replenishes optimal
hydration levels, was on display boasting a triple firming complex
of patented Bionic, NeoGlucosamine and Matrixyl Peptides to
plump and fill skin. The Canadian giant Valeant Pharmaceuticals
International presented its new Neotensil daily under eye reshaping
procedure, available through Obagi Medical and sold in clinics.
Finally, pigmentation problems always take centre stage at the AAD
and this year was no different. ZO Skin Health, Inc., from Dr. Zein
Obagi, introduced two new GSR Systems, comprehensive home
care kits designed for normal to dry and normal to oily skin types, as
well as two new specialised pigmentation treatment programs, ZO
Multi-Therapy Hydroquinone System and ZO Non-Hydroquinone
Hyperpigmentation System.
Wendy Lewis has authored 11 books on
antiageing and cosmetic surgery, and regularly
lectures internationally. She is the president of
Wendy Lewis & Co Ltd and founder/editor in
chief of Beautyinthebag.com
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“The Tri-Wave is without a doubt
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ever bought and would
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Dr Simon Ravichandran
Cosmetic Doctor and Medical Director of Clinetix, Glasgow
Aesthetic Technology Limited
Park View House, Worrall Street
Congleton, Cheshire CW12 1DT
t: 0845 689 1789 | e: [email protected]
w: www.dermaluxled.com
Clinical Practice
Special Feature
@aestheticsgroup
Aesthetics Journal
Suzi Lewis-Barned speaks to medical practitioners
regarding the fat loss and skin tightening
treatments they use in combination at their clinics
Body contouring for the
summer -choosing the
winning combination
Body contouring is an increasingly popular
market among a wide group of male and
female patients seeking treatment for
a variety of conditions, including those
resistant to exercise and diet regimens.
Although as Esther Fieldgrass, founder and
CEO at EF Medispa explains, treatments
typically appeal to women aged 25 to
65, the male market is also now reported
to be growing; gynaecomastia treatment
increased by 24% and male liposuction was
up 28% last year, according to the British
Association of Aesthetic Plastic Surgeons’
(BAAPS) annual audit for 2013.
Partly driven by the visible success of
treatment, Dr Andrew Weber, medical
director at Bodyvie Clinics, feels the
popularity of this market is likely to be due
to the pressure many women feel after
browsing the content of popular magazines.
“People see pictures of other women and
they feel they must have that look – there’s
a sense that it’s easily achievable for them
too. Of course, some of the time, it isn’t,” he
says. Jill Zander, owner of the Jill Zander
Skin Rejuvenation Clinic, has also noticed
considerable growth in the market, as
well as the increasing availability of new
devices to serve this demand. She explains,
“Demand is increasing tremendously and
will continue to grow – we are investing
more than ever in new devices and,
without doubt, everyone who offers fat loss
treatments should also offer skin tightening,
either through a different device or in
combination devices.”
20
People visit cosmetic clinics for treatments
that target a range of problems: loose skin
that needs tightening or firming; ‘stubborn’
areas of fat including around the abdomen;
‘bingo wings’; fat thighs and/or buttocks.
And, according to Jill Zander, a key patient
group is younger women looking for anticellulite treatment.
What treatments are combined?
According to Dr Grant Hamlet, founder and
director at You by Design cosmetic surgery,
combination therapies are showing “true
promise” although different combinations
need to be used depending on the nature
of the problem. Esther Fieldgrass of EF
Medispa explains, “We put specific treatments
together because they will enhance the
texture of the skin as well as the performance
of the treatment. As an example, after Vaser
LipoSelection we will use manual lymphatic
drainage to help with the healing process of
the body by using the massage to stimulate
any particular fatty areas that we want to get
rid of. If there is a deep pocket of fat we may
use carboxytherapy (carbon dioxide therapy)
to pump blood and oxygen into that area to
remove any fatty deposits.”
Dr Martyn King, co-owner at the Cosmedic
Skin Clinic and medical director of the
3D-lipolite program, uses the 3D-lipo
machine, a multi-platform device, to combine
a range of treatments that will vary according
to the client’s expectations, gender and
areas of concern. He explains, “For slimmer
clients who are just concerned about a
Aesthetics | May 2014
Aesthetics
aestheticsjournal.com
particular area (such as ‘muffin top’, inner
thighs, or upper arms) then cryolipolysis
works well. For all over body contouring we
tend to use a combination of all treatments
over several sessions and cellulite is often
treated by a combination of radiofrequency
and dermology.” He adds, “For patients
who are most interested in total weight
loss, we would combine weekly treatments
with a whole diet, exercise and wellbeing
programme (3D-lipolite) using meal
replacement supplements and biometric
monitoring.” These treatments are normally
offered over a course of eight sessions,
starting with cavitation, which normally
gives quick results, and combined with
radiofrequency during weekly sessions.
There may also be one or two treatments
with cryolipolysis on specific areas and most
courses are completed with dermology.
Dr King has noticed good early results
using cavitation, including improved
body measurements, with the results of
cryolipolysis tending to show after about
eight weeks.
Zander says her clinic often combines
treatments for cellulite, such as Lipotripsy
acoustic wave followed by Ballancer
treatment for lymphatic drainage. Lipotripsy
works as cellulite calcified deposits form
around fat cells, which prevent fat being
released; the acoustic wave shatters the fat
cells so the fat can escape. As an alternative,
her clinic might use the FDA approved,
non-invasive, Cynosure SmoothShapes
system, which combines laser (915nm) and
light (650nm) energy with a vacuum and
mechanical massage rollers, which allow
the expressed fat and fluids to be filtered
out of the body via the lymphatic system.
Additionally, Zander uses BTL’s Vanquish,
3D-Lipo - Before and after three sessions of
RF combined with vacuum roller
3D-Lipo - Before and after one session of cryolipolysis
duction
Fat Re
lipomed
ing
Skin Tighten
Cellulite
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
This NEW advanced device is dedicated
exclusively to the clinical market
Why choose 3D-lipomed?
• A complete approach to the problem
• Prescriptive
• Multi-functional
• Inch loss
• Cellulite
• Face and Body skin tightening
• Highly profitable
• No exercise required
• National PR support campaign
• Clinician use only
Cavitation
Complete start up and support
package available from under
£400 per month
Key advantages of this technology are high treatment efficacy,
Cavitation is a natural phenomenon based on low frequency
ultrasound. The Ultrasound produces a strong wave of pressure
to fat cell membranes. A fat cell membrane cannot withstand this
pressure and therefore disintegrates into a liquid state. The result is
natural, permanent fat loss.
Duo Cryolipolysis (New)
Using the unique combination of electro and cryo therapy 20-40%
of the fat cells in the treated area die in a natural way and dissolve
over the course of several months.
Two areas can now be treated simultaneously.
Radio Frequency Skin Tightening
Focus Fractional RF is the 3rd generation of RF technology. It
utilises three or more pole/electrodes to deliver the RF energy under
the skin. This energy is controlled and limited to the treatment area.
no pain as less energy is required, shorter treatment services and
variable depths of penetration.
3D Dermology RF (New)
The new 3D-lipomed incorporates 3D Dermology
RF with the stand alone benefits of automated
vacuum skin rolling and radio frequency.
Before
After
“I am so pleased to be given the opportunity to have the first medical version of the
award winning 3D Lipo machine in my new clinic. This multi-platform technology
offers a powerful non-surgical alternative to lipo suction with the addition of skin
tightening and cellulite reduction modalities. I’m so proud to be able to offer my
clients the very latest result driven technology.”
Dr Leah Totton - Winner of The Apprentice 2013
For further information or a demonstration
call: 01788 550 440
www.3d-lipo.com
www.3d-skintech.com
Clinical Practice
Special Feature
@aestheticsgroup
BTL Vanquish - Before treatment
Aesthetics Journal
BTL Vanquish - After treatment
Aesthetics
aestheticsjournal.com
the other is less intensive, which has
implications for the clinic and staff.”
Treatment protocols
BTL Vanquish
which she says is particularly effective for
treatment of the abdomen. “Vanquish seems
to be a forerunner in the field,” she says. “The
technology is very new and powerful, and
you have to be careful when monitoring the
temperature the patient’s skin reaches, which
must not exceed 42°C.”
Dr Ravi Jain, medical director and founder of
Riverbanks Clinic, says that for about three
years his clinic has used Med Contour. He
explains, “This system combines ultrasound,
lymphatic drainage and massage in one
system. We’ve had very good results: fat
reduction on the tummy and waistline, and
cellulite improvement on the thighs. We offer
this treatment once a week for six treatments.
Alongside Accent radiofrequency, Dr
Weber uses the Endermolab endymology
system, mesotherapy and injectable
lipolysis, Aqualyx, in his clinic. “Endymology
is a system of vacuum and rollers used for
treating cellulite,” he says. “It also provides
lymphatic drainage, which will speed up
absorption of fat. The Aqualyx, the injectable
that dissolves fat, also helps to speed up
the absorption of fat, produce more skin
tightening and tones the skin, and can also
be used as a standalone. Mesotherapy can
be used for creating volume.”
Dr Tracy Mountford, founder and medical
director of the Cosmetic Skin Clinic deploys
CoolSculpting in combination with Thermage
CPT radiofrequency skin tightening. She
stresses that before adopting any new
treatments she waits to check how they
have been performing in the market and also
waits until they have been FDA approved
as meeting safety and efficacy measures;
“It’s great to have ‘new’, but as I have always
maintained, ‘new’ does not always mean
better,” she says.
Med Contour
22
For his patients, Dr Grant Hamlet uses VASER
lipo, in conjunction with VelaShape, which
combines bi-polar radiofrequency (RF) and
infrared light energy with a vacuum and
mechanical massage. VASER lipo targets
unwanted fat using ultrasonic technology
whilst preserving important tissues such as
nerves, blood vessels and collagen and helps
with particularly stubborn areas that will not
shift through diet or exercise and can improve
overall shape.
What are the benefits of combining
treatments?
Many practitioners are confident in the use
of combination therapy to achieve optimum
results; Dr King says, “I would certainly
recommend a combination approach to
achieve the best results,” and Dr Hamlet
explains, “For example, VelaShape may
improve cellulite from a little to a lot, but
adding other technologies and techniques,
or even a surgical procedure, is definitely
going to improve your final result. We
are finding that combination treatments
also increase the longevity of results.”
The reported overall success rates of
combination treatments tend to be higher
with women because they effectively
reduce their peripheral fat, whereas men
are more likely to have problems with
visceral fat, which cannot be treated,
even with combined therapies. As Dr King
explains, “One size does not fit all; clients
are different and treatment areas cannot all
be treated with the same technology,” an
approach endorsed by other practitioners
who confirmed the need to ‘mix and match’.
Esther Fieldgrass adds that ensuring
patient comfort whilst achieving the best
possible end result is key when conducting
combination treatments; “We want
something that creates the best effects with
little down time,” she says.
The practical considerations are also
important as Dr Claire Oliver, medical
director at Air Aesthetics Clinic, explains;
“The Exilis treatment can be used to target
areas of fat that another applicator may
not be able to fit,” she says. “Furthermore,
one treatment is resource intensive whilst
Aesthetics | May 2014
For Esther Fieldgrass, the key is to see
how a patient is responding to treatment
and to adjust the protocol accordingly to
achieve the optimal result. As she explains,
“Body contouring is an art and practice is
required to see where [practitioners] are
going to get the best results.” Dr Hamlet
stresses the importance of careful patient
consultation and monitoring to this effect.
“We treat what needs to be treated,” he
says. This approach is also adopted at
Dr Weber’s clinic, as he explains, “Some
people respond better than others to
specific treatments; it’s a question of finding
a treatment, or combination of treatments,
that are effective on that particular person.
As a rule of thumb you can assume a
treatment is going to work in 95% of
patients but the other 5% are not going to
respond very well – so then it’s a question
of having something as an alternative.”
Jill Zander suggests six to 10 Lipotripsy
treatments followed by Ballancer, then
mixing in SmoothShapes but, as she
explains, it’s never a case of ‘one size fits
all’. “What we try to do is to individualise
and personalise packages,” she says.
“We also offer packages at different price
points – this is a great way to encourage
clients to commit to completing a full course
of treatment.” Dr King’s experience has
led him to believe that radiofrequency
treatment is best for skin tightening,
especially of the lower abdomen postpregnancy. He explains that cavitation
works best for larger areas of fatty
tissue, and reaches greater depths than
radiofrequency while cryolipolysis can
destroy 25-30% of fat cells, although the
results do not appear quickly. This is why
his treatment protocol often begins with
cavitation, for which the results are more or
less instantaneous.
What are the difficulties and
limitations of combination therapies?
Dr King suggests that whilst most patients
are suitable for combination treatments,
the normal exceptions apply, including:
those with unrealistic expectations (for
example liposuction-style results), people
in poor health, pregnant women and
those breastfeeding, patients fitted with a
pacemaker and those with uncontrolled
diabetes and taking immunosuppressants.
Dr Oliver adds that she will not offer
3
Pr ½ MMy
og o
ra nt
m h
lite
program
A New Three Dimensional Approach to
Clinical Weight Loss and Body Contouring
1
2
+
lite+
3
A New Three Dimensional Approach to
Medical Weight Loss and Body Contouring
3D-lipo Treatments
3D-lipolite Diet & Nutrition
3D-lipolite Exercise Plan
We can’t say that the 3D-lipolite
program has changed her life.
But Sharon can.
Following the birth of my baby I tried many diets desperate to get
back my pre-pregnancy figure and weight which didn’t work. Unlike
these other quick fix weight loss programs this one has educated
me to eat correctly and I am convinced that I will maintain the results
achieved as I have adapted to the change of lifestyle and new
healthier eating habits.
I have gone from a size 14 to a size 8 in four months and feel better in
myself with restored confidence.
Thank you to all at 3D-lipolite.
“I’ve been so impressed by the results of my own clinical
trials that I would recommend this program to anybody”
- Dr Martyn King
(Finalist Aesthetic Practitioner of The Year 2013/14)
3½ Month Clinical Trial Results. Sharon Morrow, 37 Years of Age from Rugby
Weight Loss: 9.6 kilos (1.51 stone)
Hip Measurement loss: 16.5cm
Waist Measurement loss: 20cm
Chest Measurement loss: 8cm
Exclusive territories available.
Do not miss out on this unique business opportunity.
Call 01788 550 440
For full details of our
clinical trials contact us
www.3d-lipolite.com
www.3d-lipo.com
www.3d-skintech.com
Clinical Practice
Special Feature
@aestheticsgroup
treatment to people who are more than
two stone above their ideal body weight.
Although there may be a number of
risks associated with using treatments
in combination, Dr Ravi Jain advises that
the main consideration is to check for
sensation; “A lot of these treatments can
cause temporary altered sensation to the
skin so we need to know a patient has
normal sensation in the skin before we do
any treatment, let alone mix treatments,”
he says. “If they can’t feel pain, you may be
doing them harm; if there is bruising from
treatment you don’t want to do another
treatment until that has settled. CoolTech
is a very effective treatment, but if you try
to repeat it too soon before the full effects
of the first treatment have taken effect
you could end up with over-correction. It’s
important to make sure you do not overtreat people.”
CoolTech
Advice for
practitioners
wishing
to invest
in body
contouring
devices
Dr Ravi Jain
highlights the
importance of
auditing results
Aesthetics Journal
on patient satisfaction to help
improve the services you offer.
“Each practice, no matter what
technology they have, needs to
audit their results and be able to
communicate satisfaction levels
to their patients,” he says.
“If satisfaction levels are
low, use a different type of
technology to change that, we
need to be above 80%. You have to think
about the patient’s point of view before the
clinic’s; if you get that right your business
will be taken care of quite nicely.” Dr Claire
Oliver agrees that understanding your
patients’ needs is the key to success, as
well as being aware of financial investments
that you are making. “Understand and
identify what your clients require and
choose your system from there,” she says.
“Be mindful that investment in technologies
requires a commitment to marketing to
ensure the targeted payback of the system
is achieved.”
Dr Weber also agrees that practitioners
should be conscious of the investments
they make in devices. “Investing in devices
is a big financial commitment; with lasers
you’re looking at close to £100,000 with
some. Endymology is still running at about
£30,000 and radiofrequency is around
£50,000. You need to get the most out of it
and make certain that the device is going
Device selection
With no shortage of choice within the body contouring device market, our
contributors were invited to highlight the main factors they had considered
when selecting devices for their clinics.
Esther Fieldgrass’s decision factors included: published research results; the
existence of good back-up support for any equipment procured; high quality
continuous training for the clinic’s therapists; and actual clinical results from an
in-clinic two-month trial period.
Dr Martyn King took patient conversion rates into account when it became
apparent that a combination approach was far more popular with his patients.
Dr Tracy Mountford spoke to colleagues in the profession that she felt she could
trust, as well as checking the device was FDA approved.
Dr Grant Hamlet considered whether or not a device would complement the other
treatments already offered in his practice and whether any future modifications
were planned that would help his patients, (e.g. a larger handpiece for the
VelaShape III that can be used to treat cellulite).
Dr Claire Oliver highlighted the significance of ‘no downtime’, as well as the need
to select a proven technology that was safe, effective, approved and that could be
profitably deployed.
Dr Andrew Weber placed greater reliance on the objective feedback from
colleagues and the results of clinical studies than on the pitch of device sales staff.
He also took account of the nature of the treatment and whether it was likely to be
pleasant and well tolerated by his patients.
24
Aesthetics | May 2014
Aesthetics
aestheticsjournal.com
to stand the test of time, so try to do your
research.” He explains that trialling products
and gathering feedback from other users
is a good way to test the effectiveness of
devices before making an investment. Dr
Jain adds that it’s important to keep up-todate with technological advancements; “If a
clinic’s technology is over four or five years
old, the chances are they need to improve
it,” he says.
