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VOLUME 2/ISSUE 5 - APRIL 2015
Launched in 2011, Juvéderm VOLUMA® with lidocaine
is the first and only FDA approved product with VYCROSS™
technology indicated for the restoration of facial volume
including cheeks, cheekbones and chin.1
Noticeable results long after treatment, up to 24 months.2
97.4% of patients reported satisfaction as “improved to
very much improved” with the cosmetic effect of JUVÉDERM®
VOLUMA® with lidocaine immediately after treatment.3
REFERENCES:
1. Juvéderm® VOLUMA® with lidocaine Instructions for Use (IFU). 2. Jones D, Murphy DK. Dermatol Surg. 2013: 1-11
3. Dormston W. Poster presented at 8th European Masters in Aesthetics and Anti-Aging Medicine (EMAA). 12-14 Oct 2012. Paris, France.
Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK
Date of Preparation: March 2015 UK/0171/2015
15367 UK VYCROSS Ad Aesthetics Journal March 2015_Front Cover.indd 1
Managing
Obesity CPD
Dr Sotirios Foutsizoglou gives an
overview of approaches and treatment
Advances in
Lasers
Dr Elizabeth Raymond
Brown provides an
update on lasers in
aesthetics
Treating the Lips
Aesthetic practitioners
share their advice,
methods and
techniques for lip
augmentation
16/03/2015 12:02
Seasonal
Marketing
Charlotte Moreso
on how to create a
summer marketing
campaign
Not all HA
dermal fillers are
created equal.
Cohesive Polydensified Matrix®
(CPM®) Technology1,2
OPTIMAL
TISSUE
Optimal tissue integration1,2
INTEGRATION
Intelligent rheology design
Injectable Product of the Year
BEL202/0315/LD Date of preparation: March 2015
Contact Merz Aesthetics
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Email: [email protected]
The filler you’ll love
1. BEL-DOF3-001_1. Belotero® technology, March 2014. 2. Tran C et al. in vivo
bio-integration of three Hyaluronic Acid fillers in human skin: a histological study.
Dermatology DOI: 10.1159/000354384.
www.belotero.co.uk
Contents • April 2015
06 News
The latest product and industry news
12 Production in Pringy
We visit Allergan’s manufacturing and R&D facility in Pringy, France
14 Conference Reports
Reports from the annual AAD meeting and Interventional Cosmetics meeting at the RSM
Special Feature
Treating the Lips
Page 23
16 On the Scene
Out and about in the industry this month
18 News Special: Aesthetics Conference and Exhibition
A review of the hugely successful ACE 2015
CLINICAL PRACTICE
23 Special Feature: Treating the Lips
Aesthetic practitioners share their approaches to lip augmentation
28 CPD Clinical Article
Dr Sotirios Foutsizoglou explores obesity management with an overview of treatments and approaches
35 Topical and Oral Antioxidants
Ms Rozina Ali and Eva Escofet address the use of topical and oral antioxidants
41 Advances in Lasers
Dr Elizabeth Raymond Brown provides an update on the latest advancements in aesthetic lasers
45 The Importance of Skin Texture
Dr Sharon Crichlow discusses the importance of skin texture in aesthetic treatment
49 Case Study: Treating Filler Complications
Frances Turner Traill on her experience of managing a dermal filler complication
51 Treating the Perioral Area
Dr Souphiyeh Samizadeh details the treatment of perioral ageing
54 Advertorial: AestheticSource
A chance to find out more about the scientific research behind NeoStrata skincare
55 Abstracts
A round-up and summary of useful clinical papers
IN PRACTICE
57 Seasonal Marketing
Charlotte Moreso looks at the best methods of creating a summer marketing campaign
61 Building Patient Loyalty
Pam Underdown outlines useful strategies for retaining patients
64 Handling a Legal Complaint
Dr Askari Townshend shares his experience of dealing with a legal complaint
66 In Profile: Constance Campion
We talk to aesthetic nurse Constance Campion about her passion for the anti-ageing specialism
68 The Last Word: Photography
Dr Steven Dayan argues for patient awareness around
image distortion
Subscribe to Aesthetics
Marketing
Creating a seasonal campaign
Page 57
Clinical Contributors
Dr Sotirios Foutsizoglou specialises in minor
cosmetic surgery and aesthetic medicine.
Founder and medical director of SFMedica, he has
extensively lectured and presented at national and
international conferences and meetings.
Ms Rozina Ali is a consultant reconstructive
and aesthetic surgeon, specialising in facial
aesthetic surgery. Graduating from St Thomas’
Hospital Medical School, she now holds numerous
qualifications.
Eva Escofet is a highly established nutritional
therapist with 12 years of clinical experience. She
owns a multidisciplinary clinic in Surrey, and is also
co-owner of Aneva Nutraceuticals, specialists in
nutraceutical products.
Dr Elizabeth Raymond Brown is a laser
specialist, currently academic lead for the MSc. in
Non-Surgical Facial Aesthetics (NSFA) at UCLan,
Preston, and a professional trainer with an array of
laser experience.
Dr Sharon Crichlow works as a consultant
dermatologist at the Skin to Love Clinic in St.
Albans, UK. Her interests include treatment of acne
scarring and pigmentary disorders commonly seen
in patients with skin of colour.
Frances Turner Traill is an independent nurse
prescriber and runs her own aesthetic clinics in
Scotland. An active board member of the British
Association of Cosmetic Nurses (BACN), she leads
the Scottish Regional Group’s educational meetings.
Dr Souphiyeh Samizadeh is a dental surgeon
with a special interest in aesthetic medicine.
She is an honorary clinical teacher at King’s
College London and clinical director of Revivify
London clinic.
NEXT MONTH
• IN FOCUS: Lifting and Tightening • CPD: Vitamin A
• Treating the Gluteus Maximus • Review of Electronic
Record Keeping Systems
Entry for the Aesthetics
Awards opens May 1st.
Full list of categories
in next month’s issue
Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical
aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228
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Editor’s letter
The highly anticipated ACE 2015
weekend came and went, and it was brilliant.
We have had the most positive feedback ever,
so my thanks to all of you for attending and
participating to make ACE the best conference
of its type. The free education on offer proved
Amanda Cameron
extremely popular, with packed Expert Clinics
Editor
and Masterclasses featuring live demonstrations
from top practitioners, while the Business Track offered imaginative
and effective ways for augmenting business. Delegates also had the
chance to meet with suppliers and distributors who shared exciting
innovations, and the exhibition floor was a hub of activity throughout
the weekend. The new format Conference programme attracted great
numbers of delegates seeking thorough, interactive learning from
international speakers. The four modules provided comprehensive
guides to key areas of medical aesthetics, utilising novel approaches
for maximising engagement, with the voting technology stimulating
some interesting debates.
A special thanks must go to Mr Dalvi Humzah who, as chair of the ACE
Steering Committee, played a huge part in the seamless execution
and high quality of the educational programme.
To see packed sessions right up to the close of the event on Sunday
was truly a proud moment for us, proving that the scientific and nonclinical agendas that we had assembled succeeded in providing
incredibly engaging and high-quality learning for a huge range of
interests and professional needs. If you missed out this year, see
pages 18-21 for a review of some of the event’s highlights.
With many exhibitors booking immediately for next year’s event,
and speakers already planning exciting sessions for the educational
agenda, work for ACE 2016 is already underway.
So what do we look forward to next? This issue features some
great topics that continue our focus on high quality education –
these include the second part of Dr Sotirios Foutsizoglou’s weight
management CPD article. This detailed feature is relevant to all
practitioners as, in caring for our patients’ health and wellbeing, we
deal with weight matters and body issues on a daily basis. This month
is our Smile issue, and we explore this area in a roundtable discussion
from leading practitioners on their best techniques for treating the lips
(p. 23) and in a detailed overview by Dr Souphiyeh Samizadeh into
perioral ageing (p. 51). I would also like to remind you that entry is open
for the Aesthetics Awards as of May 1, and you will be able to find all
the categories and entry information in the next issue of Aesthetics.
Let us know what you think of this issue by tweeting
@aestheticsgroup or emailing [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 our educational, clinical and business content
Dr Mike Comins is fellow and former president of the
British College of Aesthetic Medicine. He is part of the
cosmetic interventions working group, and is on the faculty for
the European College of Aesthetic Medicine. Dr Comins is also
an accredited trainer for advanced Vaser liposuction, having
performed over 3000 Vaser liposuction treatments.
Mr Dalvi Humzah is a consultant plastic, reconstructive and
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.
aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic
surgeon in the NHS for 15 years, and is currently a member of the
British Association of Plastic, Reconstructive and Aesthetic Surgeons
(BAPRAS). Mr Humzah lectures nationally and internationally.
Dr Tapan Patel is the founder and medical director of VIVA
and PHI Clinic. He has over 14 years of clinical experience and
has been performing aesthetic treatments for ten years. Dr
Patel is passionate about standards in aesthetic medicine and
still participates in active learning and gives presentations at
conferences worldwide.
Sharon Bennett is chair of the British Association of
Cosmetic Nurses (BACN) and also the UK lead on the BSI
committee for aesthetic non-surgical medical standard. Sharon
has been developing her practice in aesthetics for 25 years and
has recently taken up a board position with the UK Academy of
Aesthetic Practitioners (UKAAP).
Mr Adrian Richards is a plastic and cosmetic surgeon with
12 years of specialism in plastic surgery at both NHS and private
clinics. He is a member of the British Association of Plastic and
Reconstructive Surgeons (BAPRAS) and the British Association of
Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards
and has written a best-selling textbook.
Dr Christopher Rowland Payne is a consultant
Dr Sarah Tonks is an aesthetic doctor and previous
dermatologist and internationally recognised expert in cosmetic
dermatology. As well as being a co-founder of the European
Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was
also the founding editor of the Journal of Cosmetic Dermatology
and has authored numerous scientific papers and studies.
maxillofacial surgery trainee with dual qualifications in both
medicine and dentistry. Based at Beyond Medispa in Harvey
Nichols, she practises cosmetic injectables and hormonalbased therapies.
PUBLISHED BY
EDITORIAL
Chris Edmonds • Managing Director
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[email protected]
Suzy Allinson • Associate Publisher
T: 0207 148 1292 | M: 07500 007 013
[email protected]
Amanda Cameron • Editor
T: 0207 148 1292 | M: 07810 758 401
[email protected]
Betsan Jones • Assistant Editor
T: 0207 148 1292 | M: 07741 312 463
[email protected]
Chloé Gronow • Journalist
T: 0207 148 1292 | M: 07788 712 615
[email protected]
Hazel Murray • Journalist
T: 0207 148 1292 | M: 07584 428 630
[email protected]
ADVERTISING
Hollie Dunwell • Business Development Manager
T: 0203 096 1228 | M: 07557 359 257
[email protected]
Sadia Rahman • Customer Support Executive
T: 0203 096 1228 | [email protected]
MARKETING
Marta Cabiddu • Marketing Manager
EVENTS
Helen Batten • Events Manager
Kirsty West • Assistant Events Manager
DESIGN
Peter Johnson • Senior Designer
Chiara Mariani • Designer
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Aesthetics Journal
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ARTICLE PDFs AND REPRO
Material may not be reproduced in any form without the
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© Copyright 2015 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
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Awards
Talk #Aesthetics
Follow us on Twitter @aestheticsgroup
#Safety
Good Surgeon Guide @goodsurgeon
Just because he/she is a #plasticsurgeon doesn’t mean he/she is
an expert in every single procedure. Do your #research well. #gsg
#Learning
Dr. Ahmed Al-Qahtani
@aqskinsolutions
During our #AQ #growth #factor
training in #Indonesia. Great
turnout.
#Media
Emma Bedford @MissEmmaBarlow
Good to see the fabulous @drtapanp giving advice on burns
treatment on tonights @BBCCrimewatch. Feel for the poor
victims of acid attacks.
#Journal
Medico Beauty @medicobeauty
@aestheticsgroup I just got my copy! Look forward to reading all
the great articles this evening. Can’t wait for #ACE2015
#Aesthetics
Dr Rita Rakus @DrRitaRakus
We featured in the Aesthetics
magazine from a SkinCeuticals
event we attended in February.
#SkinCeuticals #aesthetics
#Training
Luisa Scott @Nurse_Luisa
Great @EllanseUK training day with @Dr_AskariT and the team
#Interview
Lorna Bowes @LornaBowes
With lovely Betsan of @aestheticsgroup after interviewing Leigh
Ann Catlin and Cathy Mueller of NeoStrata Co. Great questions.
#skinfitness
#Equality
PHI Clinic @PHIclinic
Let’s hear it for the girls @PHIclinic. How blessed we are to have such
talented, brilliant women on board #InternationalWomensDay
#Education
Dr Chrysopoulo @mchrysopoulo
@cpelletiere @DrRothaus No single “best procedure” for everyone.
Patient education re ALL options key to ensuring fully informed
decisions
#Clinic
Dr Ravi Jain @DrRaviJain
Looking forward to a day of male
cosmetic surgery @Riverbanks.
We have #gynecomastia & Vaser all
day #surgeonselfie
Entry for the Aesthetics
Awards 2015 opens in May
From May 1, practitioners, clinics, distributors and manufacturers
are invited to submit their entry for the prestigious Aesthetics
Awards ceremony, to be held in London on December 5, 2015.
Last year’s event saw more than 500 members of the medical
aesthetics profession celebrate the great achievements of our
speciality in 2014, in an elegant ceremony and an evening of
entertainment which proved a huge success amongst attendees.
Consultant plastic surgeon Mr Dalvi Humzah, who won the Training
Initiative of the Year award, said, “The Aesthetics Awards is one of the
premier awards events for aesthetics, recognising excellence and the
outstanding achievements of practitioners, surgeons and suppliers.”
The Aesthetics Awards categories cover all aspects of the specialty,
including awards for Medical Practitioner of the Year, Best Customer
Service by a Manufacturer or Supplier, Treatment of the Year and
Product Innovation.
Each category submission requires a thorough and high-quality
written entry that meets the criteria for submission. Entries are then
judged by an expert panel or decided upon via a combination of
judging and votes from industry professionals. Details for each
category will be available on the Aesthetics Awards website.
Dr Maria Gonzalez of the Specialist Skin Clinic in Cardiff, and winner
of the Sinclair IS Pharma Award for Best Clinic Wales, said, “As the
medical director of a new clinic, it was a moment of great pride to
receive an Aesthetics Award. The entire process was motivating for
the team of clinic staff whose work was rewarded by this success. All
in all, an excellent night.”
This year, two new categories have been added to the line up. Awards
will be presented to the Best Clinic Group made up of three or more
clinics, and the Best Clinic Group comprising ten clinics or more.
Sponsors for three categories have already been announced.
Sterimedix will support the Injectable Product of the Year, whilst
NeoCosmedix will once again sponsor the award for Association/
Industry Body of the Year. HealthXchange will continue to support The
Janeé Parsons Award for Sales Representative of Year, in memory of
their colleague and her outstanding work within the industry.
The eagerly anticipated event will be held at the Park Plaza
Westminster Bridge Hotel in Central London.
Submit your entries via www.aestheticsawards.com from May 1.
Standards
BSI ‘Aesthetic NonSurgical Standard’ update
A public consultation on the draft European Standard for nonsurgical aesthetic treatment has begun.
Covering a wide range of non-invasive treatments, the new standard,
titled, ‘Aesthetic medicine services – Non-surgical medical procedures
(EN 16844)’, aims to address a variety of aesthetic procedures.
Carried out across Europe, professional organisations and the general
public can comment via the British Standards Institute, who are
responsible for the UK consultation. Open until May 4, 2015, the public
can have their say on www.bsigroup.com.
Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015
aestheticsjournal.com
@aestheticsgroup
Aesthetics Journal
Aesthetics
LED Phototherapy
Aesthetic Technology launches
Dermalux Tri-Wave Compact device
Aesthetic device manufacturer Aesthetic Technology has added a new product to
its Dermalux LED Phototherapy range. The Dermalux Tri-Wave Compact device uses
non-thermal light energy to naturally stimulate skin rejuvenation and aid skin conditions,
aiming to safely and effectively treat a wide range of indications; including ageing, acne
and pigmentation. The non-invasive device delivers narrowband wavelengths at optimised
intensity and dose with red 633 nm, blue 415 nm and new infra-red 830 nm. According to
the company, the Dermalux Concurrent Modality Treatment feature allows for individual
wavelength treatments, or simultaneous use of all wavelengths to accelerate results and
reduce treatment visits. Using the latest LED technology, the manufacturer claims the
device is also a significant development in the treatment of inflammatory skin conditions.
Managing director of Dermalux Huw Anthony said, “With our development programme
now in full swing and with more systems to come over the next 18 months, plus our recent
launch into the export markets, we are excited by what the future may hold for Dermalux.”
The Dermalux Tri-Wave Compact device is available in the UK from April.
Patient safety
BAPRAS launches patient safety
campaign
The British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) has
launched a campaign to persuade patients to think carefully about aesthetic treatment.
BAPRAS created the campaign ‘Think Over Before You Makeover’ in response to results
of their research into cosmetic surgery choices. The major study indicated that two million
people in the UK are considering or will undergo cosmetic surgery in the next year. It
showed that, on average, a quarter of patients don’t check the credentials of their surgeon,
while a fifth aren’t aware of the risks associated with the procedure they are undertaking.
The results further suggested that a fifth aren’t clear on the potential outcomes of their
procedure before going ahead. BAPRAS president and consultant plastic surgeon Nigel
Mercer said, “Cosmetic surgery is not something to be taken lightly and yet thousands of
people are putting themselves at serious risk by rushing into major procedures recklessly,
without consideration for their own safety.” Members of BAPRAS hope that this campaign
will ensure patients carry out the appropriate research on prospective treatments and
prospective practitioners, before making the decision to undergo surgery. Mercer added,
“‘Think Over Before You Make Over’ is not here to promote cosmetic surgery; we recognise
that thousands of people will choose to have surgery this year and we want all these people
to read our campaign advice so they can make informed choices and protect themselves
from bad practice.”
Fat reduction
New statistics reveal surge in nonsurgical fat reduction procedures
The American Society for Aesthetic Plastic Surgeons (ASAPS) has announced that
non-surgical fat reduction procedures rose by 43% in 2014. Since they began recording
figures, it’s the first time that more than 100,000 non-surgical fat reduction procedures were
performed in one year. ASAPS president Michael Edwards said, “Non-surgical fat reduction
is a new frontier in the realm of cosmetic procedures. The rise in its popularity is indicative of
the public’s desire for non-surgical alternatives in lieu of their invasive counterparts.”
However, he added, “Not everyone is a candidate for non-surgical treatment as well. Many
will still be better served from a surgical approach to include liposuction.”
News in Brief
3D-lipo opens Kuwait head office
Aesthetic device manufacturer 3D-lipo
has launched a new head office in
Kuwait. The office, which will focus
on providing support to their Middle
Eastern distributors, has six 3D-lipo
treatment rooms, a reception area and
offices to handle distribution in the
region. Managing director of 3D-lipo Roy
Cowley said, “It offers a fantastic bridge
to conquer expansion into the entire
middle-eastern territory.”
Seppic launches first cosmetic
ingredient derived from
their macroalgal cell culture
innovations
BiotechMarine, a subsidiary of specialty
ingredient developer Seppic, are to
launch Ephemer in April at the incosmetics trade fair in Barcelona.
The new ingredient is a gametophyte
extract taken from macroalgal cells,
extracted at an ephemeral stage in the
life cycle of Undaria Pinnatifida seaweed.
Seppic claims the macroalgal cells
accumulate anti-oxidant molecules,
creating an ingredient that can be
manipulated for use in skin protection.