In terms of what technology to opt for,
practitioners have differing opinions. “I
feel the combination of radiofrequency
and ultrasound will be the future of body
contouring,” says Jill Zander. However,
Dr Ravi Jain believes everyone should
be looking into cryo technology. “A good
cryo system means no treatment should
be required more than once every three
months or once every two months,” he
explains. “We’ve found it to be a one-off
treatment in most of our patients.”
He also finds benefits in designing your
treatment package specifically for each
patient. “When we have sold courses
of three treatments, patients have had
treatment in different areas, as there was
no need to repeat in the same area,” Dr
Jain explains. “So now, depending on how
big the patient is, we adjust our package
offers. If they have two fistfuls of fat, we
are confident that they will only need one
treatment. If they have a whole tummy [of
fat] they may need two hours, which is two
sessions.” He also explains that you should
design your treatment packages to achieve
optimum efficiency; “Don’t combine one
weekly treatment with another weekly
treatment as the patient will be with you
forever; instead, combine a weekly, perhaps
with a one-off treatment.” It is clear that
there are multiple different combinations
of treatments available on the market that
appear effective and choosing the right
combination requires careful analysis against
a range of selection criteria determined by
your clinic’s particular priorities. Ultimately,
success will be about choosing the right
combination for your patient group that
provides them with the optimum results.
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Clinical Practice
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point
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Aesthetics Journal
Aesthetics
aestheticsjournal.com
Lip Augmentation:
an art and a science
Sharon King discusses the anatomy
and physiology of the lower face in
relation to lips
INTRODUCTION
Lips are viewed by many as the most beautiful feature of the face.
Aesthetically, they provide a focal point of beauty and, functionally, they
are part of the apparatus of speech in addition to providing a visual
display of varied human emotions. Patients often have a clear idea of
what look they want before seeking treatment of the lips with dermal
fillers, although this may not always be ideal. Patients who want to look
like a favourite celebrity or those asking to look significantly younger
pose a challenge to any practitioner as the shape of the lip alters with
age and lip volume naturally decreases. Critical changes in the perioral
area can include vertical rhytids, increased prominence of nasolabial
folds (the crease that runs from nose to the corner of the mouth), ptosis
of the oral commissures (sagging of lines from the corners of the mouth),
thinning of the lips, and flattening of the upper lip with less definition of
the Cupid’s bow.1 Rejuvenation of the lips is a commonly requested and
frequently performed procedure with numerous strategies available to
practitioners. Common approaches include adding volume to the body
of the lips or accentuating the vermillion border (lipline) usually through
the injection of dermal fillers or enhancement of the lip line using semipermanent makeup. Volume is added to create a more protruding
and pouty lip, based on the fundamental belief that volume loss is a
significant part of the ageing process.
ASSESSMENT AND MEASUREMENT
Figure 1
Before proceeding with lip enhancement
there are a few basic rules that should
be considered. The Ancient Greeks are
accredited with applying the ‘Golden Ratio’,
with canons dictating that the lower lip should
be 1.614 times as thick as the upper lip and
(Figure 1) Copyright
that the upper lip should protrude 2mm
Cosmedic Skin Clinic 2014
further than the lower lip. We should observe
these rules when looking at aesthetic enhancement to maintain a
natural look and balance for the face.2
• In general the distance between both oral commissures should
be equal to the distance between both mid pupil points if the four
points were linked to form a square5 (Figure 1)
• In Caucasians the proportion of the upper lip in relation to the
lower lip should be 1 to 1.618mm (other ethnicities may have
dimensions approaching 1 to 1).
• The height/volume of the upper lip should be between 0.65-0.85
that of the lower lip. Although men have relatively thinner upper
lips than women, the ratio in both genders is similar.
• A well-shaped cupid’s bow with full philtral columns is the ideal.3
Several other methods have been used for evaluating lip position and
its influence on facial profile. Among the most popularly referenced
are Rickett’s ‘E’ line, Steiner’s ‘S’ line, Holdaway’s ‘H’ line, Burstone’s
26
‘B’ line and Sushner’s tissue nasion-chin line ‘S2’. (Figures 2-6) Naidu,
while studying the consistency of the five reference lines, found that
the S2 line, the E line and the B line had the smallest variation and
therefore provided the best reference lines in judging the horizontal
position of the lips in profile.4
Rickett’s line (Figure 2) shows the relationship of the lips in relation
to the nose and chin. Although the upper lip should protrude slightly
more than the lower lip in the vertical plane (1-3mm), for aesthetics
there should be a 4mm space and 2mm space between the maximum
protuberance of the upper and lower lips respectively. Burstone’s B
line (Figure 5) joins the soft tissue sub nasally and the skin pogonion
(with the mid point of the chin as its lower point of reference).
Sushner’s line (Figure 4) is drawn from the soft tissue nasion (the
bridge of the nose) to the soft tissue pogonion. Holdaway’s line (Figure
6) is a line drawn from the soft tissue pogonion to the upper lip.5
Figure 2 Rickett’s E line
Figure 3 Steiner’s S line
Figure 5 Burstone’s
B line
Figure 4 Sushner’s S2 line
Figure 6 Holdaway’s
H line
The height of the upper face, mid face and lower face should be
approximately equal to maintain symmetry. The lower face can be
split into thirds, with the upper third being the sub nasal point to the
mouth (ideally 1.1cm) and the lower two thirds, the mouth to the chin.
On projection the upper lip should project 1-2 mm forward from the
lower lip.2
Some common errors that tend to lead to poor aesthetic results
include:
1. Treating the vermillion border only, particularly in older patients
2.Placing too much product in the centre of the lips
3.Failing to achieve balance by over injecting the upper lip versus the
lower lip or vice versa
4.Placing product throughout the lips without paying attention to
defining features creating shapeless lips
5.Injecting too much dermal filler in general
6.Not retaining balance with the surrounding structures in the perioral
area or the face in general.2 For example over projection of the lips,
giving the all too familiar ‘trout pout’
Aesthetics | May 2014
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PHYSIOLOGY
Before performing a lip augmentation using dermal fillers,
it is essential to understand the anatomy. An unqualified or
inexperienced injector is more likely to inject into the wrong
tissue plane resulting in an unsatisfactory treatment or cause
complications by injecting dermal filler into muscle or a
Aesthetics Journal
Aesthetics
aestheticsjournal.com
A good understanding of the
anatomy of the lip and lower
face, and the application of
the fundamental rules of
measurement, will also
enable the practitioner
to achieve a result that is
aesthetically pleasing with
less risk of the errors
around 1.5cm inferior to the oral commissure. The facial artery then
carries on to the nasolabial groove as the angular artery forming
branches to the alar and anastomosing with the dorsal nasal artery.
(Figure 7) © 2008 Encyclopedia Britannica, Inc.
neurovascular vessel. A good understanding of the anatomy of
the lip and lower face, and the application of the fundamental
rules of measurement, will also enable the practitioner to achieve
a result that is aesthetically pleasing with less risk of the errors
referred to above, thus providing a safer outcome and more
effective treatment. If we were to dissect the tissue of the human
lip, we would find that from superficial to deep, the layers of the
upper and lower lips include the epidermis, subcutaneous tissue,
orbicularis oris muscle fibres and mucosa. In cross section, the
inferior and superior labial arteries run their course between
orbicularis oris muscle fibres and the mucosa. Minor salivary
glands are present within the lip itself but are absent from the
vermillion border.
BLOOD SUPPLY
Blood is supplied to both lips from the external carotid artery,
which ascends from the facial artery in the neck over the middle of
the mandible. The facial artery runs deep in the platysma, risorius
and zygomaticus major and minor muscles and superficial to the
buccinator and levator anguli oris where it branches into the inferior
and superior labial arteries. The superior labial artery is located
around 1cm above the oral commissure and the inferior labial artery
(Figure 8) Copyright medicalartwork.co.uk
NERVE SUPPLY
Motor nerve supply is provided via the seventh cranial nerve
(Facial Nerve), whilst sensory function of the perioral region is
provided via the maxillary and mandibular branches of the fifth
cranial nerve (Trigeminal Nerve). The infraorbital nerve is a terminal
branch of the maxillary nerve and exits via the infraorbital foramen,
which is situated below the infraorbital rim. This usually lies in the
mid-pupilliary line and it runs beneath the levator labii superiosis
and superficial to the levator anguli oris to supply the lateral nasal
sidewall, alar, columella, mid cheek and upper lip. The lower lip
and the chin receive their sensory supply from branches of the
mandibular nerve. A further branch of the mandibular nerve, the
alveolar nerve travels through the body of the mandible and
exits via the mental foramen, this is located below the apex of
the second premolar with a variance of 6-10mm laterally. The
nerve is located in the mucosa as it exits the foramen and can
often be visible in the mucosa. Having taken in to consideration
the nervous and venous supply to the lips and lower face, next
we give consideration to the muscles of the lower face. A better
understanding of the function of each of the various muscle groups
and their intersection points in relation to the lips will give a more
aesthetically pleasing result from the treatment.
MUSCLES
Precise movement of the lips is essential for respiration, ingestion,
phonation and facial expression. Thus, there are numerous muscles
working together to produce the appropriate function. In order to
describe the muscles acting on the lip, they have been divided
below into three groups - Group I are muscles acting on the angle
of the mouth at the modiolus, Group II attaching above the lip
(elevators) and Group III acting on the lower lip (depressors).
Muscle Group I
The modiolus is the area at each commissure, which serves as an
attachment for several of the muscles of the lower and upper lip.
Within this group are the orbicularis oris, buccinator, levator anguli
oris, depressor anguli oris, zygomaticus major and risorius muscles.
Orbicularis oris is a sphincter muscle, which causes the lips to
purse and presses them against the teeth when contracted. Further
muscle fibres of other muscles insert superficially in to orbicularis
28
Aesthetics | May 2014
oris. In cross section orbicularis oris is seen as a long vertical
segment that curls out at the superior and inferior margins. Motor
movement is provided by the buccal and marginal mandibular
nerves. In the upper lip the fibres of orbicularis oris are few,
sparing the central region, this gives rise to the philtral column,
which is devoid of dermal attachment, and thus this gives rise to
a concave depression or cupids bow.
Buccinator arises from the posterior alveolar process of
the maxilla (Pterygomandibular raphe), a ligamentous band
of the buccopharyngeal fascia and the body of the mandible
it inserts into the modiolus. Its function is to press the cheek
and lips against the teeth. Motor movement is supplied via the
buccal branches of the facial nerve. The parotid duct joins the
buccinator at the edge of the masseter muscle.
Levator anguli oris arises from the canine fossa of the maxilla
beneath the infraorbital foreman and descends vertically and
inserts in the modiolus with the function of elevating the oral
commissure. The buccal and zygomatic branches of the facial
nerve innervate this muscle and the facial artery and infraorbital
nerve travel superficially on the surface of the muscle.
Depressor anguli oris (DAO) lies on the mandible below the
canine and first premolar and inserts in to the modiolus. The
marginal mandibular branch of the facial nerve supplies the DOA
and enters the muscle deep. The DAO’s function is to depress
the oral commissure, this brings the smile line down, a feature
often associated with negative perceptions.
Risorius arises in the fascia over the parotid gland and passes
horizontally forward superficial to the platysma and inserts into
the skin at the angle of the mouth, drawing the commissure
laterally to help produce a pleasing smile. The buccal branch of
the facial nerve enters the muscle deep. This muscle helps to
produce the smile that is unique to human emotions.
Zygomaticus Major originates in the cheek area of the
zygomatic arch just anterior to the zygomaticotemporal suture
line, passing over the buccintor and inserting into the modiolus.
Superiorly its fibres are deep and inferior and run superficially
to the facial vessels and facial nerve. The zygomatic and buccal
branches of the facial nerve supply zygomatic major and
upon contraction, the corners of the mouth are lifted obliquely
upwards and laterally, lifting in the corners of the mouth, resulting
in a smile.
Muscle Group II
A further group of muscles insert in to the upper lip. These
are levator labii superioris, levator labii superioris alaeque nasi
(Otto’s muscle) and zygomaticus minor.
Levator labii superioris is a quadrilateral muscle arising from
the inferior orbital rim under orbicularis oculi and attached to
the maxilla above the infraorbital foramen. Muscle fibres insert
into the dermis of the upper lip skin and into the orbicularis oris
muscle. The buccal branch of the facial nerve innervates this
muscle and its action is to elevate the upper lip.
Levator labii superioris alaeque nasi, this muscle has the
longest name of any muscle in the human body. It is sometimes
referred to as ‘Otto’s muscle’ after an anatomist who argued that
its anatomical name was too long. It is not to be confused with
levator labii superioris; this completely separate muscle arises
from the frontal process of the maxilla. Its interior fibres insert
on to the lateral alar cartilage and the dermis of the upper lip
and orbicularis oris. Again nerve innervation is provided by the
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Aesthetic Journal April 2014 Issue
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buccal branch of the facial nerve and, upon contraction, levator
labii superioris alaeque nasi dilates the nostril and elevates the
upper lip into a snarl.
Zygomaticus Minor originates from the zygoma, seated below
orbicularis oculi and laterally to the zygomaticomaxilliary suture.
Fibres pass downward and inferiorly insert into orbicularis oris.
Innervation is supplied by the buccal branch of the facial nerve
and blood supply via the labial branch of the facial artery. Upon
contraction, zygomaticus minor elevates and pulls the commissure
laterally, contributing to the smile but also the formation of the
nasolabial fold.
Muscle Group III
Depressor Labii inferioris originates from the anterolateral
mandible and medial to the insertion of the depressor anguli oris
and lying deeper than the depressor anguli oris. Its fibres pass in
a fan like distribution into the lower lip dermis and orbicularis oris
muscle, depressing the lower lip and pulling it slightly laterally.
Mentalis, a paired central muscle of the lower lip, arises from
the anterior midline of the mandible and inserts into the dermis. It
pulls down on the margin of inferior orbicularis oris and everts the
central portion of the lower lip. In conjunction with orbicularis oris
contraction, the mentalis muscle allows the lips to ‘pout’. Externally,
mentalis contraction causes wrinkling of the chin skin (a dimpled
chin), as used in expressions of doubt or displeasure.
Platysma is a broad thin sheet of paired muscle made up of
fibrous bands arising from the fascia covering the upper part
of the pectoral and deltoid muscles, passing upwards over the
clavicle, the fibres proceed upwards and insert into the inferior
border of the anterior mandible. The fibres cross superiorly just
before reaching the edge of the mandible border and attach to
the bone of the lower jaw and also have insertions into the skin
(Figure 9) Removal of
granulomatous material lower lip
unknown HA. Copyright Cosmedic
Skin Clinic 2014
(Figure 10) Removal of
granulomatous material lower lip
unknown HA. Copyright Cosmedic
Skin Clinic 2014
and subcutaneous tissue of the lower face. Many of the fibres of
platysma blend with muscle fibres of neighbouring muscles around
the angle of the mouth and lower face. The cranial branch of the
facial nerve provides innervation and predominant blood supply
via the submental branch of the facial artery.6,7,8
TREATMENT TECHNIQUE AND MINIMISING RISK
Starting with the vermillion border, and working from lateral to
medial, slowly inject the filler (retrograde technique) and aspirate,
or draw back, prior to injection to minimise the risk of intra-vascular
injection. Volume can be created by injecting into the wet/dry
border at mid-depth. Complications or unwanted side effects can
occur with the injection of any dermal filler no less so than when
injecting the lips, hence the importance of seeking training in
this specific technique from an experienced trainer. The first step
to avoiding complications is to ensure an appropriate product
for the indication is used. Adverse events, however, can still
30
Aesthetics Journal
Aesthetics
aestheticsjournal.com
occur and may be immediate or delayed in onset. Complications
might include injection site reactions, infection, sensitivity and
allergy, bruising and trauma from poor injection technique. After
a thorough consultation and medical history the practitioner
should consider herpes prophylaxis if indicated before treating
with dermal fillers (Aciclovir 200mg 5 times a day for 5 days).9
There is no evidence-based data to support the belief that fillers
play a triggering role in recurrent herpes infection and thus there
is no rationale in using an antiherpes prophylaxis regimen with
every patient. However, patients who have had an history of
developing cold sores after a filler injection may benefit from it.10
Filler injections should not be performed if there is an adjacent
site of infection e.g. intraoral, mucosal or dental infection or herpes
labialis for lip injections. Stopping anti inflammatory drugs and
refraining from alcohol for two to three days prior to injection can
help to minimise the risk of bruising. Practitioners should discuss
with the patient the treatment fully including expected results
and potential complications. Any pre-existing asymmetry or skin
conditions should be highlighted and of course good pre- and
post-treatment photographs are essential.
Products which are placed too superficially may result in
nodules or the presence of a bluish tinge known as the Tyndall
phenomenon. This can also be a result of hemosiderin caused by
intradermal bleeding.11 Nodules formed of hyaluronic acid (HA) in
the lip can sometimes be punctured and their contents expressed.
(Figures 9 and 10) Consider injections at the lip angles to offer
extra support and injection of the philtral column if needed for
optimum aesthetic results.
CONCLUSION
When treating the lips and perioral region it is important to create
and maintain an overall plan. Understanding the anatomy of the
region as well as taking into consideration the age, gender and
ethnicity of the patient will ultimately give a more favourable and
aesthetically pleasing result. Assessment using well-defined scales is
helpful and taking into account additional factors such as volume and
movement will create a more natural appearance.
Sharon King RN, NIP is a director and clinical nurse
specialist at Cosmedic Skin Clinic, board member of
The British Association of Cosmetic Nurses, member
of the Aesthetic Complications Expert Group and
Aesthetic Nurse Practitioner of the Year (Aesthetics
Awards 2013-14). She has worked as a clinical trainer for
some of the leading suppliers to the aesthetics industry during her 10
years in aesthetic practice.
REFERENCES
1. Chisholm BB, ‘Facial implants: Facial augmentation and volume restoration.’ Oral &
Maxillofacial Surgery Clinics of North America, 17(1), (2005), pp.77-84.