Jan Marini launches new face and
neck creams
Skincare company Jan Marini has
added two anti-ageing creams to its
product portfolio. The updated Age
Intervention Face Cream and the new
Marini Juveneck aim to reduce the signs
of ageing on the face and neck. Director
of Outline Skincare Clinic Mary White
said, “Harnessing the use of peptides,
along with Vitamin E and hyaluronic acid
to deeply hydrate, Marini Juveneck is
giving my ladies a noticeable lift.”
Molecular-based skincare
products launched
Aesthetic practitioner Dr Gabriela Mercik
has launched a molecular-based facial
skincare line. The products include the
Advanced Molecular Face Mask and
Magic Beauty Face Lift, which aim to
moisturise, hydrate and replenish skin.
After conducting research into the
indications of molecular water, Dr Mercik
claims she has created a formulation that
will protect the skin from ageing due to
its hydrating properties.
@aestheticsgroup
Aesthetics Journal
Television
Industry
BBC commissions series
based on Harley Street
The BBC has commissioned a three-part series based on Harley Street’s medical
neighbourhood and history.
The programmes, called ‘Inside Harley Street’, will give viewers the opportunity to
learn about the world of private medicine and explore the types of treatments available today. Directed by ‘Welcome to the World of Weight Loss’ director Vanessa
Engle, the programme will be broadcast on BBC Two, and each episode will feature
interviews with both practitioners and patients. Episode one will look at private
healthcare, the second will focus on aesthetic medicine and the final episode will
address complementary and alternative medicine.
Kim Shillinglaw, controller of BBC Two and BBC Four, said, “With Vanessa Engle’s
trademark warmth and humour, this series takes us behind the closed doors of this
very British institution to give a revealing insight into some very modern concerns,
from the role of private healthcare to the lengths we’ll go to for the latest cosmetic
and alternative treatments.”
Prescribing
HealthXchange launches
online pharmacy
Medical supplier
HealthXchange Pharmacy has
launched an online prescribing
system. The new service will
allow practitioners to process
prescriptions online, create and
sign orders, pay online and
have the ability to re-order using
a one-click process. Once an
order is made, it will be stored
in a computer system to make future orders more efficient and build an order
history. HealthXchange claim the system is suitable for sole practitioners as well as
larger corporate businesses. The e-pharmacy is compliant with the Medicines and
Healthcare Products Regulatory Agency (MHRA) regulations and will be available to
use on any mobile device. Managing director of HealthXchange Pharmacy Karen Hill
said, “For too long practitioners, clinic owners and pharmacies have had to rely on
paper-based prescribing and be at the mercy of the fax, scanner or email account.”
The system is available now.
Actavis completes
acquisition of
Allergan
Allergan has announced that the pending
acquisition of the company by Actavis is now
complete. The news comes following the confirmed
clearance by the European Commission three days
earlier, which satisfied the final regulatory conditions
to the closing of the pending acquisition.
The confirmation of completion rounds up a
$70.5 billion cash and equity deal, which began
in November 2014, combining the companies to
create one of the world’s top 10 pharmaceutical
companies by sales revenue. The companies have
predicted combined annual pro forma revenue of
more than $23 billion in 2015. “The combination
of Actavis and Allergan creates an exceptional
global pharmaceutical company and a leader in a
new industry model – Growth Pharma,” said Brent
Saunders, CEO and president of Actavis. “Anchored
by world-renowned brand franchises, a leading
global generics business, a premier pharmaceutical
development pipeline and an experienced
management team committed to maintaining highly
efficient operations across the organisation, we
are creating an unrivaled foundation for long-term
growth.” He added, “With the acquisition now
complete, we will immediately begin implementing
our comprehensive integration plans to ensure that
we leverage our strengthened global organisation
to generate sustainable organic earnings growth
from our newly expanded base, and continue
our ascent into the fastest-growing and most
dynamic growth pharmaceutical company in global
healthcare.” It has also been announced that Actavis
intend to use ‘Allergan’ as their corporate name.
Saunders said, “By adopting the Allergan name for
the corporation we will ensure that our corporate
identity reflects the dramatic evolution of our
company within the pharmaceutical industry.”
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Aesthetics Journal
Aesthetics
Brand development
Skincare
5 Squirrels adds products
to Your Signature Range
Medico Beauty
launches
LUNA Fusion
Private label cosmeceutical supplier
5 Squirrels has added three new
products to its Your Signature Range
portfolio. The additions to the existing
five-product line are C-10, Refine and
Protect 45. The C-10 is a Vitamin C
serum containing 10% L-ascorbic
acid, which the company says is essential to achieving optimal skin health. Refine
is an intensive eye cream that contains Vitamin E and Lactic Acid, which aims to
improve the appearance of periocular ageing. Protect 45 is an SPF 45 daily tinted
moisturiser. The product includes a small amount of mineral makeup, which conceals
any undesired SPF residue without making a significant change to the natural skin
complexion. Co-founder of 5 Squirrels Gary Conroy explains that the products
contain clinically proven and tested ingredients, which have been developed with
leading UK healthcare professionals. The range can be branded specifically to your
clinic, which the company claims reduces the burden of development and regulatory
issues. Conroy said, “The importance of brand development in clinical practice has
never been so crucial as the UK medical aesthetics market enters a more mature
era. UK leading clinics have adopted this approach and have seen huge benefits in
patient retention, recruitment and brand recognition.”
Skincare distribution company Medico Beauty has
launched a treatment that combines the CosMedix
skincare range with the Foreo Dual T-Sonic Wave.
LUNA Fusion is a new skin treatment protocol aimed
at the treatment of dry, sensitive and rosacea skin. The
Foreo Dual T-Sonic Wave is a hand-held device that
pulsates 8,000 times per second. It sends sonic waves
across the body, with the purpose of cleansing the
treatment area. The CosMedix formulations, used in
conjunction, utilise a process called Chiral Correction
to purify active ingredients and aid in the treatment of
sensitive skin. Medical aesthetician Caroline McLean
of La Belle Forme clinic in Glasgow offers the LUNA
Fusion treatment to her patients. She said, “In our clinic
we often meet patients who experience sensitive skin
and rosacea. The LUNA Fusion fully integrates with
all advanced services and supports the successful
resolution of these conditions.”
Dermal filler
Radiofrequency
Study suggests polycaprolactonbased dermal filler induces
neo-collagenesis
Viora launches V20
multi-technology
platform
A new study suggests that polycaprolaction-based (PCL) dermal fillers may be
able to induce neo-collagenesis when injected into human tissue.
The study aimed to show that Ellansé, a novel PCL-based dermal filler by Sinclair
Pharma, would be able to revive collagen in human tissue.
Previous clinical studies indicated that Ellansé was capable of encouraging neocollagenesis in rabbit tissue. The new pilot study, however, published in the Journal
of Cosmetic and Laser Therapy, suggested that the filler may also be capable of
inducing neo-collagenesis when injected intra-dermally into human tissue.
The study monitored two patients who undertook a temple-lifting procedure using
Ellansé, injected intra-dermally into the tissue. Biopsies were analysed to show the
improvement of collagen formation around the PCL particles, which, according to the
researchers, maintained their original state 13 months post treatment, and showed
that tissue migration of the PCL particles had not occurred at this stage.
Aesthetic distribution
company AZTEC
Services has
announced the launch
of the V20 multitechnology platform.
The V20 consists of
light and radiofrequency
technologies, which
enable practitioners to
offer patients multiple
treatment options using
one system.
The three handpieces
on the device include
the V-IPL, which aims to enhance IPL treatments, the
V-ST to aid skin tightening treatments, and the V-FR,
which aims to improve fractional radiofrequency
treatments using Viora’s SVC technology.
Board-certified plastic surgeon Dr Daniel Man uses
the device in his clinic. He said, “With different
technologies within one system, and Viora’s use
of combination protocols, the treatment of difficult
conditions such as stretch marks and scars, can be
addressed with more efficacy and success.”
@aestheticsgroup
Events diary
10 – 12 April 2015
International Master Course on Ageing
Skin – IMCAS Annual Meeting, China
www.imcas.com/en/china2015/congress
th
th
30th April – 2nd May 2015
Cosmetex 2015 Conference, Melbourne
www.cosmetex.org
14th – 19th May 2015
American Society for Aesthetic Plastic
Surgery (ASDS) Annual Meeting, Montréal
www.surgery.org/downloads/microsite/
meeting2015/welcome.php
7th – 9th July 2015
British Association of Dermatologists
(BAD) Meeting, Manchester
www.bad.org.uk/events/annualmeeting
Topicals
No-needle
hyaluronic acid filler
treatment launched
A Swiss-developed
topical gel filler has been
launched in the UK with
the aim of plumping
skin without the use
of needles. Fillerina
comprises a blend of six hyaluronic acids, which aim
to increase tissue volume in cheeks and lips. The gel
also contains peptides that aim to stimulate collagen
production and soften the appearance of fine lines
and wrinkles.
The at-home kit contains 14 doses of 2ml gel filler,
14 doses of 2ml nourishing film and two precision
applicators, which can be used to aid successful
application of the topical gel. According to Labo, the
Fillerina manufacturers, the treatment should be used
once daily for 14 days.
Three different grades of gel strength are available,
as well as a range of creams in lower strength doses
than the gel. Dr Elisabeth Dancey of Bijoux MediSpa
said, “I recommend Fillerina to my patients for two
reasons. For use if they have a fear of needles, or for
a skin ‘boost’ between their botulinum toxin or filler
treatments.” Following a double blind, randomised
clinical trial, results have been proven to be effective
and last between two and a half to three months.
Aesthetics Journal
Dermal filler
FDA recommends expanded
use of Radiesse for hand
augmentation
The Food and Drugs Administration (FDA) Medical Devices Advisory
Committee has announced a majority vote in recommending the expanded
use of Merz Aesthetics’ Radiesse dermal filler to include volume correction
in hand augmentation. The FDA’s General and Plastic Surgery Devices Panel
of the Medical Devices Advisory Committee voted the hand treatment as safe,
with a majority of 11 to three. According to clinical studies conducted by Merz
over 12 months, it was indicated that Radiesse had produced a statistically
significant improvement of volume loss in the hands after three months,
remaining stable over time, with effectiveness after treatment similar to that
seen following initial treatment.