2. Goodman,G Duckless, ‘Lips: How to Rejuvenate the Older Lip Naturally and Appropriately’ Cosmetic Dermatology, Vol 25 No 6 (June 2012)
3. Swift A, Remington K, ‘BeautiPHIcation: a global approach to facial beauty.’ Clinical Plastic Surgery., 38 (2011), pp. 347-377
4. Naidu D, ‘Comparisons of the Consistency and Sensitivity of Five Reference Lines of the Horizontal Position of the Upper and Lower Lip to Lateral Facial Harmony’ The Orthodontic Cyber Journal, (2010) http://orthocj.com/2010/11/comparisons-of-the-consistency-and-sensitivity-of-
five-reference-lines-of-the-horizontal-position-of-the-upper-and-lower-lip-to-lateral-facial-harmony/
5. Hoefflin SM, The beautiful face: The First Mathematical Definition, Classification and Creation of True Facial Beauty (California, Steven M. Hoefflin, M.D, 2002)
6. Nelson DW, Gingrass RP, ‘Anatomy of the mandibular branches of the facial nerve.’ Plastic Reconstructive Surgery, 64(4), (1979), pp.479-82
7. Gray H, Grays Anatomy The Classical Collector’s Edition, (Crown Publishing, 1977)
8. Pinar Y A, Bilge, O,Govsa F, ‘Anatomic study of the blood supply of perioral region.’, Clin Anat., 18(5), (Jul 2005), pp.330-9
9. British National Formulary (BMJ Group London, 2013)
10. Duffy DM, ‘Complications of fillers: Overview’ Dermatol Surg, 31 (2005), pp. 1626-33
11. Bergeret-Galley C, Latouche X, Illouz YG, ‘The value of a new filler material in corrective and cosmetic surgery: DermaLive and DermaDeep’, Aesthetic Plast Surg, 25 (2001), pp. 249-55
Aesthetics | May 2014
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Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150.
5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a
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BEL092/0314/FS Date of preparation: March 2014
Clinical Practice
Treatment Focus
@aestheticsgroup
Aesthetics Journal
The SPF debate: benefits
and limitations
It’s vital to use SPF profusely, says aesthetic
specialist Deborah Forsythe
Deborah Forsythe is a
medical aesthetic specialist
and member of the Allergan
faculty responsible for
validating practitioners on
injection techniques. She specialises in nonsurgical dermal facial rejuvenation.
There is a dark side to the sun. The US
government has officially identified
ultraviolet radiation (UVR) both from the
sun and from tanning machines as a known
cause of cancer in humans.1 UVR produces
DNA changes that may lead to mutations
in genes involved in the development
of skin cancer.1 The US Environmental
Protection agency (EPA) estimates that the
sun causes 90% of all non-melanoma skin
cancers2 and other research links it to 65%
of all melanomas.2 Therefore, along with
other sun safety strategies, sunscreens that
absorb or block UVR serve an important
protective function. Sun Protection Factor
(SPF) is a concept that was first described by
chemist Franz Greiter in 1962. Coincidentally,
Greiter is also one of four people variously
credited with bringing to market the first
sun protection products in the 1930s and
40s. Recent changes to both the Food and
Drug Administration (FDA) SPF rules and the
European Cosmetic Regulation 1223/2009
have underlined the need for ‘broad
spectrum SPF’3.
To understand the SPF debate, we need to
be clear about the difference between SPF
and ‘broad spectrum SPF’, and for this we
need to understand what we are using them
for. Ultraviolet Radiation (UVR) is produced by
the sun and measured by wavelength, from
100 to 400. (Fig 1)
Even when the weather is cloudy, over 80%
of UV rays penetrate the cloud layer, and
other factors can increase UV exposure. For
example, sand will increase UV exposure by
Figure 1
32
Wavelength
From
To
Notes
UVA
100
290
Not filtered by glass
Penetrates dermis
Intensity consistent all day, all year
UVB
290
320
Unable to penetrate glass
Affects epidermis, causes sunburn
Most intense in summer - 70% of
annual exposure
Vitamin D synthesis
UVC
320
400
Absorbed by ozone layer
No effect on skin
Aesthetics | May 2014
Aesthetics
aestheticsjournal.com
up to 20% due to reflection of the rays, and
snow will do the same but with up to an 80%
increase in exposure. Within UVR, UVA and
UVB are not present in similar quantities they are split as 95% UVA and just 5% UVB.
However the different wavelengths are
responsible for different concerns, concisely
described by the European Commission,
document IP/06/571 04/05/20064 as, “UVB
radiation is the cause for ‘sun-burn’. UVA
radiation causes premature skin ageing,
interferes with the human immune system,
and is an important contributor to the skincancer risk.”
UVR affects skin both acutely and in the
longer term. Immediate effects are sunburn,
immunosuppression and DNA damage. As
reported by Green et al5 sunburn is due
to UVB radiation, and is an inflammatory
response known as apoptosis, which
breaks down damaged keratinocytes in
a sort of cell-suicide whereby severely
damaged cells are killed in an attempt
to prevent them becoming cancerous.
Sunburn is also associated with an
increased risk of melanoma, particularly
before the age of 20.6
Long-term UVR effects are caused by
both UVA and UVB damage. Fisher GJ
et al7 reported that UVA reaches the
dermis and is absorbed by fibroblasts
and stimulates matrix metalloproteinases
(MMPs), causing a reduction in collagens
I, III and VII, a reduction in fibrillin and an
increase in elastotic material It is these
changes that lead to the visible signs of
ageing – skin laxity, facial volume loss, fine
lines and wrinkles. Chronic sun exposure
is associated with an increase in risk of
squamous cell carcinoma (SCC)6 as UVA
and UVB radiation creates free radicals
(unstable oxygen molecules that have lost
one of their two electrons) which damage
cell function and can alter RNA and DNA.
Basal cell carcinoma (BCC) is the most
common skin cancer, and is also due to
long-term sun exposure. SPFs are mostly
combinations of physical and chemical
ingredients; zinc and titanium oxides are the
most frequently used physical screens, and
work by scattering the light and blocking it
from the skin; avobenzone, benzophenones,
dibenzoylmethanes, ecamsule, octocrylene,
octyl methoxycinnamate, PABA,
phenylbenzimidazole sulfonic acid and
salicylates are among the more common
chemical sunscreens, and they work purely
by absorbing UV light.8
The EU document IP/06/571 goes on to
state, “However, the so-called SPF only
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FOR FURTHER DETAILS, SCIENTIFIC & CLINICAL INFORMATION PLEASE CONTACT AESTHETICARE ®
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protects against sunburn (UVB radiation).”4
This led to changes in EU legislation
including the need for a UVA logo or seal to
inform consumers that a given product has
‘broad spectrum SPF’ (i.e. includes protection
against UVA), a ban on the terms ‘sun-block’
and ‘total protection’, and improved labelling
with standardised verbal descriptors.
In the US, SPF is measured when product
is applied to the skin at a uniform thickness
of 2mg/cm2. If it takes 10 minutes to burn
without a sunscreen and 100 minutes to
burn with a sunscreen, then the SPF of that
sunscreen is 10 (100/10). 2mg/cm2 equates
to approximately 30ml to cover the body,
and approximately 1.2g to adequately
cover the face. In Europe, The European
Commission guidelines recommend a higher
level of 35g to cover the body, equivalent
to six teaspoons of cream. Guidelines from
@aestheticsgroup
Cancer Council
Australia are clear:
“Apply sunscreen
liberally – at least a
teaspoon for each
limb, front and back
of the body and
half a teaspoon for
the face, neck and
ears. Most people
don’t apply enough
sunscreen resulting
in only 50-80% of the
protection stated on
the product.”9
SPF15 provides
greater than 93%
protection against
UVB. Protection
against UVB increases to 97% with SPF of
30+. Therefore the difference between a
SPF 15 and a SPF 30 sunscreen may not
have a noticeable difference in actual use
as the effectiveness of a sunscreen has
more to do with how much of it is applied,
how often it is applied, whether the person
is sweating heavily or being exposed to
water. EU Commissioner Markos Kyprianou,
responsible for health and consumer
protection says, “Consumers must be made
fully aware that no sunscreen product can
provide 100% protection against hazardous
UV-radiation. There are serious health risks,
such as skin cancer, linked to insufficient
protection from the sun. EU citizens need to
be fully informed about what sunscreens will
and will not do for them.”4
There is a vast body of evidence of the
damage that UVR can cause, from the
The deficit of UV stimulation is virtually
as dangerous as its surplus, argues Dr Tiina
Orasmae-Meder
Generally speaking,
the advice given
by cosmetic
dermatologists to
patients regarding
sunscreen is to
insist that it should be worn during all seasons, anywhere and
by everyone, suggesting to their patients, “There is no safe
tan.” Indeed, the damaging effect of ultraviolet (UV) has been
researched thoroughly. It’s been confirmed many times that the
skin damage caused by UV radiation is a major risk factor for all
types of skin cancer, including melanoma and basalioma1.
Degradation of dermal amorphous substance, increased activity
of free radicals resulting in enhanced lipid peroxidation, activated
metalloproteinase and direct activation of transcription factors,
Dr Tiina Orasmae-Meder is
a dermatologist and founder
of Meder Beauty Science,
based in Switzerland, and also
works at Iris Brand Vigilance
to guide cosmetic safety
34
Aesthetics Journal
Aesthetics
aestheticsjournal.com
immediate pain of ‘sun-burn’ through to
cosmetic and health implications of long
term exposure.
Protection against photo damage is critical.
Many procedures carried out by aesthetic
practioners increase the risk of damage
associated with exposure to UV radiation.
For maximum protection against the
damage of UVA and UVB a broad spectrum
SPF is essential.10 However the manner
of application of the SPF is vital to ensure
not only protection against ever present
UV damage, but continued support for the
epidermal and dermal structures to prevent
premature ageing.
REFERENCES
1. World Health Organisation (WHO), Environmental Health Criteria
(EHC) 160: Ultraviolet radiation, United Nations Environment
Programme, World Health Organization, International Commission
on Non-Ionizing Radiation Protection (Geneva: WHO, 1994)<http://
www.who.int/uv/publications/EHC160/en/>
2. United States Environmental Protection Agency, Sunscreen:
the Burning Facts (EPA, 2006) < http://www.epa.gov/sunwise/doc/
sunscreen.pdf>
3. Regulation (EC) No 1223/2009 of the European Parliament and of
the Council of 30 November 2009 on cosmetic products’, Official
Journal of the European Union (2009) <http://eur-lex.europa.eu/
LexUriServ/LexUriServ.do?uri=OJ:L:2009:342:0059:0209:en:PDF>
4. Council Directive of 27 July 1976 on the approximation of the
laws of the Member States relating to cosmetic products, (European Commission, 2010) <http://eur-lex.europa.eu/LexUriServ/LexUriServ.
do?uri=CONSLEG:1976L0768:20100301:en:PDF>
5. Green A, Williams G Logan V, Strutton G, ‘Reduced melanoma
after regular sunscreen use: randomized trial follow up’, J Clin Oncol,
29(3) (2011), pp. 257–63.
6. Bowes L., ‘Understanding the dermal effects of heightened
exposure to the sun’, Journal of Aesthetic Nursing, 1(1) (2011), pp.
25-31.
7. Fisher G.J., Datta S.C., Talwar H.S. et al, ‘Molecular basis of sun
induced premature skin aging and retinoid antagonism’, Nature, 379
(6563) (1996), pp. 335–9.
8. Skin Cancer Foundation < http://www.skincancer.org>
9. Cancer Council of Australia <http://www.cancer.org.au>
10. National Institute for Health and Care Excellence, Skin cancer
prevention: information, resources and environmental changes
(PH32) (NICE, 2011) <www.nice.org.uk/guidance/PH32>
FURTHER READING
Armstrong B.K., Kricker A., ‘How much melanoma is caused by sun
exposure?’, Melanoma Res, 3(6) (1993), pp. 395-401.
such as the activator protein 1 (AP-1) and nuclear factor kappalight-chain-enhancer of activated B cells, NF-kB are known effects
that UV radiation has on human skin. It is without doubt that
ultraviolet rays, especially UVB-type, cause degradation of the
skin’s main structures. However, lack of consideration of the UV
spectrum as a factor affecting human organisms is unfavorable.
One of the basic vitamins, liposoluble vitamin D, is synthesised
only if activated by skin exposure to UV radiation. Therefore the
absence of such stimulation may result in vitamin D deficiency,
and the development of hypovitaminosis. Insolation deficiency
in individuals who for various reasons have only limited sun
exposure (for example prisoners, Arctic dwellers and people
with disabilities that make it hard or impossible to spend time
outdoors) is known to enhance the development of osteoarticular
disorders (such as decrease in bone tissue density, pain
syndrome, undesired changes in ligament elasticity, stiffness and
dystrophic degeneration of joints) and characteristic changes of
skin2. Furthermore, vitamin D deficiency is linked to a higher risk of
certain types of cancer, cardiovascular pathologies, and decrease
Aesthetics | May 2014
A New Dimension in Non-Surgical Technology
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to launch a phenomenal new multi-functional device for the face.
Here are just some of the reasons why 3D-skintech will become
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• Complete treatment portfolio for anti-ageing,
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Full canopy LED ensures both rapid treatment time and excellent
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Blue (425nm - 470nm), Yellow (590nm) and Green (520 - 564nm)
ensures effective treatment for anti-ageing, pigmentation, acne and
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3D-skintech peels and clinical skincare
A compact range of medical grade peels and cosmeceutical skincare
products complete the Skintech’s unique offering and enables you
to both use as a “stand-alone” service or combine with equipment
protocols.
‘To compliment our core injectable business the 3D-skintech has added an array of
new result driven facial services to our clinic’s menu as well as the combination services
for our more curative patients. We recognized that this device offered the stand alone
quality of each technology in a unique machine that will ensure that we both deliver the
results but equally can make money from the start due its affordability. As a clinician
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Clinical Practice
Treatment Focus
@aestheticsgroup
in immunity system function.3
From an aesthetic point of view, both insufficient and excess
exposure to UV radiation causes rather similar skin changes.
Excess UV is a risk factor for skin tumours and accumulative
pigmentation disorders (hyperpigmentation, mostly of chloasma or
melasma type). However, if we look at the potential acceleration of
ageing as a process of structural proteins’ degradation, then the
deficit of UV stimulation is virtually as dangerous as its surplus.
To establish a safe time frame for insolation, it is crucial to
remember that there are different levels of UV radiation. The
intensity of its impact depends on several factors: the number of
rays penetrating the atmosphere, their angle to the Earth, and the
presence or absence of barriers (dust in the air, clouds, high levels
of ozone).
In Saint Petersburg, Oslo, Stockholm and some other cities the
level of UV radiation is so low that it can be disregarded. The UV
index 1 is considered a negligibly low level of UV radiation and in
the course of the northern winter the UV index may equal 0 for
significantly long periods of time. At this time, I would advise that
using sunscreen is not necessary because there is no damaging
impact to protect the skin from.
A noticeable damaging effect (i.e. with visible results on
unprotected skin after 20 minutes exposure to the sun) is
caused by sun radiation with UV index 5 or higher. In England
the season of intense UV (around UV index 7) lasts for no more
than two weeks, usually at the end of June. The UV index in
England virtually never goes higher than 8, a level that borders
between “high risk” and “very high risk”. In England, the average
UV index from the end of October until the beginning of April
rarely exceeds 3. The intensity and characteristics of the vitamin
D synthesis varies and is individual. For some people, several
minutes of exposure to the sun is sufficient to activate the
synthesis completely, whilst others need more time. According
to a large survey held in the USA in 2001-2006, around 8% of
the population are in the vitamin D deficiency risk group, and
another 24% face the risk of insufficient intake. Together these
two groups make up almost a third of the country’s population3.
Various research shows that some vitamin D deficiency, at least
half-related to insufficient insolation, is diagnosed in over a billion
people over the world3.
Aesthetics Journal
Aesthetics
aestheticsjournal.com
In Saint Petersburg, Oslo,
Stockholm and some other cities
the level of UV radiation is so
low that it can be disregarded.
The UV index 1 is considered
a negligibly low level of UV
radiation and in the course of the
northern winter the UV index
may equal 0 for significantly long
periods of time.
Of course, a lot depends on the laboratory data that researchers
rely on, specifically the level of 25-hydroxycholecalciferol (25(HO)
D) that is considered borderline. Today most researchers agree
that the level of 25(HO)D < 30 nMol/L corresponds to a vitamin
D deficiency risk, and level 30 to 49 nMol/L signifies insufficient
intake. Level 50 nMol/L and higher allows us to call the intake
sufficient4.
The nutrition available to an average person does not cover the
need for vitamin D due to low amounts of it in staple foods and
high caloric value of the food that contains calcifierol5. According
to research data, people living between the 37th and 50th
parallels (most European countries and a large part of North
America) do not receive the amount of insolation necessary for
independent vitamin D synthesis in winter time5, and for those who
live north of the 50th parallel (Scandinavian countries and most of
Russia) the level of UV radiation is not high enough for complete
synthesis all year round6.
I absolutely concur with the consensus that it is completely
necessary to use sunscreens when open body parts are exposed
to the sun with UV index higher than 5. It is important to remember
that even with the low UV index its impact can be doubled in the
mountains or by the sea due to the light reflecting from snow
or water. But for city dwellers, in the days when UV index is not
higher than 4 and especially when the solar activity is minimal and
UV index equals 1–2 or less, I believe there is no objective need to
protect the skin from the sun.
Moreover, excessive use of sunscreen may lead to the
development of vitamin D deficiency and related problems, like
the acceleration of the natural skin ageing process, early wrinkles
and loss of skin tone. The guidelines for using skin protection
against the sun are too general and based on an assumption that
ultraviolet radiation in any form has a solely damaging effect.