Merz further claimed that the results showed no detrimental effect on hand
function post-treatment, and no new safety issues had been identified.
“The data presented show Radiesse is safe, effective and non-invasive, and
we support its approval process,” said Dr Lawrence Green, a board-certified
dermatologist, speaking on behalf of the American Society for Dermatologic
Surgery Association (ASDSA). The panel further voted that the available data
was sufficient to characterise hand function post injection, though it was
suggested that more hand function tests for daily living should be undertaken
in future studies. They also recommended that the photographs from the study
should be evaluated by unbiased, blinded healthcare professionals, rather than
on-site.
In addition to including long-term study data on those with severe handvolume loss, the panel advised that the study guidelines in the future should
evaluate patients who receive surface treatments in order to determine where
applicable time lags between treatments should exist. In 2006, Radiesse
received FDA approval for the use of the dermal filler in treating indications of
subdermal implantation for restoration and/or correction of the signs of facial
fat loss in people with HIV, as well as for the correction of moderate-to-severe
facial wrinkles and folds.
Cellulite
Exilis Elite receives FDA
clearance for cellulite treatment
The Food and Drugs Administration (FDA) has approved Exilis Elite as a
treatment for the temporary reduction of cellulite.
The non-surgical radiofrequency device from BTL Aesthetics has been
primarily used to reduce wrinkles and tighten skin. The device uses
monopolar technology to heat the skin, which aims to remodel, tighten and
firm collagen tissues. With the new FDA approval, practitioners will now also
be able to use the technology as a cellulite reduction device.
UK-based practitioner Dr Kannan Athreya said, “The fact that the Exilis Elite
has received FDA approval as far back as 2009 for non-surgical treatment of
wrinkles, and then this year for the reduction in the appearance of cellulite,
is a testament to its power and reliability to provide consistent and reliable
results.”
Scott Mills, the US vice president of sales at BTL Aesthetics, added, “We are
committed to working closely with our partners in the aesthetics community
to build on the initial results and continue to improve our capabilities for
treating cellulite.”
@aestheticsgroup
Aesthetics Journal
Aesthetics
Aftercare
Episciences launches new
post-procedure care kit
Skincare manufacturer Episciences has launched an aftercare range
for patients who have undergone moderate to deep skin rejuvenation
procedures.
The Essential Recovery Kit will be added to the Epionce skincare range and
aims to address skin irritation post-procedure, soothe the skin to minimise
stinging, boost hydration and reduce downtime.
The manufacturer claims the ‘take-home’ care kit will address patients’ needs
after treatments such as micro-needling, fractionated laser and mid-depth to
deep chemical peel treatments. Priming Oil, Enriched Firming Mask and Medical
Barrier Cream are included in the kit. CEO of Episciences Dr Carl Thornfeldt
said, “After a deeper resurfacing procedure, the skin is so sensitive and
vulnerable. Most of the products on the market do not fully address what the
skin needs to heal quickly, completely and without negative side effects such as
stinging, long-term sensitivity or even dark spots.” The Essential Recovery Kit is
available in the UK now.
Industry
VENN Healthcare launches
Lutronic in UK
VENN Healthcare has acquired the UK-distribution rights to global aesthetic
device company Lutronic.
The main products in the distribution company’s initial offering will include
microneedling radiofrequency device Infini, long-pulsed Alexandrite and Nd:YAG
laser Clarity, and dual-pulsed Q-switched Nd:YAG laser Spectra XT.
Managing director of VENN Healthcare Jim Westwood said, “Lutronic is not only
challenging competitors, but in some instances we believe the systems offer
better results and a more versatile device for customised treatments. As we
know, the aesthetic market is growing at a rapid rate and with patient demand on
the rise, we enter the UK market in a strong position with a range of high quality,
proven systems.”
Skincare
Scandinavian Skincare
Systems UK launches new
skincare range
Scandinavian Skincare Systems UK has launched MÖ Scandinavian
Cosmeceuticals, a range of products that includes professional strength peels.
According to the company, the cosmeceutical range targets skin on a molecular
level, speeding up the cell renewal process.
The company’s flagship product is the Stem Cell Corrector, which uses the stem
cells of a Swiss apple to aim to regenerate cells in patients’ skin.
CEO of Scandinavian Skincare Systems Paul Olavesen-Slabb explained that the
formulations are clinically tested to reduce wrinkles, improve elasticity, enhance
collagen production, balance sebum properties and smooth irritated skin. The
new range is paraben-free, natural and organic, and vegan certified with no
animal ingredients. The products are available to aesthetic medical professionals
via the company’s online shop, which is closed to the general public.
60
Roy Cowley, founder and managing
director of 3D-lipo Ltd:
Why did you create 3D-lipo?
I regard the 3D-lipo device and
brand as a culmination of my
25 years of experience within
the industry. I strove to create
something fundamentally
different, results driven and affordable to both
clinic and customers. Our point of difference is
that we do not stand behind a trend that would
make us directly comparable to competition
in the market, but created a multi-technology
platform that meant that we had the ability to
treat fat removal, loose skin and cellulite from
one amazing machine. The key to this was also
to ensure that all individual technologies were
comparable or better than that of stand-alone
devices. Once I had achieved all of this, we
stood behind our differences, being the unique
3D approach, and embarked on a national PR
awareness campaign.
What do you attribute to 3D-lipo’s vast success?
There are several factors that have contributed to
our success, those being fantastic results, multiple
treatment applications and affordability. These
are the foundations. However, without a doubt
the success built from these foundations is wholly
down to the massive national media exposure
that the brand has achieved. This has highlighted
our results and point of difference, creating
massive awareness not only within our industry
but also to consumers nationwide.
How does 3D-lipo support its customers?
As a company we pride ourselves on our
support, which at times has been difficult due
to the vast expansion in the UK and overseas. It
all starts with great training and local marketing
assistance and continues with our constant
efforts to gain national exposure behind our
unique devices, which in turn drives patients
through our customer’s doors from our clinic
finder on our website. During the week that
Amy Childs launched 3D-lipo in her own clinic,
we were getting more than 3000 hits on our
website per day from the social media activity
and national media articles from customers
hungry for the 3D-lipo treatment. Our branding
and USP ensures that it is only 3D-lipo
customers that benefit from this support.
This column is written and supported by
@aestheticsgroup
Aesthetics Journal
Associations
Data
Survey indicates one in five US
women intend to have cosmetic
treatment
A survey has suggested that one in five women are currently pursuing or
intending to have cosmetic treatment. Conducted on behalf of RealSelf by Zeitgeist
Research, the survey comprised 5,053 women in the US between 18 and 64
years old. It explored the trends of the US market for beyond-the-counter beauty
procedures and the potential for expanding the industry.
The results found that of the women surveyed, one in five are currently pursuing
or planning to have cosmetic surgery. During the survey, it was also indicated
that of 87% of women who were unhappy with at least one area of their body, the
trend to seek cosmetic treatment has risen by more than 200%, with these women
representing an estimated market of more than $75 billion. Of those who were willing
to seek treatment beyond the retail floor, 62% would also consider surgery. The
24% of women who are planning for less invasive treatment represent an estimated
market of $12 billion. Another area explored in the survey was motivation, which
stated that 65% of women wanted to feel more comfortable with themselves, whilst
one third (29%) were also considering cosmetic work due to a milestone life event.
“While the total market has previously been calculated by the procedures performed
in the past year, we can see that the total addressable market is actually far greater,”
said Tom Seery, CEO of RealSelf. “As cosmetic procedures continue to become
mainstream, millions of women are overcoming social stigma to pursue cosmetic
changes they have been researching, often for years.”
R&D Report
Production at Pringy
Aesthetics visit the production site
and R&D hub for Allergan’s crosslinked family of hyaluronic acid
dermal fillers
The Allergan Medical site in Pringy, France, was acquired in 2007.
Currently, it houses 240 employees, 33 of which carry out the
vital research and development work that has secured Allergan’s
place as one of the forerunners in the manufacturing and
distribution of dermal fillers. Pringy is what Allergan employees
refer to as the ‘centre of excellence’. This is because the site in
France works as the base for all of Allergan’s manufacturing and
R&D activity for Juvéderm – the company’s diverse range of
cross-linked, hyaluronic acid dermal fillers. In its two neighbouring
buildings, the site has produced around 28 million syringes
BACN announces
new board member
The British Association
of Cosmetic Nurses
(BACN) has announced
that former Wigmore
Medical chairperson
David Hicks will take
a position on their
board. A pharmacist by
profession, Mr Hicks actively supported nurses at
Wigmore Medical, and the BACN expressed their
delight at his appointment.
The move has been announced among several
changes currently happening at the BACN, which
includes an office move to Bristol.
Sharon Bennett, BACN chairperson, said, “He
brings with him a pair of safe hands, a wealth
of experience, and will strengthen the current
committee with his knowledge of our specialist
area of medicine and his business acumen.”
Current BACN board members supported the
move unanimously. Of his new position, Mr Hicks
said, “I am honoured to be part of the BACN.”
since 2000. The approach at Pringy is a holistic one. “One of the
big strengths we have in Pringy is the proximity of the R&D and
manufacturing,” explains senior general director Claudie Allaire.
“This proximity provides a great sense of collaboration, reactivity
and flexibility.” Inspecting this notion closer, director of engineering
Pascal Brice notes that, in fact, three worlds combine together at
Pringy, “Here we are manufacturing a medical product, whereas
the syringe is a pharmaceutical device, yet the packaging belongs
to the luxury industry.” As a pharmaceutical company, Allergan
has five plants across the world – in Texas, Costa Rica, Brazil,
Ireland and France – and more than 10,000 employees. With the
confirmation of an acquisition by Actavis in place, this network
is set to expand. A theme of continual expansion is evident in
Pringy, where plans are in place to increase capacity and automate
processes in order to increase quality control; next year they will
introduce a state-of-the-art camera system to inspect syringes.