REFERENCES
1. Marija Buljan et al, ‘The Role of UV Radiation in the Development of Basal Cell Carcinoma’, Coll
antropol., 32 (2008) <http://www.ncbi.nlm.nih.gov/pubmed/19138022>, Suppl. 2, pp. 167-170.
2. M. Nathaniel Mead, ‘Benefits of Sublight: A Bright Spot for Human Health’, Environ Health Perspect.,
116(4) (2008) <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2290997/>, pp. 160-167.
3. Holick MF, ‘Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers,
and cardiovascular disease’, American Journal Clinical Nutrition, 80(6 Suppl) (2004), pp. 1678S-88S
4. Wolpowitz D1, Gilchrest BA, ‘The vitamin D questions: how much do you need and how should you get
it?’, Journal of the American Academy of Dermatology, 54(2) (2006), pp. 301-17
5. Ross AC, Taylor CL, Yaktine AL, Del Valle HB, Dietary Reference Intakes for Calcium and Vitamin D,
(Washington (DC): National Academies Press, 2011)
6. Harinarayan CV, Joshi SR, ‘Vitamin D status in India — Its implications and Remedial Measures’, Journal
of the Association of Physicians of India, 57 (2009), pp. 40–48
36
Aesthetics | May 2014
F or m e d i u m to d e e p
d e pr e s s i o n s i n clu d i n g
na so - l ab ial F o lds . 1
WITH LIDOCAINE
A highly versatile, injectable gel
using VYCROSS™ technology.1
reference: 1. Juvéderm VOLIFT with Lidocaine DFU, 2013.
Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK | May 2013 UK/0658/2013
Clinical Practice
Clinical Focus
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
Pigmentation:
a topical issue
Ruth Donnelly speaks to leading aesthetic
practitioners regarding their recommendations
for treating pigmentation problems using skincare
The treatment of pigmentation is a rapidly
emerging market in aesthetics. “Dark
patches, irregular skin tone, sun spots on
the hands, face, chest, neck and red faces
are some of the most ageing conditions
on the skin,” says esteemed consultant
dermatologist Dr Nick Lowe. Many
practitioners treat the condition with laser
and light-based treatments, using skincare
as a complementary resource. However,
with a recent influx of cosmeceutical
products designed specifically for the
purpose, some experts in the field assert
that topical treatment should be every
practitioner’s front line when it comes to
pigmentation.
A 2012 study conducted by Dr Lowe
showed that a combination cream
programme can be as effective as
treating pigmentation with Intense Pulsed
Light. An independent double blind
study was carried out on 24 randomly
selected subjects with mild to moderate
pigmentation, who received either the
cream treatment (12 subjects) or IPL (12
subjects). Results showed that when
measured with the complexion analysis
computer, 10 of 12 subjects (83%) of
those treated using the cream treatment
programme showed improvement,
as did those treated with IPL (10 of 12
subjects/83%).1 “This study clearly shows
that a daily combination of the right creams
can be highly effective for redness and
pigmentation,” says Dr Lowe.
With the number of ways to treat
pigmentation evidently on the rise,
approaches vary. However, most leading
practitioners agree that skin preparation
is key. “People with colouration need to
be medically blended as best they can
before they go on to further treatment,”
38
says Beverly-Hills based dermatologist
Dr Harold Lancer. “So the protocol in my
clinic is that everyone is evaluated by
me then at the end of that consultation
a treatment plan is created to include
lightening, exfoliating and epidermal
and dermal rebuilding agents; topical
medical treatments are used for at least
a two to four week period before any
instrumentation is considered.”
Dr Mervyn Patterson agrees that skin
needs to be fully prepped before the
commencement of any treatment, be
it laser, IPL or topical. “It’s important to
control all aspects of the pigmentation
process whilst at the same time controlling
inflammation, without disrupting the
external skin barrier,” he says. “Tackling
pigmentation without first repairing the
skin barrier and dampening chronic
inflammation would be like repainting the
walls of a building without first fixing the
roof.”
Key patient groups
Although commonly thought of as an
age- or ethnicity-related issue, people of
all ethnic groups, ages and both genders
experience pigmentation problems.
However, the way you treat the problem
will differ depending on many factors,
foremost of which, according to Dr Lancer,
is the patient’s ancestry. “Pigmentation
concerns are the most difficult arena in
cosmetic dermatology,” he says. “Because
the lighter the ancestry – not just the
clinical presentation of the patient, but
the geographical origin of their greatgrandparents and grandparents – the
chances are, the better result from
treatment. So if you have a pigmentary
problem in a person from a Swedish
origin then chances are you will get a
Aesthetics | May 2014
better result than in someone with a fairer
complexion but who is from a Moroccan or
Italian ancestry.” Founder of Pharmaclinix
Advanced Cosmeceuticals and chemist,
Shashi Gossain agrees that pigmentation is
a complex issue. “Types of skins and types
of melasma are very different,” she says.
“Some people have very light patches, and
some patches are very deep due to long
exposure to sun damage, so you have
to be careful and specific on what and
how you treat. You absolutely cannot use
lasers to treat hyperpigmentation on skin
types III to V, because of the risk of postinflammatory hyperpigmentation, which is a
lot more common in the darker skin tones.”
Hydroquinone – the gold standard?
Hydroquinone has been deemed to
be the gold standard for the treatment
of pigmentation for over 50 years2.
However, it has been reported that 80%
of patients can develop a resistance
to hydroquinone if used for more than
a few months3, and the ingredient has
also been shown to cause ochronosis,
a skin condition presenting as severe,
irreversible darkening and coarsening of
the skin, in darker Fitzpatrick skin types.4
Although hydroquinone can still be found
in most of the major prescription-only
skincare lines, some doctors prefer not
to use the ingredient, for reasons of both
safety and efficacy. “I reject hydroquinone
or hydroquinone/retinoid combinations
because of the irritation rates and risk of
profound rebound of pigmentation once
the bleaching agents are withdrawn,” Dr
Mervyn Patterson explains. Dr Lowe takes
a different approach, combining agents
to achieve optimal results. “It’s key when
treating pigmentation to use a combination
of numerous safe lightening agents to work
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Date of prep: October 2013
References
1. Rzany B et al, Dermatol Surg 2012;38: 1153–1161
2. Cartier et al, J Drugs Dermatol. 2012; 11 (1)(Supp): s17-s26
(*Results taken from a mean value across all treatments performed in study)
3. Farhi D et al, J Drugs Dermatol 2013; 12: E88-E93
Clinical Practice
Clinical Focus
Active Ingredients
Lorna Bowes lists some of the key
ingredients that she would recommend
when choosing a skincare line to treat
pigmentation
Fruit and lactic acids – exfoliate to
reduce superficial hyperpigmentation
Vitamin C – reduces melanin
production
Neoglucosamine – reduces tyrosinase
and exfoliates
Tertahydrocurcumin (THC) – inhibits
tyrosinase production; antioxidant
properties
Oligopeptide 34 – reduces tyrosinase
and melanin production; antiinflammatory properties
Kojic acid – chelates copper and
inhibits tyrosinase production (although
many manufacturers have chosen to
withdraw products containing kojic
acid due to concerns of dermatitis and
toxicity)
@aestheticsgroup
Aesthetics Journal
on different aspects of melanin production.
This is a preferable approach to only using
prescription hydroquinone products.” Other
practitioners claim that the ingredient can
be used safely if clinicians are cautious:
Dr Lancer says, “We use hydroquinone
treatment under tremendous clinical
observation; we don’t use prescription
level hydroquinone, our chemists make it
to our specification. Depending on how it’s
manufactured and what it’s blended with,
it works differently; discolouration from
hydroquinone can occur only if it’s used in a
misguided fashion.” The shift away from the
use of hydroquinone has led cosmeceutical
companies to conduct significant research
into what other ingredients can be used
to treat pigmentation problems. Lorna
Bowes, aesthetic nurse and director of
AestheticSource.com, UK distributor of
NeoStrata, says, “There are multiple plant
extracts known to resurface, reducing
superficial hyperpigmentation, and inhibit
tyrosinase, which is a key enzyme in the
production of melanin.”
Topical versus light-based treatments
Although proven to effectively treat
pigmentation, lasers and light sources do
have their limitations. “There are many
things that will not respond [to lightbased treatment], even in the most ideal
circumstance,” Dr Lancer explains. “There
are certain hormonal situations such as
oestrogen imbalance that can cause a high
risk rate or non-response rate to lasers and
light sources.”
Dr Marc Ronert, president and medical
director of Image Skincare, claims that the
new Iluma line from Image yields similar
results to laser treatment. He adds that,
“The active ingredients in the Iluma line
have also been clinically proven to block
melanin production, which is not possible
with a laser.” These ingredients include
Belides (bellis perennis (daisy flower)) and
Indian Kudzu Pueraria tuberosa leaf cell
extract, claimed by the company to limit
melanogenesis.
Many clinicians clearly agree that it is
possible to receive effective results
from the use of skincare products alone;
however, patient education is key to
yielding those results.
Patients before and after treatment with cream1
40
Educating your patients to increase
positive outcomes
Dr Nick Lowe explains that the efficacy of
a skincare range depends on the user’s
commitment to the regime. “The biggest
Aesthetics | May 2014
Aesthetics
aestheticsjournal.com
problem with treating pigmentation with
skincare is patient compliance, especially
regarding sun protection,” he says. “The
secret of success is through compliance
in the use of lightening products, and
year-round sunscreen use is absolutely
essential. The skin must always be
protected with a day cream containing
anti-oxidants and broad-spectrum UVB and
UVA protection. Without this, any benefits
from creams or IPL will be undone as sun
exposure is one of the primary causes of
pigmentation and contributes to redness.
“Patient education about this is very
important. There is a myth that patients
need not apply their skin lightening creams
if they are on a sunny holiday. This is
absolute nonsense. In fact this is when they
need it most.”
Dr Stefanie Williams agrees; “Whether a
prescription or non-prescription option
is chosen, the patient must use a broadspectrum sun protection with SPF 45 or 50,
every single day, whether sunny or not,” she
says. “However, it’s not only sun protection,
but also sun avoidance that is crucial. One
day of excess sun can undo months of
treatments.” The clinician’s job is therefore
to ensure that patients understand the
importance of sticking to the prescribed
treatment programme.
Another key factor in patient education
is managing expectations. Although the
overall results from a skincare regime can
be extremely effective, it will take longer for
those results to appear than with a course
of laser treatments, and patients need to
be aware of that. “It’s important to tell the
patient that any improvements are gradual,”
Dr Williams explains. “The best result can
take as long as six months.”
However, topical skincare for the correction
of pigmentation can be combined with inclinic treatments, such as chemical peels,
for maximum effect. Dr Lowe claims that the
combination of skincare with Dermasweep
can prove particularly effective.
“Dermasweep uses a vacuum action to lift
the skin as the particle-free dermabrasion
brushes sweep away dead skin cells,” he
explains. “This disturbs the skin barrier
just enough to enable the infusion of an
antioxidant skin lightening complex. There
was a good presentation on brush-delivered
systems at the recent American Academy of
Dermatology conference. This system can
also be used with laser or intense pulsed
light treatments to improve results.”
ELEGANT • FULFILLED • MY TIME
Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product
Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from
complexing proteins as a powder for solution for injection. Indications Temporary improvement
in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important
psychological impact for the patient. Dosage and administration Unit doses recommended for
Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is
20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May
be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18
years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type
A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis,
Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site.
Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for
treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or
taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic
lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming.
Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use
with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should
be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised
pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection.
Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory
problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10);
common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very
rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza
infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders;
Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia,
dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal
disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon:
pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders;
Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle
twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or
rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines)
and other indications. Overdose May result in pronounced neuromuscular paralysis distant from
the injection site. Symptoms are not immediately apparent post-injection Bocouture® may only
be used by physicians with suitable qualifications and proven experience in the application of
Botulinum toxin Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number:
PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer
Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: November 2013.
Full prescribing information and further information is available from Merz Pharma UK Ltd., 260
Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143
Adverse events should be reported. Reporting forms and information can be found at
www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd
at the address above or by email to [email protected] or on +44 (0) 333 200 4143.
1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2012 September Available
from: URL: http://www.medicines.org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a
single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et
al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another
botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154.
4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily
practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01
Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA.
1139/BOC/NOV/2013/LD Date of preparation: March 2014
Clinical Practice
Clinical Focus
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
The ones to watch
Super Light Skin Tone
Perfector by Dr Nick Lowe
Iluma by Image Skincare
Super Light Skin Tone Perfector by Dr Nick Lowe
Dr Lowe’s most powerful skin lightening cream yet, the cream contains an increased number
of skin lightening active ingredients, from three to nine. Octadecenedioic acid and liquorice
root extract limit melanin production in the skin cells that produce pigment, niacinamide and
azalaic derivative lightens skin, whilst ferulic acid provides natural antioxidant protection against
pigmentation. Preliminary studies showed that 71% of subjects showed a visible reduction in the
appearance of pigmentation spots, 77% of subjects reported a more even skin tone and 82%
of subjects reported a more radiant complexion after just four weeks of use. “The key is to use
products with proven active ingredients, such as niacinamide, liquorice extract and anti-oxidants,”
says Dr Lowe.
Iluma by Image Skincare
“What really makes Iluma unique is the use of a revolutionary new delivery system called
Vectorize Technology,” says Dr Ronert. The company claims that the Vectorize delivery system
creates non-ionic vesicles that penetrate the deeper layers of the skin, releasing active
ingredients for a prolonged time. With active ingredients including green tea extract, Dipeptide-16,
Vitamin C and Coenzyme Q10, the Iluma range aims not only to correct pigmentation problems
but to prevent their recurrence.
Epionce MelanoLyte Pigment
Perfecting Serum and Melanolyte Tx
Medik8 White Balance Click
NeoStrata Enlighten
REFERENCES
1. Hassan, H. Lowe, NJ. Barlow, R. Harris, D., ‘Four methods of evaluation of facial erythema and pigment treated with intense pulsed light or cream’, Journal of Cosmetic and Laser Therapy 14 (2012), pp. 200-206
2. Halder R. M. and Richards G.M., ‘Topical Agents Used in the Management of Hyperpigmentation’, Skin Therapy Letter, 9(6) (2004) <http://www.medscape.
com/viewarticle/482649_2>
3. Hill, Rosalind, ‘Zein Obagi: ZO Skin Health’, PRIME Journal, (2012) <https://www.prime-journal.com/zein-
obagi-zo-skin-health/>
4. Phillips, James, ‘Ochronosis in Black South Africans
Who Used Skin Lighteners’, American Journal of
Dermatopathology, 8(1) (1986) <http://journals.lww.com/
amjdermatopathology/Abstract/1986/02000Ochronosis_in_
Black_South_Africans_Who_Used_Skin.3.aspx>
5. Epionce, Melano Corrective System vs. Obagi® Nu Derm
for Hyperpigmentation (Episciences, Inc.: www.epionce.
com, 2011) <https://www.epionce.com/wp-content/
uploads/2011/09/5_ClinicalStudy_EpionceMCSvObagi.pdf>
42
Epionce MelanoLyte Pigment Perfecting Serum and Melanolyte Tx
“An independent clinical study showed that Epionce MelanoLyte Pigment Brightening Lotion and
Pigment Perfecting Serum are as effective as hydroquinone/retinoid combinations without the
irritation5,” says Dr Patterson. “Epionce Pigment products contain a wide blend of proven botanical
ingredients that are effective at controlling all the steps in the pigmentation process and at
reducing inflammation.” Active ingredients include turmeric, paper mulberry, bamboo and apple,
and the promotional pack claims that, if used together, the two products address all the steps
leading to irregular pigmentation.
Medik8 White Balance Click
A brightening serum containing kojic acid, niacinamide, alpha-arbutin and linoleic acid, Medik8
White Balance Click claims to combat seven signs of hyperpigmentation, including sun damage,
age spots, dark spots, melasma, uneven skin tone and blotchiness. “We use the Medik8 White
Balance Click in our clinic because it contains a good concentration of a number of effective
over-the-counter anti-pigmentation ingredients,” says Dr Williams.
NeoStrata Enlighten
NeoStrata Enlighten is a three-product regimen containing NeoGlucosamine, THC, Vitamin C,
Oligopeptide 34 and selected plant extracts. “In a study presented at the European Academy of
Dermatology meeting in 2012, NeoStrata Enlighten demonstrated efficacy when used alone to
lighten hyperpigmented areas, as well as providing all over brightening of skin tone,” says Lorna
Bowes. “A group of 30 ethnically diverse women used the Enlighten three product regimen for 16
weeks; clinical grading, chronometer measurement, photography and self-assessment were used
to establish efficacy and 93% of patients showed clinical improvement within four weeks.”
The future is bright
With technology and products improving all the time experts agree that treatment for
pigmentation can only get more effective in years to come. “The topical chemistry of
products we use is reinvented every six to 18 months,” Dr Lancer says. “So chemistry and
technology is always improving.” As consumers become ever more aware of the ageing
effect of dark spots and uneven skin tone, clinics will need to have more tools at their
disposal to treat a diverse range of patients, and it seems that skincare could play a pivotal
role, as both a post-procedure regimen and a stand-alone treatment.
Disclaimer: Please refer to the European Commission directive 1223/2009 Scientific Committee on
Consumer Safety for opinions on certain ingredients
Aesthetics | May 2014
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Scar
Treatment
Aesthetics Journal
Aesthetics
aestheticsjournal.com
understand this, and it almost seems trivial to even consider such
unimportant issues as overhang and stretch marks – they are often
considered our battle scars to be worn with pride.
For me, treatment for the caesarian section overhang happened by
accident. I had acquired a CoolSculpting machine and one of my
patients requested I treat her caesarian section overhang. There
was sufficient mobility of the fat to treat with CoolSculpting and the
results were very encouraging. Unfortunately, many women do not
realise that there is such an effective, non-invasive treatment for this
fat bulge, and still believe the only treatment is invasive liposuction.
However, if clinicians increasingly focus their attention on treating
both striae distensae and the caesarean overhang, our patients will
as a consequence feel that they don’t have to just “put up “ with the
sequelae of pregnancy.
Dr Carolyn Berry shares her
experiences in treating caesarean
scars and stretch marks
There has been an interesting evolution of ‘body awareness’ in
aesthetic practice. In the past, we have been primarily concerned
with rejuvenating the face, but certainly in my practice, there has
evolved an increasing emphasis on improving body concerns. This
is particularly noticeable at this time of year, as our patients prepare
for their summer holidays. Interest in body image increases year on
year and I anticipate it will continue to do so. As practitioners, we need
to be appropriately skilled in order to address our patients’ concerns
and provide them with the best possible results. Whilst we are seeing
a growing male population in our practices, the majority is still made
up of women. A large proportion of these women have children
and very few women go through pregnancy without any sequelae.
Stretch marks are a very common problem, particularly on the lower
abdomen. The caesarean section scar itself is rarely a significant worry
because it now lies very low, however the ‘overhang’ affects virtually
100% of women post caesarian section, even the very thin. This is
due to the reflection of the abdominal fat of the rectus muscles of the
anterior abdominal wall.
Caesarean section overhang
Most women aspire to wearing a bikini post childbirth. It is a marker of
body attractiveness because it is unforgiving and shows every bulge
and imperfection, and even those without abdominal stretch marks
struggle with the ‘fatty pouch’ or overhang following caesarian section.
Because of this I am increasingly asked to provide correction. Many
of these women are not existing patients, and are not already having
aesthetic treatments. However, successful treatment of this area often
leads to further interest in other aesthetic procedures.
As a doctor I have been pre-occupied with the caesarean overhang
for many years, having first noted it when I worked in general practice.
What fascinated me was that it did not just occur with heavier women,
but also with very slim women with a flat abdomen. Even these women
experienced a little bulge, tending to sit just above the bikini bottoms.
Unfortunately there is very little in medical literature about this
phenomenon, and it appears thus far to have been largely ignored
by doctors. The overriding consensus would appear to be: baby
well, mother well, scar clean and healed, job well done. One can fully
44
Dr Berry uses CoolSculpting to treat caesarian section overhang
Striae distensae
Unlike the overhang, there is thankfully some helpful information
on stretch marks. Striae distensae (stretch marks) are an extremely
common, therapeutically challenging form of dermal scarring.1
Aetiology remains somewhat of a mystery with various possible
causes cited including hormones, physical stretch and structural
alterations to the integument. Genetics would also appear to be an
important factor in determining susceptibility of connective tissue.2
Various treatments have been trialled over the years. However,
few high-level randomised controlled trials evaluating treatments
for striae distensae exist. The histology of stretch marks is that of
a scar and the development likened to that of wound healing.3 In
the early stages there are inflammatory changes with recent striae
distensae showing superficial perivascular lymphocytic infiltrate
around the venules.4 In the later stages there is thinning of the
epidermis due to flattening of the rete ridges and loss of collagen
and elastin.5
Many therapies have been tried over the years, including topical
agents, and these have had limited success. Vitamin E creams
may have some effect on prevention of stretch marks6 and
Tretinoin was found to have better results in striae rubra but even
this was limited.7 As our patients’ expectations have evolved
they now expect significant change and good results, and are
increasingly unhappy with minor improvements, which means we
as practitioners are under pressure to deliver.
Treatment
With the knowledge that we are dealing with scar tissue, it is
reasonable that we treat striae distensae in a similar manner to a
scar. Scar tissue needs to be damaged and stimulated to initiate
Aesthetics | May 2014
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Aesthetics Journal
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Clinical Practice
Techniques
reconstructive surgery showed a substantially beneficial effect of
PRP for several indications, including better wound healing rate, an
increased survival rate of fat grafts and an enhancement of bone
graft regeneration.14 Platelets contain a number of bioactive factors
that contribute to the process of wound healing, such as platelet
derived growth factor and transforming growth factor.15
Technique
I had already observed that PRP
has really revolutionised my
treatment of scar tissue in general,
and therefore predicted similarly
positive results when treating
striae distensae.
repair mechanisms and so the more invasive treatments will
yield better results. Having researched the literature and various
treatment modalities it became apparent to me that lasers presently
appear to give the best results.8 Various lasers improve the
appearance of striae distensae: the pulse dye improves immature
striae rubra,9 and the Nd:Yag laser gave satisfactory results in
treatment of striae distensae in a study of 20 patients.10
The most encouraging results to date have been with fractional but
unfortunately the studies with fractional laser available are few and
limited. A 2007 Brazilian clinical study showed that Fraxel improved
texture and appearance of mature, white striae distensae in skin
type I to IV. The study demonstrated an early new indication for
stretch mark treatment with Fraxel.11 This certainly looks promising
and from reviewing the literature, it would seem that fractional is the
laser currently giving the best results in treating striae distensae.
However mention should also be made of radiofrequency. Of
note is a study evaluating the effectiveness of a radiofrequency
device in combination with a pulsed dye laser, in which 89% of the
patients showed good to very good overall improvement. This is of
particular interest because the study population was Asian and only
one developed hyperpigmentation, which then improved in three
months.12
So where does this leave treatment of striae distensae? I for one
want more efficiency and whilst the studies show improvement,
we want reproducible and excellent results. How therefore
can I improve upon the results of fractional laser, and maximise
stimulation of the repair mechanisms?
The answer would appear to be with platelet rich plasma. I had
already observed that PRP has really revolutionised my treatment
of scar tissue in general, and therefore predicted similarly positive
results when treating striae distensae. General studies encouraged
this thought and good results have been achieved by adding PRP
treatment to fractional radiofrequency. Objective assessment in
one study showed 71.9% of participants reported “good” or “very
good” overall improvement.13 A review study of PRP in plastic and
As previously mentioned, I apply my scar treatment to stretch marks
and caesarian section scars. If the patient has loose skin, which
they often have as the abdominal skin has lost elasticity due to
the striae distensae, I will start them on a course of radiofrequency
with weekly treatments. Not only will this tighten the skin but it also
causes visible improvement in the striae distensae without further
treatment. Usually after three treatments, the patient has CO2
fractional resurfacing and immediately afterwards, I inject their PRP
under the treated skin, paying particular attention to the worst striae
distensaes and to the caesarian scar. I mainly use a mesotherapy
technique, or inject the length of the striae distensae. The settings
for the CO2 laser will depend on assessment of the patient’s skin
and apparent depth and severity of the lesions. The first treatment
is usually milder to allow me to assess what they will tolerate and
how long their healing time is. When healed, the patient will return
to their radiofrequency for a further three treatments after which
I will repeat the process. I only treat skin types I to IV with this
method as studies have shown treatment of IV to VI can cause
side effects, including hyperpigmentation.16 In darker skins I use
radiofrequency and skin needling with PRP injections.
Dr Carolyn Berry was brought up and trained in Belfast.
Practicing as both a research fellow and GP, she founded
the Firvale Clinic in 2008. Her aim is to bring excellence
in Aesthetics medicine, through treatments and research
of new techniques. Firvale Clinic is now one of the
most technically advanced clinics in the UK, offering a wide range of
treatments to its patients.
REFERENCES
1. Al-Himdani et al. Striae distensae: a comprehensive review and evidence based evaluation of prophylaxis and treatment. British Journal of Dermatology, 170, (2014), pp. 527-547.
2. Burrows NP, Lowell CR, ‘Disorders of Connective Tissue’. Textbook of Dermatology (Blackwell Science, 2004), pp. 46-47.
3. Atwal GS, Manku LK, Griffiths CM et al. ‘Striae gravidarum in primiparae’, Br J Dermatology, 155 (2006), pp. 965-9.
4. Arem AJ, Kischer CW. ‘Analysis of Striae’, Plast Reconstr Surg,65 (1980), pp. 22-9.
5. Pierard GE, Nizet Jl, Adant JP et al. ‘Tensile properties of relaxed excised skin exhibiting stria distensae’, J. Med Engl Technol, 23 (1999), pp. 69-72.
6. Wierrani F, Kozak W, Schramm L N et al. ‘Attempt of preventative treatment of strie gravidarum using preventative massage ointment administration’, Wiener klinische Wochenschrift, 104 (1992), pp. 42-4.
7. Kangs, Kim KJ, Griffith CE et al. ‘Topical tretinoin (retinoic acid) improves early stretch marks’, Arch Dermatol, 132 (1996), pp. 519-26.
8. Elsaie ML, Baumann LS, Elsaaiee LT. ‘Striae distensae (stretch marks) and different modalities of therapy: an update’, Dermatol Surg Vol 35 (2009), pp. 563-573.
9. Karsai S, Roos S, Hammes S, et al. ‘Pulsed dye laser: what’s new in non-vascular lesions’, JEAD, 21(2007), pp. 877-90.
10. Goldman A, Rossato F, Pratti C. ‘Stretch marks: treatment using the 1,064 nm Nd:YAG laser’, Dermatol Surg, 34(2008), pp. 1-7.
11. Macedo OR, Macedo O, Bussade M et al. ‘Fractional photothermolysis for the treatment of striae distensae’, JAAD, 56 (2007), p. 204.
12. Ho D, Moskowitz K, Sum R, Dee J, Rudolph A,Burch C, Pebley W and Orser C. ‘Wound Healing Properties of Reconstituted Freeze-Dried Platelets’, Wound Repair and Regeneration, 13 (2005), pp. 1067-1927.
13. Suh DH, Chang KY, Son HC et al. ‘Radiofrequency and 585 nm pulsed dye laser treatment of striae distensae: a report of 37 Asian patients’, Dermatol Surg 33 (2007), pp. 29-34.
14. Suh DH, Lee SJ, Lee JH, Kim HJ, Shin MK, Sang KY. J. Cosmet Laser Ther, 14 (2012), pp. 272-6.
15. Sommeling CE, Heyeman A, Hoeksematt, Verbelen J, Stillaert FP, Monstrey S, J. Plast Reconstr Aesthetic Surg, 66 (2013), pp. 301-11
16. Nouri K, Romagosa R, Chartier T, Bowes L and Spencer JM. ‘Comparison of the 585nm Pulse Dye Laser and the Short Pulsed CO2 Laser in the Treatment of Striae Distensae in Skin Types 4 and 6’, Dermatologic Surgery 25(1999), pp. 368-370.
Aesthetics | May 2014
45
Clinical Practice
Spotlight On
@aestheticsgroup
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Rapid Polymerising
Collagen: Tissue in a Syringe
Collagen could be returning to the UK aesthetics
market with the development of a new collagen
dermal filler portfolio. But what benefits does
collagen have to offer the modern practitioner?
Collagen was the original dermal filler; it rapidly became so
synonymous with volumising that it is still often used as a popular
term for all fillers, particularly in the lips. Introduced in the 1980s, it
was skin-friendly, safe, soft and natural. However, there was a small risk
of allergic reaction to bovine collagen, so patients required a skin test,
and the product lasted as little as two to four months post-injection.
The emergence of safe, long-lasting and reversible hyaluronic acid
fillers decreased the demand for collagen. A durable, cross-linked,
porcine collagen product, Evolence, was launched in 2004 but was
withdrawn again in 2009 for business reasons. However, whilst HA
fillers are now incredibly sophisticated, some doctors are still nostalgic
for the unique properties of porcine collagen, particularly for fine,
delicate skin indications.
At IMCAS, at the beginning of 2014, EternoGen attracted a great
deal of interest as the company unveiled a new collagen portfolio
comprising Rapid Polymerising Collagen (RPC) and Gold Nanoparticle
Collagen (CG Nanomatrix). Charles Weatherstone, EternoGen’s
marketing director, announced that, “Both have been formulated with
unique integral shielding protection from collagenase degradation to
offer long-lasting, natural-looking treatment results.”
“They are also designed to provide high biocompatibility, facilitating
natural integration with the skin at a cellular level, which minimises
the risk of inflammatory reactions and post-treatment problems,” says
Weatherstone. “A lidocaine combination has also been developed
to ease discomfort on injection of RPC.” Given the sheer number of
hyaluronic acid fillers, we might question why the aesthetics market
needs a new collagen filler. Weatherstone explains, “Skin is 80%
collagen, and collagen is lost with age. Injected hyaluronic acids hold
the skin up well, but they stay as a bolus, and don’t integrate with the
skin. On the other hand, RPC is a liquid that trickles through the dermis.
After a few minutes, it polymerises to form a mesh of tissue that won’t
migrate or change shape.”
“In our studies, just two weeks after injection, blood vessels started
to grow into the injected collagen,” he says. “After 53 days, you
could look at the injection site under a microscope and the collagen
was completely integrated into the dermis. It all became one tissue,
which is why we call it ‘tissue in a syringe’. It also improves skin
smoothness and radiance.” EternoGen has conducted investigations
into conjugating collagen with gold nanoparticles to provide additional
benefits and enhanced duration. The research, carried out at
University of Missouri, demonstrates that Gold Nanoparticle Collagen
(CG Nanomatrix) has the potential to further increase resistance to
degradation with treatment results lasting for up to two years. The
addition of gold nanoparticles also provides antioxidant benefits. “This
has the potential to reduce possible inflammatory reactions, such as
swelling,” Weatherstone says. “The product will also not need a skin
test before use, and it will be long-lasting and easy to use.”
Christopher Inglefield, plastic surgeon and medical director of London
46
Figure 1
Histology of RPC vs HA one month post-injection
Rapid Polymerising Collagen
resembles host tissue’s cellular and
vascular structure
Hyaluronic Acid remains as a
distinct blue bolus
Bridge Plastic Surgery, has recently been conducting human trials
using the new collagen portfolio. He says, “The RPC collagen is a
clear liquid which injects very smoothly through a 30 or 32G needle,
having the lowest extrusion force for fillers. It is associated with mild
to moderate discomfort on injection. We are in the middle of a human
safety study and all is proceeding well. “RPC is unique in replacing the
skin’s lost collagen,” he says. “Therefore it is suitable for rebuilding the
skin, where lines or wrinkles are a concern, or for example, for treating
acne scars and post-surgical scars.” He continues that RPC’s unique
ability to integrate with human skin is its key strength compared to
other fillers. “RPC collagen can be used in a mesotherapy treatment
or as a volumising produce because of the in-situ polymerisation,” he
says. “This remains stable with no risk of product migration.”
Some doctors remain wary because of previous cases of patients
experiencing reactions; However, Mr Inglefield says, “There will always
be concerns about the use of porcine collagen despite numerous
safety studies and hundreds of thousands of patients who have
benefited from porcine products.
“The producers of EternoGen are being scientific and ethical in the
development of the product to ensure that they launch a highly
developed and researched product,” he says. “Collagen started the
revolution in non-surgical aesthetic medicine; HAs have provided a
very beneficial tool in restoring lost volume, but collagen is the gold
standard in providing true rejuvenation of the skin.
“I firmly believe there is a clear need for a skin friendly collagenbased filler to provide safe, natural-looking results and the skin
health benefits that both consumers and physicians seek today,”
says Mr Inglefield. “RPC is particularly suited for delicate and
challenging treatments in the peri-orbital and peri-oral areas where
the risk of lumps and product migration needs to be minimised.”
Whilst hyaluronic acid fillers produce long-lasting, safe results, recent
developments of RPC, enabling it to integrate completely into the
dermis, and the potential of Gold Nanoparticle Collagen to last for up
to two years, mean that there could soon be an increased demand
for collagen in the aesthetics market.
Aesthetics | May 2014
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Awards
Special Focus
@aestheticsgroup
Aesthetics Journal
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The Aesthetics Awards bring together the very best in medical aesthetics and leaders in the industry to celebrate the
achievements of the past year. For 2014, twenty-one prestigious awards categories have been designed to recognise the
finalists and winners for their services to the profession and industry. Awards are presented to those who have worked hard to
represent the highest standards and have truly excelled in the field of aesthetic medicine, from clinics and individual practitioners
to manufacturers and suppliers.
Following the success of last year’s awards, the 2014 event will be bigger and more glamorous than ever. To be held on Saturday
6th December at the luxurious Park Plaza Hotel in Westminster, the evening will play host to 500 guests, new award categories
and exciting entertainment. Aesthetics is delighted to announce Changing Faces as the official charity of the awards once again.
Entries will be open from 12th May until the end of June, whereby a shortlist of finalists will be selected based on the key category
criteria. Finalists will be announced in September and online voting and judging will commence until the end of October. The
award winners, and those who have been highly commended and commended in their categories, will be announced at the
awards presentation evening in December and winners will be invited on to the stage to receive their award in front of an
audience of their peers, colleagues and friends.
The categories for
The Aesthetics Awards 2014 are as follows:
The Pinnell Award for Product
Innovation
This award recognises the most innovative and
dynamic products on the market. To be eligible
for nomination, products must have been
launched into the UK market in the 12 months
before the 2014 Awards entries opened.
Entrants should demonstrate how their product
provides a new and original treatment, leading
to a better patient experience.
Cosmeceutical Range/Product of
the Year
This award will go to the best cosmeceutical
range or product. This can be any professional
use product range but must be retailed in UK
medical aesthetics clinics. The winner should
demonstrate support from practitioners and
strong safety and efficacy evidence.
Injectable Product of the Year
This award will go to the manufacturer or
UK distributor of the injectable product
deemed to be the best available in the
UK. Entrants will be required to explain
the potential and realistic outcomes of
treatment along with good evidence of
safety and efficacy.
48
Treatment of the Year
This award will be given to the
manufacturer or supplier with the best
medical aesthetic treatment as voted
for by Aesthetics journal readers. The
winner should show how this treatment is
a valuable addition to the UK market for
patients and practitioners.