“We will be the first pharmaceutical company to inspect syringes
with gel using technology,” says Brice. This type of approach aims
to eliminate human error, he says, and it is this approach of careful
monitoring and continual development of technologies that puts
the manufacturing and development of the Juvéderm
range in line with regulatory standards closer to that of
the pharmaceutical requirements for prescription-onlymedicines (POMs). The mission at Pringy, emphasises
Brice, is to exceed customer expectations and quality
control is evidently a key term. “We are proud of our
strong commitment to quality which influences everything
we do,” says Allaire. “From sourcing our ingredients, to
manufacturing through to our suppliers – it’s all designed
to deliver the highest quality product possible.”
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@aestheticsgroup
RSM ICG-7: International
Multidisciplinary Annual
Meeting, London
More than 130 aesthetic medical
professionals attended the Royal
Society of Medicine’s Interventional
Cosmetics Group’s 7th International
Multidisciplinary Annual Meeting (RSM
ICG-7) on February 27-28. The two-day
Dr Kathryn Taylor Barnes and
event featured unique presentations
Dr Kate Goldie following their
presentations
from a range of practitioners, who
discussed everything from treating filler complications to managing
your online reputation. Former president of the European Society
for Cosmetic and Aesthetic Dermatology (ESCAD) Dr Christopher
Rowland Payne chaired a number of sessions, where he aimed to
ensure the high level of scientific content was maintained. Following
the meeting, he said, “It was a really great multi-disciplinary, highly
scientific discussion. We had international speakers from all parts of
the world and a very focused audience – comprising people from the
cutting edge of aesthetics – interacting and engaging with each other
and the speakers.” Each day was divided into four and five sessions,
respectively, between which delegates could discuss their learning
with fellow speakers and attendees.
On Friday afternoon, general practitioner and aesthetic medicine
specialist Dr Kathryn Taylor-Barnes presented ‘Aesthetic treatments
in gynaecology – casting light “down under”’. This session invited
The American Academy of
Dermatology (AAD) Annual
Meeting, San Francisco
Lorna Bowes offers an aesthetic
glimpse of the AAD 2015 annual
meeting in San Francisco
San Francisco was always going to attract an impressive number
of dermatologists – this year it was confirmed that the event had
received more than 18,000 registrants. With this number in mind,
it’s unsuprising that three distinct sites were needed for the AAD
2015 annual meeting; even then its lecture theatres and exhibition
halls were full and buzzing. One aptly named ‘Hot Topics’ session
addressed photoprotection, with board-certified dermatologist Dr
Henry W. Lim (chairman of the department of dermatology at Henry
Ford Hospital in Detroit), warning that although some authorities
suggest a little sun exposure is acceptable, “There is no safe dose
of ultraviolet exposure.” It was further emphasised that, “The regular
use of photoprotection prevents photoageing and cancers.” Joining
Dr Lim in the same session was Dr Zoe Draelos, private practitioner
and consulting professor of dermatology at Duke University, North
Carolina, to discuss the conundrum of cosmeceuticals; bemoaning
the lack of dosage information supplied by most manufacturers. This
same topic resurfaced in the session ‘The Science of Cosmeceuticals
and Nutraceuticals’, with a panel including Dr Draelos looking at the
Aesthetics Journal
much debate from the audience as delegates conferred both the
clinical and ethical aspects of gynaecological rejuvenation treatments.
Dr Taylor-Barnes said, “The audience was very receptive to my
presentation and asked me challenging questions. Non-surgical
rejuvenation of the female genitalia is often deemed a controversial
area in aesthetic medicine development, but all agreed that it will
become more mainstream and popular with the average woman
in the future as there is a genuine need for these treatments.”
The meeting hosted international speakers, including those from
Switzerland and Morocco, and their international knowledge and
perspective impressed both organisers and delegates. Dr Rowland
Payne commented that Mr Alain Tenenbaum, a Swiss-based plastic
surgeon, gave a particularly thought-provoking talk on intramuscular
carbolic acid gluteoplasty and gluteopexy, which was supported by
Dr Taylor-Barnes who said his presentation was “most memorable”.
Closer to home, UK-based consultant plastic and reconstructive
surgeon Mr Dalvi Humzah impressed delegates with his anatomy
expertise during his ‘Essential anatomy to avoid complications from
injectables’ presentation.
Nurse practitioner and delegate Constance Campion said, “I am
always happy to hear Mr Humzah speak as he is a specialist. Plastic
surgeons aren’t always integrated enough into aesthetics, so I
was glad he presented and I fully supported our plastic surgeon
colleagues who were there.” Following the close of conference
on the Friday, speakers were invited to a dinner in the Toynbee
Mackenzie ENT Room at the RSM, which Dr Taylor-Barnes described
as a “real highlight of the meeting as it took place in such a beautiful
and prestigious venue”. According to Dr Rowland Payne the meeting
was a huge success and the best measure of this was delegates
expressing their desire to attend again next year.
science of cosmeceuticals for acne and skin lightening, as well as the
science and cutaneous effects of nutraceuticals. One main theme of
this session was getting to the core of the clinical evidence behind
a product line – the importance of asking whether there is sciencebased, published data with reliable sources behind it – as well as
reviewing ways to battle misinformation.
A session by Dr Heidi Waldorf on ‘Aging gracefully’ looked at
defining the parameters of ‘graceful aging’ from a consumer versus
a medical perspective, making suggestions for therapeutic plans for
preventions, rejuvenation and maintenance, including reviewing the
choices and timings of cosmeceuticals, injectable neuromodulators,
soft tissue fillers and various devices for non-invasive rejuvenation.
Perhaps the hottest topic of this year’s annual meeting was robotic
hair transplants from Artas, which, with 35 million men experiencing
hair loss, is a growing area of commercial development. Though
balding is itself not harmful, the emotional effects can be both
frightening and traumatising. In discussion was a new system
enabling physicians to harvest healthy follicular units in a minimally
invasive procedure
delivering a healthy,
intact graft. Providing
a wealth of topics over
the five days, the AAD
meeting proved yet
again a crucial source
of educational activity
within the field of
dermatology.
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Lumenis ResurFX
Workshop, London
Aesthetic practitioners were
invited to an afternoon
of learning, courtesy of
international energy-based
medical company Lumenis, on
March 19. Held at the PHI Clinic,
Harley Street, the event brought
together both inexperienced and
well-practised laser users. First,
delegates enjoyed a light lunch and networking session, followed by
an introduction to the Lumenis devices and the UK sales team.
Dr Tapan Patel then discussed his experience of using the new
ResurFX device. For the laser beginners present, Dr Patel offered
a beginner’s description of how the system should be used, whilst
ensuring he also gave an advanced explanation to the more
experienced attendees present. Delegates then participated in
an engaging question and answer session, allowing the Lumenis
team and Dr Patel to address all concerns from the audience.
Questions queried patient suitability, modes of treatment, suggested
anaesthesia and recommended lengths of time between ResurFX
procedures. Of the meeting, aesthetic practitioner Dr Askari
Townshend said, “Hearing Dr Patel talk is always a fantastic
opportunity to learn about the nuances of advanced laser treatments.
Seeing how he’s treating acid burn victims’ scars with the new
fractional non-ablative device by Lumenis has been amazing.”
Eden Aesthetics business
seminar, London
Eden Aesthetics Distribution
invited aesthetic practitioners
to a one-day business seminar
at the Academy of Medical
Sciences in London, on
February 26. Welcomed to
the free seminar with coffee
and cake, attendees were
presented with a selection of talks covering various business topics.
During the two-hour lunch break, they also had the opportunity
to watch live demonstrations of treatments and test products
being discussed. Topics covered included the importance of a
clinically proven range with Epioncé, and how to market your brand
for optimum results, courtesy of digital marketing agency Blow
Media. In the afternoon aesthetic practitioner Dr Mervyn Patterson
demonstrated how to maximise facial lifting with Voluma using a
cannula. Of the demonstrations, he said, “I think there were a lot of
very interested people present, and they’re seeing some cutting
edge technology, new ways to combine micro-needling treatments
and the very latest in quadrapolar radiofrequency skin tightening.”
Reflecting on the business talks, attendee Ayse Suleyman said, “It’s
quite informative to know what the next step would be for longterm retention of your patients. That’s really important for us as a
business.”
Aesthetics Journal
Skin Geeks Image
Skincare Worldwide
Launch Party, Brighton
Clinic owners and aesthetic
practitioners met at Stanmer
House, Brighton, for the Skin
Geeks Image Skincare Worldwide
Launch Party on March 16. The
event introduced three new
Image Skincare products added
to the Skin Geeks distribution portfolio, including the ILUMA
Intense Brightening Eye Cream, the MAX stem cell masque and
the ILUMA Intense Brightening Exfoliating Powder. Attendees
were able to test the skincare, whilst education specialist Victoria
Hiscock gave a thorough explanation of the science behind the
ranges. One attendee, Dr Dev Patel, clinical director of Perfect
Skin Solutions in Portsmouth, said, “Although I’m already familiar
with Image Skincare, I’m always impressed by the clinical research
that goes into creating these products and enjoy coming to these
events to learn more.” At the close of the launch party, managing
director of Skin Geeks Don Maree said, “Our core value at Skin
Geeks is science-based education so, for us, this is a must attend
industry event. We are showcasing our new technology and it’s a
fantastic opportunity for us to meet our clients to update them with
all the new products.”
PicoWay workshop,
London
Hosted by Syneron Candela,
international practitioners
were invited to attend a oneday workshop on the PicoWay
laser at PHI Clinic, London,
on March 6. The day began
with an introduction, followed
by a detailed discussion
of the science behind
PicoWay from Dr Jayant Bhawalkar, vice president of research
at Syneron Candela. Attendees were invited to watch tattoo
removal demonstrations in the clinic’s treatment rooms, whilst
qualified practitioners had the opportunity to test the laser. Hamish
Mcnair, director of clinical education EMEA at Syneron Candela,
discussed clinical protocols and Food and Drugs Administration
data before breaking for lunch. In the afternoon, aesthetic
practitioner Dr Tapan Patel performed another live treatment
demonstration, which was followed by practice marketing advice
and time for questions to round up the day by 4pm. “Venues like
this are really useful, because they’re so big we can communicate
the benefits of this device and this technology to the physician
community,” said Dr Bhawalker. “Having a forum like this, which is
an all-day session, the physicians not only get to hear the science
behind Pico, but really understand why those parameters are
important.”
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Aesthetics Journal
ACE 2015
in Review
We look at the highlights
from the Aesthetics Conference
and Exhibition 2015
The Aesthetics Conference and Exhibition (ACE) 2015 has been
hailed a huge success following overwhelmingly positive feedback
and requests to attend next year from delegates, speakers and
exhibitors alike.
The conference, held on March 7 and 8 in Central London, was the
perfect opportunity for aesthetic professionals to come together over
one weekend and enjoy the vast range of learning and networking
opportunities available at ACE.
ACE attracted more than 2,500 visits to watch the 61 outstanding
clinical and business sessions, delivered by 71 speakers throughout
the two-day event. With such an extensive offering, ACE attracted a
variety of industry specialists, statistics showing 33% to be cosmetic
doctors, surgeons, dermatologists and GPs, and 26% aesthetic nurses.
Of the remaining delegates, 13% were found to be dentists, while 10%
made up aestheticians and 18% clinic managers.
Alongside a comprehensive exhibition floor, which featured 100 top
exhibitors, the weekend’s educational programme incorporated four
agendas: interactive Conference modules, live demonstration Expert
Clinics, Masterclasses and a Business Track. Each agenda featured
respected and experienced speakers from across the aesthetics
industry, who shared invaluable advice and knowledge on a variety of
treatments, techniques and business insight, with more than 63 CPD
points available across the weekend.
Amanda Cameron, Aesthetics editor and ACE 2015 programme
organiser, said, “This year we saw an increase in attendance over
both days of the conference, with packed demonstration theatres and
business workshops right up until the last session on the Sunday. We
received overwhelmingly positive feedback from delegates, who really
enjoyed the interactivity of the sessions, such as the individual voting
keypads utilised in the main conference auditorium.” During sessions,
delegates were able to interact with the speakers via the latest
conference technology and throughout the event had free access to
the Exhibition, Expert Clinics, Masterclasses and Business Track.
The Conference programme featured four dynamic and interactive
modules which explored the entire patient journey across
different areas of aesthetics, including the role of fat, injectables
and dermatology. Mr Dalvi Humzah, renowned consultant plastic
surgeon and ACE 2015 Steering Committee chair, joined his fellow
practitioners and friends Dr Tapan Patel and Dr Raj Acquilla, with a
guest appearance on Saturday from Canadian aesthetic doctor and
international speaker Dr Arthur Swift, to present two main Conference
sessions over the weekend, exploring the anatomy of the face and
treatment with injectables. Reflecting on the sessions, Mr Humzah
said, “It was exhilarating, we had great fun with each other and great
interaction with the audience. There were questions asked on some
interesting and challenging topics. I was delighted to work with Raj,
Tapan and Arthur Swift, and each of us have been able to contribute
a different perspective.” A key focus was facial anatomy, a concept
which Mr Humzah feels is crucial to safe injection. “I am very keen on
making sure people working in this area know about the anatomy
and relate back to this in their practice,” he said. “I have an interest
in anatomy, and I thought this way we could bring the subject to life
on stage, using the videos, using the demonstration and using the
models, so practitioners could see that this really is the way forward.”
Dr Arthur Swift also presented on behalf of Merz Aesthetics at the
Merz Aesthetics Live Demonstration Zone, where he launched the
new Belotero Volume with Lidocaine filler. He noted the importance
for delegates to understand the scientific background of products and
techniques, while retaining a focus on the overall goal – beauty.
“I think when you start to understand the science behind the product
and how the product works, sometimes it’s very easy to go ahead
and lose your focus on what we’re trying to achieve,” he said. “These
conferences aren’t just important, they’re crucial. Conferences like this
are really the fibre of how we do our work.”
Alongside the injectables sessions, the Conference agenda also
included ‘The role of FAT in medical aesthetics’, which drew together
a vital debate about how fat should be managed in the aesthetics
industry. Panellists took to the stage to discuss the latest and most
effective ways of managing weight loss, and, with the use of audience
interaction, found that attendees were divided 50/50 on whether
plastic surgeons should be the only ones to perform liposuction. A
board of industry experts were then invited to present their lipolytic
technology to the audience, offering a wide overview of what is
available in the industry today, allowing the audience to decide on
their preferred technology. Mr Taimur Shoaib, consultant plastic
surgeon and co-chair of the fat session, said, “I think the strongest
point of the session was the variety of the people in the audience and
on the panel.” He continued that the Conference brought together
@aestheticsgroup
Aesthetics Journal
Aesthetics
“a multidisciplinary team of people,
where we can discuss patient
concerns by asking people from a
variety of different backgrounds.”
Sunday’s ‘Aesthetic Dermatology
Clinic’ provided delegates in
attendance with an insight into
the newest innovations and skin
treatments available in aesthetic
dermatology in 2015. During the
three-hour session, aesthetic nurse
Anna Baker argued for the use of
photodynamic therapy (PDT) for the
treatment of basal cell carcinoma,
which was supported by respected
dermatologist Dr Stefanie Williams,
who said, “In my opinion, this seems
to be one of the best methods we can use.”
“This conference is a very exciting, multidisciplinary one which brings
together all different aspects of cosmetic practice,” said Dr Christopher
Rowland Payne, who chaired the dermatology session alongside
Dr Williams. “It’s the opportunity for multidisciplinary discussion and
talking about different treatments and developments and has a very
interactive audience who participate in everything.”
Set on the busy exhibition floor, the two Expert Clinic live
demonstration theatres saw consistently full benches throughout
the entire event. Within the programme, which offered independent
and sponsored classes, sessions were presented by Lynton Lasers,
Rosmetics, AestheticSource, Medico Beauty, Fusion GT, Sinclair
Pharma, HealthXchange, BTL Aesthetics, 10 Laser, Skinceuticals
and NeoCosmedix, covering topics from chemical peels to lasers.
Amongst the vast array of topics, debates, techniques and treatments
presented by esteemed speakers, Mr Humzah was joined on stage
by Dr Elizabeth Raymond Brown to address the importance of good
photography within aesthetics.
While highlighting ethical issues around consent of use with patient
images, Dr Raymond Brown offered delegates key guidance in image
taking. During the session, She said, “If you do one thing today –
check your white balance. It will make a huge difference to your image
results,” also reinforcing the idea that spending money on a decent
camera would provide more detailed and effective images.
In particular, the Vitamin Infusion Debate garnered a huge amount
of interest. The Expert Clinic panel was chaired by nurse practitioner
Sharron Brown and comprised Dr Martin Kinsella, Richard Sikkel,
Dr Jacques Otto and Constance Campion. Though views on
the treatment were divided, all panellists agreed that thorough
consultations prior to vitamin drip treatments were crucial for
maintaining patient safety. Of the Expert Clinic agenda, Dr Simon
Ravichandran, who presented a session on advanced injectables to a
packed audience with Dr Emma Ravichandran, said, “The delegates
seem to be quite interactive here, they were quite open and asking
questions – and they’re asking the right questions.” He added, “Often
we practice independently. It’s a very lonely industry for those of us
who don’t have colleagues, friends and peers who we can turn to, but
events like this not only allow people to attend lectures and get all the
best advice and latest training, but find other people to discuss ideas
and get their advice from.”
Another popular aspect on the educational programme were the
sponsored Masterclasses, a group of seminars and workshops where
attendees could learn key best practice guidance for leading products
from the top company KOLs.
Within the broad Masterclass agenda, Mr Shoaib discussed the patient
experience in a session sponsored by Allergan. He stressed the
importance of asking vital questions of patients during consultation
and told the audience, “We need to explore their fears and anxieties.”
Other Masterclasses, sponsored by Sinclair Pharma, Medical Aesthetic
Group, Institute Hyalual, Adare Aesthetics, 3D-lipo Ltd and Galderma,
addressed acne treatment, the benefits of multi-platform treatment
approaches, thread lifting, injectables and skin rejuvenation.
For those looking to build on their non-clinical skills, the ACE Business
Track, sponsored by Church Pharmacy, gave delegates the chance
to enhance their clinics and provide the ultimate patient experience.
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@aestheticsgroup
Aesthetics Journal
Sessions provided a broad range of learning opportunities for
delegates, which included how to give a great first impression,
marketing skills, using social media, and VAT and insurance guidance.
US author and international commentator Wendy Lewis presented
two sessions over the weekend, which highlighted the importance
of social media and visual content. Reflecting on her talk, she said,
“People were really engaged and interested – social media is a really
hot topic right now and marketing your clinic is of utmost importance.
The attendance really showed that.”
Following the successful programme, co-director of Church Pharmacy
Zain Bhojani said, “The delegates have been very interested in
what the speakers have to say, so it’s nice to know they are getting
something out of it and learning something that is a bit different to the
clinical side of things. Without a doubt ACE is my favourite show.”
KEY ISSUES IN 2015
The exclusive Question Time debate on Saturday evening, free to all
attendees and sponsored by 3D-lipo Ltd, aimed to highlight this year’s
most current and important industry issues.
Former BBC presenter Peter Sissons chaired the event, with a panel
that included Wendy Lewis, Mr Dalvi Humzah, plastic surgeon Mr
Paul Banwell, professional body chairs Sharon Bennett and Dr Paul
Charlson, and Health Education England (HEE) modality lead Andrew
Rankin. The HEE recommendations for qualification requirements were
first to be discussed, with Mr Humzah insisting that it is “up to us as
an industry to set up official qualification courses,” while Bennett said
“If Europe can agree a consensus I can’t see a problem.” Regulation
and accreditation were major factors in the debate, with Dr Charlson
arguing that the General Medical Coucil are interested in accreditation
for cosmetic practitioners, in contrast to many opinions, while Lewis
raised the importance of policing your online reputation. One audience
member questioned whether the panel felt positive about the potential
for change in the industry, to which Rankin said, “The commitment
we all have to improving standards is inspiring.” Bennett was also
adamant that the future is bright and that “the climate will change and
the consumer will be looking for accredited practitioners.” To conclude
Question Time, each panelist offered a final thought. Bennett told
delegates, “Join an association, lone practitioners are dangerous.”