Equipment Supplier of the Year
Taking into account customer service,
support for practitioners and product range,
this award will be presented to the
company voted as the best equipment
supplier in the UK.
The Janeé Parsons Award for Sales
Representative of the Year, supported
by Healthxchange Pharmacy
This award, given
in memory of
Obagi territory
manager Janeé
Parsons, will be presented to the UK
industry sales representative who is
deemed to have provided the best service
to his or her company, customers and
ultimately patients.
Aesthetics | May 2014
Best Customer Service by a
Manufacturer/Supplier
This award acknowledges the manufacturer
or supplier that voters believe has offered the
best service in terms of practitioner support,
customer training and client relations.
Distributor of the Year
This award acknowledges the vital role
played by UK distributors who bring new,
international products and treatments to the
UK market. The winner will be voted for on
the basis of their customer service, product
range and services to the industry.
Training Initiative
of the Year
This award will be
presented to the
training provider or
individual trainer
who is considered to have advanced
the education of aesthetic medical
professionals most effectively during 2014
through their course. Judges will take
into consideration the dynamic method of
delivery, attendee reviews and outcomes
for participants.
@aestheticsgroup
Aesthetics Journal
Best Clinic Awards
For 2014, Best Clinic Awards will be awarded
regionally. Clinics will be judged on their
customer service, commitment to patient care
and safety and demonstration of continuous
clinical excellence. Clinics can nominate
themselves in the following regions –
Best Clinic Scotland
The Church Pharmacy Award for
Best Clinic North England
The Dermalux Award for Best Clinic
South England
Best Clinic London
Aesthetics
aestheticsjournal.com
efforts of an aesthetic nurse who has provided
exceptional care and treatment to their
patients. The winner will be judged based on
evidence provided by the entrant about him or
herself, along with patient testimonials.
Aesthetic Medical Practitioner of
the Year
This award goes to the cosmetic doctor,
dermatologist or surgeon who has excelled
in his or her field this year. The winner will
be judged based on evidence provided by
the entrant about him or herself, along with
patient testimonials.
Clinic Reception Team of the Year
This award will go to a front of house team
that has provided outstanding customer
service, along with strong practitioner support
for the benefit of both the clinic and patients.
Association/Industry Body of the Year
Best Clinic Wales
Best Clinic Ireland
The 3D-lipomed Award for Best
New Clinic, UK and Ireland
This award will recognise
the recently launched
clinics in the UK. Entrants
will need to show how they have provided an
excellent standard of care to patients along
with details of initiatives used to grow their
business during 2014. The clinic must have
been established within the 12 months prior to
nominations opening.
The Institute Hyalual Award for
Aesthetic Nurse Practitioner of
the Year
This award will
recognise the
achievements and
This award will be presented to the
association who is deemed by voters to have
achieved the most, both for their members
and aesthetic medicine as an industry and
profession in 2014.
The Aesthetic Source Award
for Lifetime Achievement
This award
recognises the
achievements
of an individual who
has had a long career
within aesthetic
medicine and honours
their significant
contribution to the
industry. Previous
winners include Mr
Chris Inglefield and
Dr Patrick Bowler.
Awards
Special Focus
How will winners be
selected?
Our judging panel will select a list of
finalists for each category, which will be
announced in September. A process
of voting will take place to select the
winners. Aesthetics journal readers
will be able to vote online to select the
winner in the following categories:
•Cosmeceutical Range/ Product of the
Year
•Injectable Product of the Year
•Treatment of the Year
•Equipment Supplier of the Year
•The Janeé Parsons Award for Sales
Representative of the Year, supported
by Healthxchange Pharmacy
•Best Customer Service by a
Manufacturer/Supplier
•Distributor of the Year
•Association/Industry Body of the Year
An expert judging panel selected by
Aesthetics will vote for the winners in the
following categories:
•The Pinnell Award for Product
Innovation
•Training Initiative of the Year
•The 3D-lipomed Award for Best New
Clinic, UK and Ireland
•Best Clinic Scotland
•The Church Pharmacy Award for Best
Clinic North England
•The Dermalux Award for Best Clinic
South England
•Best Clinic London
•Best Clinic Wales
•Best Clinic Ireland
•The Institute Hyalual Award for
Aesthetic Nurse Practitioner of the Year
•Aesthetic Medical Practitioner of the
Year
•Clinic Reception Team of the Year
The winner of the Aesthetic Source
Award for Lifetime Achievement will be
selected by Aesthetics Journal and will
be announced on the night.
How to enter
All entries must be made via the Aesthetics Awards website,
www.aestheticsawards.com. You can enter in as many categories
as you wish but you may only enter yourself, a company
you work for, or an employee who works for your company.
Nominations made on behalf of a third party will not be accepted.
You should only enter once. Multiple entry forms for the
same clinic, company, individual, treatment or product will be
disregarded. All entries must be accompanied by the supporting
evidence requested in the entry form. This information will be
used to create the list of finalists and by the judges when voting
on a winner.
The list of finalists will be announced in the September issue of
Aesthetics Journal, after which the voting process will begin.
Voting
Readers of Aesthetics journal will be able to vote for their favorite finalist in each of the appropriate categories from September. Each reader can
vote for one finalist in each category.
Multiple votes from the same email address, name and IP address will be discounted from the final result.
Aesthetics | May 2014
49
In Practice
Data Protection
@aestheticsgroup
Aesthetics Journal
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aestheticsjournal.com
Data Protection:
what every practitioner
needs to know
Dr Natalie Blakely and specialist lawyer Mandy
Luckman answer key questions about the ethical
and legal issues involved in storing patient data
Protecting your patient’s details isn’t just
crucial for your business but also for your
reputation. If you record, handle and store
medical information, then you are liable
under the Data Protection Act 1998 to
protect that information. The Act states you
should only collect the information you need,
keep it secure, ensure it is up-to-date, only
hold as much as you need and for as long
as you need it and allow the patient to see
it on request. With data protection breaches
for unauthorised disclosure and for lost and
stolen paperwork higher in healthcare than
in other sectors, collecting good quality
data and storing it securely demonstrates
good practice and could help to protect you
against litigation.
Is it legal to transport paper medical records
around?
Clinical records must be kept confidential
at all times, including during transfer
between sites. It is legal to transport medical
records if necessary but stringent security
measures must be put in place to avoid
security breaches. There are many reported
examples of data protection breaches
occurring. One such case involved a lawyer
who was transporting patient records by
hand to a court hearing. Unfortunately she
was involved in a RTA and the records were
dispersed around the site of the accident.
Clearly, although the circumstances are
very unfortunate, this had the potential of
allowing very sensitive patient information to
be accessed by unauthorised persons. This
resulted in stringent measures being put in
place to avoid the scenario recurring. For
50
example, records should only be transported
when absolutely necessary and if so, they are
stored in locked cases.
What must we do to ensure patient data
protection when transporting medical
records?
Security measures will include physical,
organisational and technological measures,
such as use of secure portable equipment
and ensuring administrative and strategic
processes are in place to guarantee that
the documentation is secure at all times.
The movement and location of records
should be controlled so that a record
can be easily retrieved at any time, any
outstanding issues can be dealt with,
and there is an auditable trail of record
transactions.
Is it legal to store patient photos on phones
and/or a personal cloud?
The Data Protection Act 1998 controls how
data is used by organisations, businesses and
public authorities (part 1 (1) (e) Data Protection
Act 1998) 1. A key principle of the Act stipulates
that information must be kept safe and secure.
There is a stronger legal protection for more
sensitive information such as information
related to health. It is therefore not advisable
to store confidential data on mobile phones
which can easily be lost or stolen, or on a
personal cloud which disseminates to other
devices around the house.
What security features should you look for
in a digital system?
Cloud-based storage systems encrypt data
Aesthetics | May 2014
and back it up on several servers: this is
called redundancy and means that, should
a server fail, your data is unaffected.
It is worth checking with your cloud
provider that their server is based within
the EU. Right now the EU provides strong
protection for personal data. If data
belonging to EU businesses or citizens
is stored outside the EU, the transfer of
that data needs to be secure with data
protection requirements at the other end, at
least as strong as those in the EU.
What happens to patient records if you
terminate the contract with a digital
provider?
EU data law states that cloud providers
must allow a person or business to move
data from one cloud provider to another.
It’s also worth checking that, should you
request it, your data will be returned to you
in a usable format, such as a PDF.
Where should patient photos be stored?
Appropriate technical and organisational
measures should be taken against
accidental loss. Therefore it is advisable
to store confidential data in a safe secure
environment or electronically where
appropriate security protections are in
place. The Data Protection Act advises
that you should have security that is
appropriate to the nature of the information
in question and the harm that might result
from its improper use, or from its accidental
loss or destruction.2 Since photographs
pertaining to medical treatment may be
particularly sensitive there will be a greater
@aestheticsgroup
Aesthetics Journal
requirement for security.
Guidance given by the Information
Commissioner’s Office states that physical
and technological security is likely to be
essential as well as management and
organisational security measures3. Physical
security includes considering the quality
of doors and locks, and whether premises
are protected by alarms, security lighting
or CCTV. It also includes how you control
access to premises, supervise visitors,
dispose of paper waste, and keep portable
equipment secure. Technological security
involves use of secure servers, firewalls and
encryption.
How long must we keep patient medical
records for?
The Data Protection Act stipulates that
records should only be retained for as
long as necessary.4 There is no definition
of ‘necessary’ in the Act; however, the
Department of Health states that the
maximum period of retention of NHS
records should be thirty years.5 The
NHS code of practice states that records
should be retained for at least eight years
for adults and 25 years for children.6 GP
records must be kept for ten years after a
patient dies or leaves the country.7 This also
applies to private records in accordance
with the Private and Voluntary Health Care
(England) Regulations 2001.8
The Medical Defence Union advises that,
if possible, records should be kept for
beyond the prescribed periods, as claims do
sometimes arise after these timescales, and
it may prove difficult to successfully defend a
claim without the records.9
Ideally, all records should be reviewed
before they are destroyed, and it is sensible
to keep any patient records where there
has been an adverse incident or complaint.
Disposal should be carried out in such a
way that protects patient confidentiality,
for example, by shredding paper records.
Computer-held records may be difficult to
delete entirely from a hard drive and it is
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aestheticsjournal.com
The movement and location of records should be
controlled so that a record can be easily retrieved at any
time, any outstanding issues can be dealt with, and there
is an auditable trail of record transactions.
advisable to seek appropriate advice from
a specialist IT company. The Information
Commissioner’s Office advised that data
retention and review schedules should be
in place for categories of personal data to
help practitioners comply with this principle.
After a set period of time the data should be
reviewed, and destroyed when it no longer
needs to be retained.10 When paper records
are no longer required, their placement in
a designated secondary storage area may
be a more economical and efficient form
of storage. There are several accredited
documentary storage facilities, which are
able to securely store NHS, medical and
pharmaceutical records.
Who do the records belong to?
Legally, although the patient owns the
information contained within the medical
records, the healthcare provider owns the
paperwork that contains this information.
The records should therefore be retained
by the treating clinician, though patients
have a legal right to access their medical
records under the Data Protection Act
1998.11 This means that any individual is
able to obtain a copy of their own medical
records upon request, subject to paying
reasonable copying charges up to a cost
of £50.12
What does the new EU directive on
information governance for 2015 mean for
practitioners and clinics?
Under current law, the Information
Commissioner’s Office can issue a
maximum penalty of up to £500,000 for
the most serious breaches of the Data
Protection Act.13 Moreover the Information
Commissioning Officer can decide to apply
fines or not at their own discretion based
on the severity of the consequences of
Other key changes in the new EU directive include:
•
•
•
•
•
•
•
In Practice
Data Protection
Higher standard of consent (Articles 4(8) and 7)
Data minimisation (Article 5)
New and strengthened rights for data subjects (Articles 12, 17 and 18)
Breach notification within 24 hours (Article 31)
Data protection impact assessments prior to risky processing operations (Article 33)
Obligation to appoint a data protection officer (Articles 35-37)
Imposition of large fines for failure to comply (Article 79)
Aesthetics | May 2014
such breaches. Fines have been imposed
in the past for incidents such as transfer
of personal data using unencrypted
memory sticks and loss of electronic
devices containing personal data.14 The
draft proposal introduces a requirement for
supervisory authorities to impose prescribed
fines of up to €1 million (£0.9 million) or 2%
of a company’s annual global turnover in
the event of a violation of the Regulation
(Article 79), regardless of the harm caused.
More serious breaches are likely to involve
deliberate misuse of data leading to
substantial damage or substantial distress.15
Dr Natalie Blakely is medical
director of the Light Touch
Clinic in Surrey and founder
of the Consentz patient
record app. While developing
Consentz she became fascinated by the
legal issues surrounding consent and how
practitioners can improve their consenting
processes, helping to protect both themselves
and their patients.
Mandy Luckman is a partner
in the Medical Law & Patients
Rights team at Irwin Mitchell
in Birmingham. Mandy leads
a team that acts exclusively for
claimants in clinical negligence cases and is
regularly contacted by the media to quote on
developments and regulation within the field
of cosmetic surgery.
REFERENCES
1. Data Protection Act 1998, Schedule 1 <http://www.legislation.
gov.uk/ukpga/1998/29/contents>
2. Data Protection Act 1998, Schedule 1, Part II, Principle 7(9) <http://www.legislation.gov.uk/ukpga/1998/29/contents>
3. Information Commissioner’s Office <ico.org.uk>
4. Data Protection Act, Schedule 1, Part I, Principle 5 <http://www.
legislation.gov.uk/ukpga/1998/29/contents>
5. Records Management: NHS Code of Practice, Part One (2006) and Part Two (2009) < https://www.gov.uk/government/
publications/records-management-nhs-code-of-practice>
6. Records Management: NHS Code of Practice, Part One (2006) and Part Two (2009) < https://www.gov.uk/government/
publications/records-management-nhs-code-of-practice>
7. Records Management: NHS Code of Practice, Part One (2006) and Part Two (2009) < https://www.gov.uk/government/
publications/records-management-nhs-code-of-practice>
8. The Private and Voluntary Health Care (England) Regulations 2001, Schedule 3, Part 1 < http://www.legislation.gov.uk/
uksi/2001/3968/contents/made>
9. MDU <www.themdu.com>
10. Information Commissioner’s Office <ico.org.uk>
11. The Data Protection Act, Part II, Section 7 <http://www.
legislation.gov.uk/ukpga/1998/29/contents>
12. The Data Protection (Subject Access) (Fees and Miscellaneous Provisions) Regulations 2000, Regulation 6 < http://www.
legislation.gov.uk/uksi/2000/191/made>
13. The Data Protection Act, Sections 55A and 55B <http://www.
legislation.gov.uk/ukpga/1998/29/contents>
14. Information Commissioner’s Office <ico.org.uk>
15. The Data Protection Act, Sections 55A and 55B <http://www.
legislation.gov.uk/ukpga/1998/29/contents>
51
In Practice
Treatment Portfolio
@aestheticsgroup
Aesthetics Journal
Building a body
shaping clinic
Wendy Lewis explains why now is the perfect
time to consider expanding your offering from
the face to the body
The emerging market segments of body shaping and skin tightening have
shown unprecedented growth in recent years. Body shaping and skin tightening
devices have demonstrated aggressive expansion and have shown explosive
growth: the British Association of Aesthetic Plastic Surgeons (BAAPS) audit for
2013 showed a 41% rise in liposuction procedures, a 16% rise in abdominoplasty
procedures and a 24% increase in male gynaecomastia body contouring
procedures.1 The emergence of energy-based systems and innovative
technologies has paved the way for more companies to enter the sector, offering
more options for practitioners as well as consumers. The time has never been
better to consider adding body-shaping procedures to your clinic offering.
Body shaping encompasses a wide range of procedures that target weight
reduction, as well as toning, firming and cellulite reduction. Skin-tightening
procedures address wrinkles and skin laxity on the face and body.
For the quickest and most dramatic results, more invasive body-shaping surgery
may be the preferred option. However, there has been a sea change in the
mindset and goals of consumers since 2008, resulting in flat levels of growth in the
surgical category. Because consumers tend to associate surgical procedures with
longer recovery times, possible risks, higher costs, an anaesthetic, a hospital stay
and visible scars, they are very open to investigating alternative options. Although
non-surgical or minimally invasive treatments may not be the right fit for obese
patients or patients with excessive skin laxity, a large percentage of consumers are
willing to accept a lesser result from a lesser procedure.
Today, there are effective forms of cosmetic enhancement procedures to target
every part of the body, which may require some improvement.
SURGICAL PROCEDURES
Whether their ultimate goal is to look great in clothes, fit into a smaller size or look
good naked, patients have a lot of options to consider. The fact remains that there
are some body issues that cannot be significantly altered through diet and exercise
alone. The category of surgery for the body has greatly expanded to include
numerous variations in ways to address excess fat, skin sagging and contouring
defects. There is a global trend of more and newer procedures making up each of
52
Aesthetics | May 2014
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aestheticsjournal.com
the major segments of cosmetic surgery for the body.
For example, to address the mid-section, surgeons
may now offer a standard abdominoplasty, modified or
mini abdominoplasty, abdominal etching, liposuction,
fat grafting or a combination procedure. This may
also be combined with a lower body lift, thigh lift,
buttock lift and/or fat grafting, as well as an upper
body lift consisting of breast augmentation, mastopexy
or reduction mammoplasty or gynaecomastia,
brachioplasty, liposuction and so on. According to
the American Society for Aesthetic Plastic Surgery
(ASAPS), 2013 marked a record upward trend in both
labiaplasty and buttock augmentation surgeries.
Labiaplasty procedures increased by 44% over
the course of the year, and buttock augmentation
procedures rose by 58%.2 The rise in vaginal
rejuvenation is often credited to the explosion of
pornography online, while the increasing interest
in buttock sculpting procedures has been at least
partially driven by an overwhelming desire to have a
firm, smooth, round bottom like many celebrities.