LATEST INNOVATIONS
The exhibition floor was the perfect opportunity for delegates to
meet with the top suppliers, gain valuable business partners and
discover the latest product innovations. Lorna Bowes, director of
headline sponsor AestheticSource, said, “The Expert Clinics seemed
packed each day with a variety of topics covered, and the format of
‘clinic sessions’ on the main agenda packed the auditorium. This was
particularly impressive given that the Merz sponsored sessions with Dr
Arthur Swift were also packed – there were an awful lot of delegates in
Aesthetics
total!” She added, “For me the highlight, as last year, was the industry
debate – time for people to air views and raise contentious issues.
Congratulations on providing a platform like this to our industry.”
David Gower of Med-fx, registration and consumables partner of
ACE 2015, also praised the quality of the exhibition, which drew in
huge numbers of professional attendees. “We see this year a much
more professional, much more vibrant exhibition,” he said. “I feel that
there has been a lot of interest in products, not just the products that
we’re offering but in general, and people who are approaching have
been very business-like and professional in manner.” Among the
exceptional feedback that was received during and after ACE, one
of the most prominent points that delegates consistenly praised was
how well the event addressed the need to keep up to date with the
latest treatment techniques and new innovations. One plastic surgeon
emphasised that, “We need to update ourselves and learn what is
available to give the best possible service to the patient.” This was
widely agreed by attendees, with a cosmetic doctor adding, “Products
change, techniques change, knowledge changes and unless you’re
keeping up to date you are really not being the best practitioner you
can be – and you’re not really giving your patients the best. So that’s
the reason you need to attend conferences like this.” Reflecting on
a weekend packed with extensive, high quality education, a nurse
prescriber further commented, “This is actually one of my favourite
conferences; ACE squeezes so much into the time we have, it’s been
very beneficial on all levels. I’m an experienced nurse prescriber and
have been injecting for 16 years, but I still learn a lot every time I come
and would definitely recommend ACE to colleagues. I’ll be back again
next year.” The success of this year’s event has firmly cemented ACE as the
leading medical aesthetics conference and exhibition in the UK and,
as such, planning for ACE 2016 is already underway.
Cameron concluded, “In view of this success, we are now already
working on next year’s event to ensure that delegates once again
will be given the opportunity to attend a conference that perfectly
complements their practice, and inspires them to push innovative
boundaries within aesthetics.” To stay up to date with the latest news and developments
for ACE 2016, register at www.aestheticsjournal.com.
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Aesthetics
Treating the Lips
Seldom does a week go by when we’re not subjected to
media propaganda about lip enhancement procedures.
Whether it’s hype about the latest celebrity to appear
with a suddenly-plumper pout, or denigration of the
trend when something goes publicly wrong; there is no
denying that aesthetic lip procedures have received
scrutiny unrivalled by other similar minimally
invasive treatments. Allie Anderson talks to
practitioners about the different ways to treat this
area of the mouth.
non-surgical procedures, so the availability and accessibility
There has been great public awareness of lip rejuvenation
means more people are having the treatment.”
procedures since the infamous Leslie Ash case in 2002, which
Lip treatment also appears to be particularly popular in certain
led to coining of the now-familiar phrase ‘trout pout’. The actress
geographical areas, as Dr Lee Walker, clinical director of Liverpoolhad her top lip injected with permanent filler to make it appear
based B City Clinics, attests. “It’s probably the second-most
fuller, but an allergic reaction caused permanent swelling and
requested treatment after botulinum toxin, because it’s a unique
resulted in the product fusing with the muscles between her lips
demographic in Liverpool,” he says. “There’s an incredibly mediaand nose.1 While her story is extreme, she was to be the first of
driven image that’s projected with young females in the city; when
many celebrities whose lips have made it firmly into the spotlight.
I speak to colleagues around the country, none of them perform
Media portrayal of lip enhancement has a profound influence on
the amount of lip treatments that I do.” Dr Walker explains that
its popularity in clinics, in a number of ways. According to a 2014
survey of 1,000 women, 63% would like fuller lips, yet 78% say they around 95% of the lip treatments he carries out are to introduce
would avoid lip fillers due to fear of ‘trout pout’ and
the health risks, as well as the cost of treatment.2 On
the other side of the coin, fuller lips are constantly
According to Dr Acquilla, age-related restoration commonly involves the
presented as desirable and achievable, and the
following points:
trend for fuller, more defined lips has translated
1. Oral commissure: to correct sad mouths and give positivity to the smile.
to an increase in the number of lip procedures
2. Lateral upper lip depression: often associated with previous lip filler but
being carried out in clinics across the UK. “Lips are
also exacerbated by ageing.
incredibly popular [as a treatment area] due to the
3. Vermilion border: to promote eversion and external rotation of the lip
rise of lip augmentation in the media and ‘celebrity
and therefore increase mucosal
culture’. The most common demographic are the
show.
budget-conscious young female patients (18-25),
4. Peri-oral rhytids: erasing
who have £150 to spend and request lip fillers
lines and wrinkles associated
to give them a sexy, glamourous pout,” explains
with ageing of the skin and
aesthetic practitioner Dr Raj Acquilla.
orbicularis oris.
As demand has grown, so has supply, adds Dr
5. Glogau Klein points and
Kieren Bong, clinical director of Glasgow’s Essence
philtral columns: for definition
Medical Cosmetic Clinic. “Unfortunately we’ve seen
of the apex of the Cupid’s bow
the general public trivialise medical procedures like
and philtral concavity.
this and underestimate the risks and the potential
6. Volumetry: precise
side effects,” he comments. “It’s not helped by
volumetric augmentation to an
the fact there are a lot of practitioners who also
upper-to-lower lip ratio of 1:1.618,
underestimate the risk and fail to convey it to
which is commonly distorted by
the general public. The market is saturated with
novice injectors.
Image courtesy of Dr Raj Acquilla
practitioners from all sorts of backgrounds offering
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38
Before
@aestheticsgroup
Aesthetics Journal
Aesthetics
After
The clinician’s expertise and skill play a
crucial part. Indeed, practitioners have a
duty to guide patients on what to expect,
and what outcomes can be achieved
with different procedures – and there is
often a mismatch between the treatment
patients initially seek, and those that are
recommended. “Of the 100-120 patients I
treat per week, more than half request lip
fillers and only 20-30% actually need and
receive them,” comments Dr Acquilla.
Treatment with Juvéderm Volbella. After image shows patient two weeks post treatment.
For those patients who do, he uses low
Images courtesy of Dr Sarah Tonks.
molecular weight hyaluronic acid fillers
“owing
to
their
excellent
tissue
integration and soft, natural results
dermal fillers for a plumper and more defined look.
at rest and on animation of the lips,” he explains. “In addition, I
While lip shaping and augmentation seems to be particularly
popular among the under-35s, a proportion of patients undergoing also complement fillers with fractional CO2 laser resurfacing of the
treatment are seeking to address or reverse the signs of ageing.
perioral skin to remove pigment and fine textural lines,” says Dr
“The lips are a focal point of the face, and our eyes are drawn to
Acquilla. Filler containing hyaluronic acid is a popular choice among
this area when we are talking. They are part of the central triangle
many practitioners to enhance and plump the lips, alongside peels
and can distinguish our age quite easily,” explains Sharon Bennett,
and botulinum toxins in the perioral region, particularly to address
independent nurse prescriber and clinical director of Harrogate
‘smokers’ lines’. However, the precise formulation and treatment
Aesthetics. “As we age, and through environmental and extrinsic
will depend on the patient and their desired result. Dr Bong says
factors, our lips will become thinner and wrinkly, with downturned
that while a large number of his patients are seeking a plumper lip
corners (oral commissures), and lack the shape and support we
(to varying degrees of fullness), others are increasingly seeking to
once enjoyed. The Cupid’s bow drops down and is no longer
reinstate hydration, which is often also a casualty of ageing. “We
upright and defined, and the philtral columns flatten.”
have a range of products that restore hydration and improve the
texture of the lips without increasing the volume,” he explains.
“We inject a product that has a concoction of ingredients such as
Dr Sarah Tonks, who practices at Omniya clinic in Knightsbridge,
vitamins, antioxidants, and hyaluronic acid, which has a very high
says that lip treatments are often carried out as part of – or as a
affinity for water and attracts up to 1,000 times its own molecular
result of – anti-ageing procedures or treatments to the rest of the
weight in hydration.”
face. “I do a lot of whole-face rejuvenation in one appointment
While there are manifold topical products available over every
with my patients, and when you rejuvenate the whole face this
high street counter, particularly aimed at rehydrating the lips, Dr
can make the lips appear smaller, as the rest of the face has more
Bong suggests that these do not provide the long-term results that
volume. I warn my patients of this and tell them they will probably
injectable treatments do. “With all our technology, it still has not
need to do the lips too, although they don’t often believe me
advanced far enough to produce a topical substance with a small
until they look in the mirror,” she explains. “A lot of people are
enough molecule that will penetrate the deep layers of the skin and
frightened of looking ‘too done’, and there is an association that if
provide sustained hydration,” he says. “Hence, a moisturiser will
you have your lips done, you will always look fake.”
only work when you apply it and won’t result in any cellular changes
To counter this, and to manage a patient’s expectations, it’s
that will provide sustained improvement.” Similarly, Dr Tonks says of
imperative to conduct a thorough consultation and to consider
topical, volumising lip treatments: “It’s like replacing missing teeth
the anatomy of the perioral area. “The skin, musculature and even
with a denture.” It is common, however, to use a topical anaesthetic
the bone structure change as part of the ageing process,” says
before treating the lip area, such as LMX 4% (lidocaine). “This is
Dr Bong. “So, first I have to listen to what patients are hoping to
effective at taking about 70% of the discomfort away, and makes the
achieve, before analysing the anatomy. Then, I consult with my
procedure manageable for the patient,” says Dr Walker. Alternatively, a
patients and make them aware of what’s achievable and more
importantly, what’s not achievable, as a result of the
constraints of the anatomy.” Similarly, to achieve
Before
After
natural and age-appropriate results when using
filler, product choice is important. “We don’t use
a one-size-fits-all filler; the problem with doing
so is that it could be too heavy for some parts of
the face, and too light for other parts of the face,”
Dr Bong explains. “We only use lip filler that has
been exclusively formulated for lip contouring and
enhancement. Within this range, there are different
grades – there’s no point giving someone a thick
grade of filler who doesn’t want too much treatment.