Cosmetic Surgery of the Body
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Abdominoplasty
Body lift
Brachioplasty
Breast enhancement
Breast lift or reduction
Buttock enhancement
Buttock lift
Calf implants
Fat grafting
Gynaecomastia
Laser lipolysis
Liposuction
Pectoral implants
Thigh lift
Vaginal rejuvenation
If you are not a trained surgeon, but are seeing
patients who are candidates for surgery and who
have the means to have it done, consider recruiting
a BAAPS plastic surgeon to your clinic a few days
per month to expand your service offering. This
way you may be able to keep those patients in your
clinic rather than risk losing them to another clinic
that is not likely to refer them back to you for nonsurgical treatments.
NON-SURGICAL BODY CONTOURING
More clinics in the UK are expanding their treatment
menu as new and effective options for fat reduction,
cellulite treatment, skin tightening, hair removal and
décolletage and hand rejuvenation evolve. The
emerging range of laser and light treatments and
non-surgical services can now effectively address
every conceivable aesthetic concern. Advanced
technologies enable many wavelengths and energies
Introducing the NEW
One Treatment
NEW FDA Clearance
Ultimate Body Platform
More Power
Innovative Design
www.syneron-candela.co.uk | [email protected]
Tel. 0845 5210698
This is not intended for the U.S. market. ©2013. All rights reserved. Syneron and the Syneron logo are trademarks of Syneron Medical Ltd. and may be registered in
certain jurisdictions. Candela is a registered trademark of the Candela Corporation. UltraSculpt and UltraShape are registered trademarks of UltraShape. PB82801EN
In Practice
Treatment Portfolio
@aestheticsgroup
Aesthetics Journal
Body Shaping – the three basic categories
and most popular treatment areas
1.
2.
3.
Skin tightening – tummy, arms, thighs, knees
Fat reduction – tummy, hips, thighs, knees, back, arms, chest (men)
Cellulite reduction – thighs, buttocks, knees
to be used on all skin types and skin
colours.
Skin tightening can be accomplished
with a variety of energies including
radiofrequency, ultrasound, heat-based
energy or a combination of wavelengths.
Fat reduction is used to target localised fat
deposits without injections, anaesthetic or
visiting the hospital. The energies used to
fight fat range from heat (radiofrequency) to
cold, ultrasound and lasers. Actual fat loss
in centimetres varies from person to person
and the downside is that results may not be
immediate and usually multiple treatment
sessions are needed. Ideal candidates are
at a good weight with only small bulges.
Each system comes with its own limitations
based on the energy used and the
configuration of handpieces. For example,
some systems use handpieces that are too
large for small body areas like upper arms,
under the chin and knees. It is important
to know before you buy exactly what the
system will treat when you are purchasing
it, not just what is planned for the future.
Most non-invasive systems just reduce
fat cells and are not intended for serious
skin tightening, so you may need more
than one device to treat a wider range of
patients.
Consider which areas patients are most
interested in treating, and what fees they
may be willing to pay, based on your
location and the demographics of your
current clientele. It is not wise to bring on
a new device with the sole purpose of
attracting a brand new segment of patients,
unless you have a huge marketing budget:
you should have enough existing patients
in your clinic to target first, and then build
up additional clientele over time.
Cellulite reduction has proven very
difficult historically, with past treatments
focusing on surface remedies; however,
new therapies are changing the way
practitioners approach cellulite. It has been
said that 90% of woman have cellulite,
which accounts for a vast number of
patients who have a potential interest in
54
this service. Cellulite patients come in all
shapes and sizes; even thin women can
have lumps and dimples, which tend to
get worse with age. There is some overlap
when it comes to the body contouring
and cellulite reduction categories,
which is why it is important not only to
research and trial several systems, but
also to have more than one method to
offer patients. Each patient represents
a unique set of circumstances, which
makes the task of consulting with patients
even more important. Some systems may
simultaneously sculpt specific areas of the
body and target cellulite, or it might take
a combination of different approaches to
deliver good results.
With regards to cellulite, it is critical to be
honest with patients. Every woman has
heard about the miracle cures and most
have a healthy degree of scepticism
about new treatments. Let patients know
up front what they can expect and how
many treatments they really need, and
build a maintenance programme into
the treatments from the beginning. Offer
advice on diet, exercise, lifestyle, and have
them come back for additional treatment
sessions as necessary.
Cellulite is like everything else you treat: it
is chronic, it often gets worse with age, and
it requires a multifactorial approach to keep
it under control.
OFF-FACE APPLICATIONS FOR ENERGYBASED SYSTEMS
If you find that patients are asking about
services that you do not yet offer, and that
you are referring them to colleagues and/
or competitors, it is time to take a look at
how best to step it up.
A good place to start is to analyse what
you already have in your clinic that may
currently be underutilised. For example, if
you are the proud owner of a multi-platform
device that targets brown spots, hair, sun
damage and acne, you already have the
ability to do off-face treatments without
incurring additional costs. The first areas
Aesthetics | May 2014
Aesthetics
aestheticsjournal.com
to expand laser therapies to would be the
chest or décolleté and the hands. If you
are currently doing full face IPL or skin
tightening, try using the same treatment
for other areas where patients may have
discolouration, crepey skin texture and
other signs of sun damage and ageing
skin.
Patients are not only conscious of the
skin quality of their face; they are also
interested in improving brown spots
on their chest, arms and legs, and are
interested in laser hair removal literally
from their hairline to their toes. If you are an
expert peeler, consider launching a body
peel programme, with peeling solutions,
microdermabrasion, dermal infusion
systems and body products for home use.
Hand rejuvenation using dermal fillers
as well as neurotoxins, fat grafting and a
series of glycolic or TCA peels, as well
as energy-based treatments, is a popular
category, which offers patients a whole
new reason to come back to your clinic
regularly. If you deal with reputable
manufacturers or distributors that stand
behind their products, you should enquire
about having the clinic staff retrained to
expand the uses of the systems you now
own. Alternatively, consider trading up. If
you have limited space, look into additional
handpieces, or upgrading your current
system(s) for newer models that work
better, faster and do more.
In the near future, many practitioners
focusing predominantly on facial injectables
and skin-rejuvenation treatments will need
to incorporate other services into their
treatment portfolio to remain competitive
and ensure clinic growth; looking into
opportunities to do so will help expand
your clinic, increase patient retention and
encourage new patients to choose you
over your competitors.
Wendy Lewis is president of
Wendy Lewis & Co Ltd, Global
Aesthetics Consultancy, the
author of 11 books on antiageing and cosmetic surgery,
and founder/editor in chief of
Beautyinthebag.com. She is an international
presenter and lecturer and has written
over 500 articles for medical journals and
consumer publications.
REFERENCES
1. The British Association of Aesthetic Plastic Surgeons, Britain sucks (2014) <http://baaps.org.uk/about-us/press-releases/1833-
britain-sucks>
2. Plastic Surgery Practice, ASAPS: Below-the-belt procedures on the rise (2014) <http://www.plasticsurgerypractice.
com/2014/02/asaps-belt-procedures-rise/>
In Practice
Marketing
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
than any TV network. This age group may
not be your exact target demographic for
treatments, however these statistics prove
how easy it is to reach people directly
through the use of video.
John Castro, owner of Websites for
Cosmetics, explains how the power
of video can be harnessed to increase
footfall to your clinic
Getting in front of the
camera: using video to
increase enquiries
The way we absorb information is still
not fully understood, despite extensive
research into the field. However, it does
seem fairly certain that humans absorb
information much better with a visual aid,
which is why video as a medium is a highly
powerful tool, and one which you should
employ in your marketing strategy.
Why video?
Video allows you to really engage and
interact with users, and deliver your
message easily, quickly and clearly. The
medical aesthetic industry is very much
driven by gaining trust from potential
clients and the immediacy of video will
help you gain that trust quicker. We have
all heard the saying, ‘people buy people’,
so put yourself in front of the camera,
deliver your message and watch your
enquiries increase. An example of good
video utilisation comes from Clinetix, a
medical aesthetic clinic based in Glasgow,
and one of our clients. Clinetix host a
highly effective video on the homepage
of their website, introducing their clinic.
Our tracking shows that aside from the
treatments tab, the video is the second
most clicked-on item on their home page.
This proves that when easily accessible,
videos entice browsers, which in turn will
increase the rate of conversion of website
visitors into enquiries. Video also helps to
gain the trust of potential clients before
they’ve even picked up the phone, as it
conveys personality. With the amount of
information online today, being personal
has never been so important.
The growth in accessing video online has
increased in recent years and continues to
do so. Today, 100 hours of video content
is uploaded to YouTube per minute and
the site reaches more 25 to 35-year-olds
Two key tips for recording video:
1. Audio
Make sure you use an external microphone. Audio is key to any video recording and
testing shows that bad audio will result in people changing their mind and clicking onto
something else. A £20 lapel microphone is sufficient.
2. Lighting
Lighting can lift a video from looking amateur to looking like professional media footage.
Natural sunlight is great but if you can, purchase some professional ‘soft box studio
lights’ as they will make a big difference to the look and feel of your recording. Studio
lighting is not expensive either. For less than £60 you should be able to pick up two soft
box studio lights online.
56
Aesthetics | May 2014
It is this growth that has changed how
consumers want to receive information,
especially marketing messages.
Consumers today are increasingly savvy,
and the use of video provides a dynamic,
interactive experience for website visitors.
This medium enables you to introduce your
company more effectively and highlight
promotions, as well as provide treatment
descriptions.
Below are the two most common reasons
clients give for avoiding the use of videos,
along with some advice to help you when
creating and posting your videos online.
“I don’t know how to record good videos”
This is the most common objection,
as everyone naturally wants to look
professional. However, today video can
be recorded using a smart phone as long
as it supports recording in HD. There are
some limitations to this, but the truth is that
many smart phones record video that is of
a good enough quality to get a message
out there. If you are, however, thinking
of investing in some equipment, a good
quality HD camera will not cost more than
£200.
“Video is too expensive”
Video does not need to cost thousands
of pounds. However, if video is to become
a focal part of your marketing strategy,
then I would suggest investing a couple
of hundred pounds in purchasing your HD
camera, lighting and lapel microphone.
Spending a portion of your marketing
money on producing videos should not be
considered a burden but an investment.
Even if you buy a higher-end camera,
some lights and a high-end microphone,
the total cost should not exceed £1,000.
Video has become so effective that
once you have invested that money and
started shooting and sharing videos, I am
convinced that you will see an increase
in enquiries. You could even make videos
on treatment aftercare and hand them out
to patients, which will inevitably increase
client loyalty as it demonstrates to your
customers that their wellbeing is important
to you, and not just when they are in your
treatment room.
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Marketing
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
Creating the right kind of videos
The type of video you record will depend on what message or end goal you are trying to achieve.
Below are four types of videos you should record and their purpose:
1. THE INTRODUCTORY VIDEO
This video is for your website home page. It
is an introduction to either you or your clinic,
and probably both. Ideally this should be
led by the clinic manager, clinical director
or owner. It is vital in any small business to
be personal and inviting. Use this video to
introduce who you are and your specialist
treatments. It should be no longer than two
minutes, ideally about 90 seconds.
2. THE CLIENT-IN-THE-CLINIC
VIDEO
Nothing builds trust more than
recommendations. It is the lifeblood of
many businesses today, but many do not
think outside the box and rely on clients
recommending within their own social circle.
By producing a video with your patients in
your clinic discussing their experience, you
will build trust with potential new clients.
3. THE TREATMENT VIDEO
This type of video is perfect for describing
and explaining your treatments. When
consumers want to undergo a medical
aesthetic treatment they will have several
questions; this video can answer those
questions and help to alleviate some of
their concerns. A short, informative video
about the treatments you offer could be
the difference between a patient booking
a consultation with you or your competitor
– and this kind of video does not always
have to be produced by you. Most large
aesthetic brands today can supply access
to their library of videos, meaning that
you can easily share this ready-made
material on your own digital platform, aiding
potential patients’ understanding of what
a particular treatment involves. However,
filming a treatment video yourself at your
clinic can be much more effective as it
instantly personalises the user’s viewing
experience.
4. THE PERSONAL EVERYDAY
VIDEO
In my opinion this video is the most effective
video strategy if used properly, and over
time. One of my 10 Online Marketing
Commandments is ‘Be Personal, Not
Promotional’ and today this is more important
than ever. Due to the amount of generic
information thrown at people everyday, your
patient is now looking for a personal touch
in their purchasing experience. A personal,
everyday video is spontaneous. It could
be about a new treatment that you plan
on introducing, or it may be that you are at
an event and want to post a video of your
experience. This should not be professional
or structured, just you in front of your camera
sharing yourself.
Where to share
Sharing your videos is crucial. It is vital that people actually click the play button, and in our
experience, there are three places where video creates an effective impact: YouTube, Facebook
and your own website.
YOUTUBE
This is where you should host your
videos. Upload them here first and
then embed and share the YouTube
video on other platforms. This is important firstly because
of Google’s recent implemented change in how they rank
websites. This change has resulted in a dramatic increase in the
appearance of videos on the first page of Google. Search Engine
Optimisation is complex and just uploading a video to YouTube
does not mean you will be page one of Google, but every little
helps. Secondly, hosting your videos on YouTube as a primary
base is important because if you upload video directly to your
website it could create speed problems when loading, as video
files are usually fairly large. You certainly do not want someone
clicking off your website because they are waiting for it to load.
YouTube is a great platform for hosting purposes and embedding
a YouTube video on your website is much more effective than
uploading it directly.
FACEBOOK
Facebook is the most effective social media
platform to share video. It’s a space where videos
are shared and watched daily as the user can
easily watch without having to leave the site. We have found that
sharing video on Facebook business pages is extremely effective.
58
On average, our written Facebook posts reach around 100
people each time according to page analytics. However, when
we post videos the number of people the post reaches exceeds
around 500 each time.
YOUR WEBSITE
It is a must to put your videos on your website. Make sure you
create a section on your website just for your video content. We
recently did this with a client of ours, Dr Anil Budh-Raja. It has
been very effective and now users can access a selection of
videos directly on his website, including videos about the doctor
and his most popular treatments.
As well as having a ‘Videos’ section, uploading videos in a blog is
also very effective. If you write a blog, complement it with a video
about what you have written. We now know that having a visual
aid to any piece of writing engages users better, and that patient
engagement is crucial to boosting enquiry conversion rates. The
personal nature of video encourages users to spend more time
on your website, which in turn will increase interest in your clinic,
services or company.
Aesthetics | May 2014
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In Practice
HR
@aestheticsgroup
John Sellers explains how to acquire
and keep hold of staff who will prove
an asset to your businesses
Nurturing your
work force
The medical aesthetics industry is extremely competitive. Most
clinics are using similar technology and offering the same
treatments, so how can your business stand out?
Though your clinic may have a similar offering to your
competitors, the service you provide can differ significantly.
Making your customers feel respected, cared for, and safe in your
hands does not stem from the reputation of the principal medical
professional alone, it is acquired from the contact your customer
has with every single member of staff involved in their treatment
journey. Your people make your business.
Advertising to attract the best industry
professionals
Making a hiring mistake can be very costly, when you take into
account the potential damage to your reputation, loss of revenue,
and training costs. Hiring the right employees is fundamental
to the continued success of your company. People are an
investment, not a cost. Define your specifications carefully. List
the requirements of the job and the personal qualities of the
ideal candidate. Define what skills and attributes are necessary
to the role, and be realistic: don’t look for something that does
not exist. You should think about the company as a whole, for
example, think about the personality that would gel successfully
with your existing staff members, and one which your customers
would appreciate. Write a clear and honest job advert. Include
the expectations of the role, the responsibilities, the salary and
benefits, the hours worked, and make each detail as accurate as
possible. If the details are too vague or are subject to change, this
might deter serious jobseekers, or might cause you to waste time
interviewing candidates who simply cannot meet your needs.
Advertise only via appropriate channels. Make sure you pick a
relevant job board for your vacancy. If job boards don’t work for
you, then industry-specific recruitment companies will utilise all
of the appropriate advertising avenues for you, and proactively
headhunt ideal candidates. Don’t forget that referrals are also
often a good method to find candidates. Ask people you trust in
the sector to recommend staff to you.
CVs and interviews: identify the right candidates
Don’t judge someone purely on their CV, but do filter out
the weakest applications. Beware CVs that have short stints
60
Aesthetics Journal
Aesthetics
aestheticsjournal.com
in employment or gaps between jobs. It may show a lack of
loyalty, or an inability to hit targets, though this may not be the
employee’s fault every time, so there is a balance to be struck.
Skills can be taught and knowledge can be instilled in someone
who has the right attitude to fit into your organisation. A CV
doesn’t tell you about an individual’s personality, emotional
intelligence or social skills. Would you rather hire someone with
the right experience but the wrong attitude, or someone with not
quite enough experience but the right attitude?
Conducting a thorough interview is one of the best ways to get a
deeper sense of a person’s character and mindset. Think about
your interview questions carefully. It’s also important to remember
that an interview is a two-way process. The best candidates will
be interviewing you, too, as they will get their pick of employers.
When you find a great candidate, don’t hang around, as the best
candidates will be quickly snapped up.
Induction and retention: lay solid foundations and
stay in touch
A good induction process will help your new employee feel
comfortable, and will reassure them that they have made the right
decision joining your company. Employees are happier in their
jobs when they fully understand what is expected of them. Set out
the company values and goals, and individual expectations and
targets, but don’t ignore the basics, as these also help to form
solid foundations. Tell your employee who they report to, how
they book holiday, and even where they can eat their lunch.
Make staffing policies clear. An ‘unwritten rule’ should be
formalised in writing if it is a regulation that you all tend to
follow. For example, if you want employees to give you a
month’s notice before booking holiday, include it in induction
documents, don’t just tell them when the instance arises.
Consider training opportunities for all employees, even if they
are very experienced, as this will show that you are willing to
invest in every staff member, and help them with training that
can complement and develop their role. Be fair; don’t make
employees work every weekend or too many late evenings. Make
sure you tell them when they are doing well in their role. You
will be amazed at how well they’ll respond to praise. If you are
in any doubt about how satisfied your employees are, organise
regular catch-ups so they can give you their feedback. Create
opportunities for progression and development. If your company
can accommodate internal promotion, create a structure where
this is possible. Otherwise, think about ways that employees can
increase their responsibilities or benefits. If your company is doing
well financially, share the success in the form of a bonus scheme.
If funds are tight, an extra day of holiday for loyal employees will
remind them that their hard work is valued.
Take some time out together as a company. You don’t have to
book an expensive away-day, sometimes just treating your team
to some cakes and having a chat during your tea break can raise
a smile after a difficult working week.
John Sellers is the managing director and owner of
ARC Aesthetic Professionals, a recruitment consultancy
specialising in the aesthetic medicine and cosmetic
surgery sector. Since 2008, John and his team have
helped numerous organisations within the industry grow
their businesses by hiring the most talented aesthetic
professionals in the UK.
Aesthetics | May 2014
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In Practice
In Profile
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
“Seeing happy patients
is why I do what I do”
Mr Christopher Inglefield, esteemed surgeon and
medical director of the London Bridge Plastic
Surgery and Aesthetic Clinic, explains his route
into plastic surgery and challenges common
cosmetic misconceptions
After completing his medical degree in 1985, it was postgraduate training that
ignited Mr Inglefield’s love for plastic surgery. “I loved the challenge and the variety
in fixing problems for patients that nobody else could fix,” he explains.
His career journey began in Canada, where he studied a BSc (Hons) in Biochemistry
and Microbiology in Waterloo, Ontario, before moving back to his birthplace, Trinidad,
The West Indies, to pursue medicine. He went on to work in general surgery,
orthopaedics and intensive care anaesthetics, before moving to the UK in 1988 to
undertake surgical postgraduate training.
Mr Inglefield attained his Fellowship of the Royal College of Surgeons (FRCS) in 1990,
and was then awarded the FRCS Plastic Surgery in 1998. He went on to work as a
paediatric reconstructive plastic surgeon and as a consultant plastic surgeon in the NHS
until 2006, when he decided to devote his time to setting up his own private practice
at London Bridge Hospital. “I was splitting my time between the NHS and private work;
I realised my service to my patients and my own quality of life would be better if they
could have me around 24/7 for follow-up care and personal contact,” he explains. In
2010, he moved his practice to Wimpole Street, where it is currently based.
Throughout his extensive career, he says that he’s seen much change in the
private medical industry. “There’s been a big increase in ensuring the private sector
provides a very high standard of medical care, and a huge increase in the standard
of products and treatments available to patients, for example, implants.” He says that
this improvement in technology has lead to the growth of non-surgical treatments,
which has opened the doors of cosmetic medicine to a much wider segment of the
population. “Only 5% of the population would have surgery, whereas 80% would have
non-surgical treatment,” he says. “Where cosmetic treatment used to be restricted
to celebrities, now practitioners treat everyone from teachers to bus drivers to chief
executives. Whoever the patient is, from cleaners to lords and ladies, they all get
treated the same in my clinic.”
Whilst the patient demographic has widened, he explains that criticism of those who
have cosmetic treatment still exists. “We live in a very judgemental society,” he says. “It is
a quality of life issue, not a necessity, to reconstruct a skier’s anterior cruciate ligament so
that they can ski again next season. They are not judged, but the person who has a large
nose and wants to improve it to increase their self-esteem, is stigmatised and considered
to be superficial. In reality, what is the difference? Any procedure done for the right
reasons in the right patient, which improves their quality of life, is a good thing.”
He also challenges the controversy behind certain cosmetic procedures, such as vaginal
reshaping, which is carried out at his own clinic. “Labial surgery is sometimes criticised
and associated with female genital mutilation (FGM), which has received a lot of attention
recently,” he explains. “This comparison is absurd and belittles FGM. I see several patients
suffering from the condition every year, and it is assault of the worst possible kind. The
majority of patients come to me requesting reduction because of physical symptoms due
to an enlarged labia; aesthetic improvement is a secondary benefit.”
For the industry to move forward and simultaneously raise standards, he advises that
an overall non-judgemental and supportive attitude is key. “I will listen to a patient,
understand who they are and why they have a desire to change something and help
them understand what is possible and whether it is good for them or not,” he says.
“Seeing happy patients is why I do what I do.”
62
Aesthetics | May 2014
What’s been the biggest lesson of your
career?
To be humble, no matter how good or
experienced you think you are, and to focus on
providing the highest standard of care I possibly
can for my patients.
What advice would you offer others?
Always put your patients first and do what’s
best for them. Additionally, challenge the
accepted; always ask why procedures are done
a certain way, and look into the evidence and
science behind what you do. Finally, embrace
technological change to offer your patients the
best solutions.
What’s the best advice you’ve received?
Aim to be well trained and to have enough
experience to deal with the difficult problems –
don’t settle for the easy job, but at the same time
don’t stretch yourself beyond reality.
What is currently your favourite treatment?
Endymed 3-Deep radiofrequency (RF) skin
tightening. It’s state-of-the-art technology in nonsurgical rejuvenation and when patients finish a
course, they want to come back for another. It’s
a multi-phased RF device, which provides more
effective heating of the collagen than bi-polar RF.
What gives you the greatest satisfaction in
your career?
Seeing my patients happy. Watching them come
back after a treatment or surgery smiling and
confident is why I exist.
What is the future for aesthetics?
Cellular therapy, using stem cells, fat cells and
fibroblasts, is advancing fast and will be used for
everything from skin rejuvenation to rebuilding
cartilage and noses. The use of ultrasound for
treating fat will become more commonplace,
but I feel radiofrequency devices will still be the
number one choice.
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In Practice
The Last Word
@aestheticsgroup
Aesthetics Journal
The last word
Collaboration between surgeons and aesthetic
doctors would provide patients with the best
treatment solutions, argues Dr Darren McKeown
The last two decades have seen significant
growth in cosmetic practice both in the UK
and worldwide. This explosion in cosmetic
interventions has been largely characterised
by newer, less invasive surgical procedures
and the emergence of a whole new field of
non-surgical procedures.
As the cosmetic interventions market has
grown, more and more practitioners from a
wide range of backgrounds have fought for a
slice of the pie, territories have been marked
out and fierce competition has emerged
between rival factions. There has developed
a ferocious battle between surgical and nonsurgical practitioners, with the former claiming
their surgical results are more durable and
longer lasting whilst the latter camp argues
that their procedures have less down time
and less risk.
There are a few surgical practitioners who will
make the argument that they are qualified to
offer both surgical and non-surgical solutions
and therefore they alone are best placed
to fully assess patients’ needs and offer
the most appropriate treatment. But in my
opinion this argument does not really cut it.
As with all things in medicine, and indeed life
in general, the more experienced you are
at one particular procedure, the better your
outcomes will be. A general plastic surgeon
who does 10 rhinoplasty operations per year
is highly unlikely to achieve the same level
of results as a rhinoplasty specialist who
does 10 rhinoplasty operations per week.
Likewise, a plastic surgeon who does the
occasional injection of Botox will not achieve
the same results as a doctor who specialises
64
in the procedure day-in, day-out carrying out
thousands of procedures per year.
Indeed, this sort of cavalier attitude towards
non-surgical procedures fails to realise the
significant benefits that can be achieved or
the degree of skill required to achieve them.
Whilst it may be easy for anyone to pick up a
syringe and inject, doing it in such a way as to
make a face look genuinely more attractive is
far from easy and requires a great degree of
skill, knowledge and experience.
I believe that this attitude extends both ways,
and there are non-surgical practitioners
attempting increasingly complex surgical
procedures, which, in some cases, may
be beyond their level of competence. In
this situation, patients might be offered the
surgical procedure the doctor can do, rather
than the one that might be best for them.
But is the competition and rivalry between
surgical and non-surgical practitioners
justified? The cosmetic market is already
a substantial size and growing every year;
there is plenty of opportunity for good
practitioners to grow a large and successful
practice, without fear of competition from
other specialists. At the heart of our practice
should always be finding the right procedure,
for the right patient, with delivery by the right
practitioner. This is good medical practice
across the board, and should equally be
applied to cosmetic practice. What is required
is closer collaboration between surgical and
non-surgical practitioners, with the focus on
the needs of each individual patient.
There are many clear overlaps between
surgical and non-surgical practice. One
Aesthetics | May 2014
Aesthetics
aestheticsjournal.com
classic example encountered every day
in the non-surgical clinic is the patient
with heavy upper eyelids who presents
requesting treatment to improve them. The
non-surgical solution is to carry out botulinum
toxin treatment using a pattern of injections
designed to elevate the eyebrows. Whilst this
does solve the problem of the heavy upper
lids, it does so at the expense of creating
a whole new problem of over-elevated
eyebrows that inadvertently age the face
and create an unnatural appearance. The
proper solution in this situation is usually
to recommend an upper blepharoplasty
to remove the excess skin followed by a
course of botulinum toxin treatment and filler
injections to improve the remaining rhytids.
By combining the two, it is possible to create
an optimal cosmetic result.
Whilst it is true that some patients simply
do not want surgery, that is an informed
decision that they need to make themselves
after having a thorough consultation and
explanation of the options available. It is not a
decision that should be dictated based upon
the availability of local skills and services.
Last year I teamed up with a surgical
colleague to offer joint consultations in my
non-surgical practice. The objective of the
collaboration was to offer our patients a
more comprehensive assessment that truly
put their needs at the heart of the process.
Patients are assessed from both a surgical
and non-surgical perspective and the options
are discussed in detail until we arrive at the
most appropriate treatment package for each
individual. By combining the skills of surgical
and non-surgical practitioners, a synergy
is achieved where the result of combining
skill sets achieves better results than either
practitioner acting independently. The overall
result is happier patients, with optimised
outcomes and rapid growth in practice. In
recent years, multi-disciplinary teamwork has
dominated the management of most areas of
medicine, although until now this has largely
evaded cosmetic practice. Perhaps now is
the time to re-think this position. Rather than
viewing other specialists as a threat, we
should look to each other as allies and work
together for the benefit of everyone, not least
for all our patients.
Dr Darren McKeown
specialises in facial aesthetics
and is medical director of the
Dr Darren McKeown Aesthetic
Medicine Institute clinic chain,
based in Glasgow and on Harley
Street. He previously trained as a plastic
surgeon and is a member of the Royal College
of Surgeons.
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+44 0808 2381500
Beautylight Technical Services Ltd
www.juvedermultra.co.ukContact: Ashaki Vidale
Mesoestetic UK
Contact: Adam Birtwistle
+44 01746 718123
[email protected]
www.mesoestetic.co.uk
Services: Cosmeceutical Skincare
Treatment Solutions, Cosmelan,
Antiagaing, Depigmentation,
Anti Acne, Dermamelan
l
DermaLUX
Contact: Louise Taylor
+44 0845 689 1789
[email protected]
www.dermaluxled.com
Service: Manufacturer of LED
Phototherapy Systems
Aesthetox Academy
Contact: Lisa Tyrer
+44 0870 0801746
[email protected]
www.aesthetox.co.uk
Service: Training
Merz Aesthetics
+44 0333 200 4140
[email protected]
Healthxchange Pharmacy
Contact: Steve Joyce
+44 01481 736837
+44 01481 736677
[email protected]
www.healthxchange.com
www.obagi.uk.com
Polaris
Lasers
Medical
Microdermabrasion
FromNeil Calder
Contact:
MATTIOLI ENGINEERING
+44 01234841536
[email protected]
www.polaris-laser.com
As featured on
s
SkinBrands
Contact:
Tracey Beesley
needle free
Mesotherapy
+44
0289
983
for the
delivery of
active 739
substances.
[email protected]
www.skinbrands.co.uk
Tel: 01234 841536
www.polarismedicallasers.co.uk
Intense Pulse Light (I2PL) & Laser Systems
Contact: Jane Myerson
T: 0208 741 1111
E: [email protected]
W: www.technicalsupport.ellipseipl.co.uk/
Services: Onsite service & repairs of
aesthetic systems. UK agent for Ellipse
IPL & Venus Radio Frequency systems
AZTEC Services
Contact: Anthony Zacharek
+44 07747 865600
[email protected]
www.aztecservices.uk.com
Service: Exclusive UK distributor
for Viora product range
delivering the promise
Lifestyle Aesthetics
Contact: Sue Wales
+44 0845 0701 782
[email protected]
www.lifestyleaesthetics.com
Contact: Jane Myerson
Ellipse-Intense
Pulse LightT: 0208 741 1111
T: 0208 741 1111
E: [email protected]
(I2PL)
&Laser Systems E: [email protected]
W: www.ellipseipl.co.uk
Contact:
Jane Myerson W: www.venusconceptuk.co.uk
Services: UK distributor of IPL & Laser
Services: UK distributor of Venus
systems,0208
IPL & Laser
training
courses
+44
741
1111
Freeze and Swan Radio Frequency (RF)
and technical support
& Magnetic Pulse (MP) systems
[email protected]
www.ellipseipl.co.uk
Services: IPL & Laser systems,
IPL & Laser training courses
and technical support
2
TECHNICAL SUPPORT
Beautylight Technical Services Ltd
Intense Pulse Light (I2PL) & Laser Systems
Contact: Jane Myerson
Silhouette Soft
Contact: Denise Daddario
+442089730518
www.juvin-essence.com
Lumenis UK Ltd
Contact: Nigel Matthews or
Mark Stevens
020 8736 4110
delivering the promise
[email protected]
www.lumenis.com
Contact: Jane Myerson
Skin Geeks Ltd
+44 01865 338046
[email protected]
www.skingeeks.co.uk
Contact: Ashaki
Vidale
Ellipse
Technical
Support T: 0208 741 1111
T: 0208 741 1111
T: 0208 741 1111
E: [email protected]
Beautylight
Technical
E: [email protected]
E: [email protected]
W: www.ellipseipl.co.uk
W: www.venusconceptuk.co.uk
Services
Ltd
W: www.technicalsupport.ellipseipl.co.uk/
Services: UK distributor of IPL & Laser
Services: UK distributor of Venus
Services: OnsiteAshaki
service & repairs
of
systems, IPL & Laser training courses
Contact:
Vidale
Freeze and Swan Radio Frequency (RF)
aesthetic systems. UK agent for Ellipse
and technical support
& Magnetic Pulse (MP) systems
IPL & Venus
Radio741
Frequency
+44
0208
1111systems
[email protected]
technicalsupport.ellipseipl.co.uk
Services: Onsite service&repairs
Lynton
of aesthetic systems. Ellipse IPL&
01477 536975
Venus Radio Frequency systems
[email protected]
www.lynton.co.uk
b
2
Bioptica Laser Aesthetics
Contact: Mike Regan
+44 07917 573466
[email protected]
www.bla-online.co.uk
Services: Core of Knowledge
Training and Laser Protection
Adviser (LPA) Services
Sound Surgical (UK) LTD
Contact: Raj Jain
+44 7971 686114
[email protected]
www.SoundSurgical.co.uk
t
m
Boston Medical Group Ltd
Contact: Iveta Vinklerova
+44 0207 727 1110
[email protected]
www.boston-medical-group.co.uk
Energist Medical Group
Contact: Eddie Campbell-Adams
+44 01792 798 768
[email protected]
www.energistgroup.com
g
MACOM
Contact: James Haldane
+44 02073510488
[email protected]
www.macom-medical.com
TECHNICAL SUPPORT
Beautylight Technical Services Ltd
c
Candela UK Ltd
Contact: Michaela Barker
+44 0845 521 0698
[email protected]
www.syneron-candela.co.uk
Galderma Aesthetic &
Corrective Division
+44 01923 208950
[email protected]
www.galderma-alliance.co.uk
h
Contact: Ashaki Vidale
T: 0208 741 1111
E: [email protected]
W: www.technicalsupport.ellipseipl.co.uk/
Med-fx
Contact: Faye Price
+44 01376 532800
[email protected]
www.medfx.co.uk
Services: Onsite service & repairs of
aesthetic systems. UK agent for Ellipse
IPL & Venus Radio Frequency systems
ThermaVein
Catherine Fuente
0161 826 3404
[email protected]
www.thermavein.com
v
Intense Pulse Light (I2PL) & Laser Systems
Contact: Jane Myerson
delivering the promise
Contact: Jane Myerson
Venus
Freeze
T: 0208 741 1111
E: [email protected]
Contact:
Jane Myerson
W: www.venusconceptuk.co.uk
+44
0208
741
1111
Services:
UK distributor
of Venus
Freeze and Swan Radio Frequency (RF)
[email protected]
& Magnetic Pulse (MP) systems
www.venusconceptuk.co.uk
Services: Venus Freeze and Swan
Radio Frequency (RF) & Magnetic
Pulse (MP)2 systems
T: 0208 741 1111
E: [email protected]
W: www.ellipseipl.co.uk
Services: UK distributor of IPL & Laser
systems, IPL & Laser training courses
and technical support
2
z
Carleton Medical Ltd
Contact: Nick Fitrzyk
+44 01633 838 081
[email protected]
www.carletonmedical.co.uk
Services: Asclepion Lasers
66
Hamilton Fraser
Contact: Wai Chan
+44 0845 3106 300
[email protected]
www.hamiltonfraser.co.uk
Medical Aesthetic Group
Contact: David Gower
+44 02380 676733
[email protected]
www.magroup.co.uk
Aesthetics | May 2014
Zanco Models
Contact: Ricky Zanco
+44 08453076191
[email protected]
www.zancomodels.co.uk
SMARTER TOOLS FOR
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RES/013/0414 Date of Preparation April 2014