Also, if it’s an older patient, we want to emphasise
contour rather than volume, so we’d use a different
grade again.”
Images courtesy of Dr Kieren Bong
@aestheticsgroup
Aesthetics Journal
The lips, though
a focal point of a
person’s face, are
of course one part
of the whole canvas
dental block can be used to completely numb the
area. The lips, though a focal point of a person’s face,
are of course one part of the whole canvas. As such,
it’s important that patients are made aware that treating
the lips in isolation without attending to the facial and
labial skin may well have inadequate results. According
to Bennett, addressing the skin of the lips before
undertaking a procedure is important. “If there is any
evidence of ageing, [tackling the skin] can improve
the lip itself greatly and reduce the need for significant
work,” she says. “Also, if you only treat the lip, but the
surrounding skin is aged, sagging and wrinkly, lacking
support and structure, then the lip will probably look
somewhat incongruous and very evident. A younglooking plump, hydrated and shapely lip surrounded
by a wrinkling face and mouth can look odd. It will not
make the patient look particularly younger if the lip is
the only area on an ageing face to be treated.”
A holistic approach should be taken to halting or
reversing the effects of ageing – and that, according
to Dr Bong, ought to incorporate a number of factors.
“Emphasis should be on the canvas of the face, which
is the skin, because it’s part of looking good that we
have radiant, healthy looking skin,” he comments.
“Ageing is a multi-faceted, multi-factorial process,
and you need to look at ageing in its entirety. To
achieve a natural result, we need to look at everything
simultaneously, including hair, teeth and skin.”
As such, patients who seek and undergo procedures
on the lips should also be given guidance on the how
the area will look against the backdrop of an untreated
face, and how treating other areas around and beyond
the lips could enhance the overall result. In addition,
patients having lip treatments should be encouraged
to support good skin health through protecting against
sun damage, topical application of antioxidants,
retinoids and peptides, and maintaining a good daily
skincare regime.
Different cultures and ethnicities have conflicting
perceptions of beauty – including what is considered
both attractive and undesirable in terms of the lips and
mouth. Dr Walker’s mostly white European patients
in Liverpool seek a very noticeably enhanced lip.
Similarly, practicing in a northern spa town, Bennett
treats a high proportion of Caucasian men and women.
“The majority of patients are looking at a one third
to two thirds [upper-to-lower lip] ratio, which we can
measure,” she comments. “Younger women often
want to emulate the look of a particular reality TV
Image courtesy of Dr Kieren Bong
star or celebrity – Kylie Jenner is very ‘of the moment’ – and they tend to prefer
an almost 50/50 ratio. We have few men requesting lip treatments and those who
do are not often wishing to have anything noticeable to others.” Dr Tonks, on the
other hand, has a lot of Arabic patients, and reports that their preferences are quite
different, as is their tolerance to more product and the way she approaches lip
treatments. “Patients from the gulf have naturally larger lips that can absolutely eat
product,” she says. “You can easily use 2ml in a patient in one sitting if they are after
something glamorous. They don’t have the problem that Caucasian patients often
do, with very thin, almost non-existent upper lips, which are very hard to do that with
in one treatment sitting.” Bennett adds that Arabic patients don’t like a wide mouth
look, which can be the result of filler injected under the oral commissures to elevate
them. People from African Caribbean backgrounds also tend to have fuller lips, and
often prefer treatments concentrated on definition at the corners of the lips, says
Dr Bong, while in the Asian community, the perception of beauty is more focused
on the shape of the face. Religion and culture also have an influence, with some
patients reluctant for friends and family to know that they have had treatment due to
a negative perception of cosmetic interventions. “Therefore, it’s much more common
that they want treatments performed in stages and a result that is much more natural
and subtle” he adds.
In order to fulfil each patient’s cultural and personal requirements, a thorough
understanding of both is necessary. Dr Acquilla comments, “I travel all around the
world teaching injection techniques in different genetic backgrounds. There is
definitely a strong link between genetics and aesthetics, such as strong lips in the
Middle East and Asia with deficiencies in Caucasian populations. The key to success
here lies in accurate assessment and treatment of the whole face in good balance
and proportion.” Despite its share of negative press, the case evidently remains
that lip treatment is growing in demand. Mass marketing has created the illusion
that lip augmentation is a quick and easy way for people to conform to the latest
beauty fad with few consequences. This is perpetuated by a concerning trend in
such procedures being offered at discounted rates or as prizes. The Keogh Review
described such advertising practices as “socially irresponsible” and recommended
they be “prohibited by the professional registers’ code of practice”,3 but unless
these recommendations are wholly embraced by the aesthetics industry, patients
are potentially being put at risk. Practitioners must ensure they market and perform
treatments ethically, embracing the Keogh recommendations rather than just paying
them lip service.
REFERENCES
1. Emine Saner, A brave face (The Guardian, 12 September 2008) <www.theguardian.com/lifeandstyle/2008/sep/12/
celebrity> [Accessed on 16 March 2015]
2. Naomi Greenaway, Out with the ‘trout pout’: Three quarters of women would AVOID lip fillers for fear of ending up with the fish-look recently spotted on Tulisa (MailOnline, 2 September 2014) <www.dailymail.co.uk/femail/article-2740840/ Three-quarters-women-AVOID-lip-fillers-fear-Tulisa-trout-pout.html>
3. Department of Health, Review of the Regulation of Cosmetic Interventions (London: gov.uk, 2013), page 43. <www.gov.uk/
government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_Regulation_of_ Cosmetic_
Interventions.pdf>
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Date of preparation: March 2015
one
point
@aestheticsgroup
Aesthetics Journal
Managing Obesity:
Approaches and Treatment
In the second instalment of a two-part weight loss special, Dr Sotirios
Foutsizoglou looks at methods of managing and treating obesity
In last month’s first instalment on managing obesity, we explored
the physiology and the role of fat, looking at its function within the
body, whilst also observing current obesity trends and statistics
from across the globe. It has been suggested that even modest
reductions in weight may be associated with health benefits, with
reductions in blood pressure, cholesterol and triglycerides achievable
with just a 5-10% reduction in initial body weight.1 Therefore, as
healthcare professionals, it is our role to aid our patients in the
understanding, management and treatment of obesity. A wide range
of interventions are available for the management of weight and
obesity. These include work/school/community programmes (for
primary prevention), dietary modification, exercise programmes,
behaviour modification programmes, pharmacological agents,
commercial programmes (e.g. Weight Watchers) and alternative
therapies. Surgery is usually reserved for those suffering from very
severe obesity (BMI greater than 40 kg/m2), for whom less invasive
methods of weight loss have failed. In this second instalment I will
discuss various weight management strategies that may be used
alone or in a combination.
Assessment and classification
When conducting an initial consultation with a patient who is overweight or obese, it is vital to assess their lifestyle, comorbidities (e.g.
hypertension, diabetes, dyslipidaemia, cardiovascular disease, sleep
apnoea) and their willingness to change. This can be done both
verbally, and through written
Figure 1: Metric
BMI Formula
assessment, with the aid of a
questionnaire. The next step
Table: Metric BMI Formula
is to utilise the BMI scale,
weight in kilograms
BMI =
referred to in the previous
————————————
( kg/m² )
article,2 in order to classify the
height in metres²
degree of obesity.
When carrying out this assessment, it is important to consider the
following factors:
• BMI may be less accurate in muscular people. Although BMI
correlates with the amount of body fat, BMI does not directly
measure body fat. As a result, some people, such as athletes,
may have a BMI that identifies them as overweight due to their
increased muscle mass, even though they do not have excess
body fat.
• For Asian adults, risk factors may be of concern at lower BMI as a
given BMI tends to be associated with higher percentage body fat
than in European populations.3
• For older patients, risk factors may be significant at higher BMIs
due to a lower correlation with percentage body fat in the old
than in the young, and a weaker association with cardiovascular
mortality and morbidity.4
For patients with BMI less than 35kg/m2 we are able to assess health
risks by using waist circumference.3 A waist circumference in men
of >102 cm, and in women
>88cm, is associated with
high risk to health.3 Although
• Normal weight 18.5–24.9
waist circumference and
• Overweight 25.0–29.9
BMI are interrelated, waist
• Obesity class 1 30.0–34.9
circumference provides an
• Obesity class 2 35.0–39.9
independent prediction of risk
• Obesity class 3 ≥ 40.0
over and above that of BMI.
It is particularly useful in patients who are categorised as normal or
overweight on the BMI scale. It’s important to note here that in South
Asian patients (of Pakistani, Bangladeshi and Indian origin) living in
England, a large waist circumference is more likely to be associated
with features of metabolic syndrome, compared to patients deriving
from Europe; for example, higher triglycerides and lower high-density
lipoproteins (HDLs) in female patients from South Asia, and higher
serum glucose in male patients from South Asia.5
Figure 2: The National Heart, Lung, and
Blood Institute Overweight and Obesity
Classification by BMI (in kg/m2):
Lifestyle changes
The next step in assessment is to understand the patient’s lifestyle (in
terms of their relationship with food, exercise and attitude to weight
and wellbeing), and to suggest interventions. Interventions should:
• Always be delivered by healthcare professionals who have
relevant competencies and appropriate training.
• Include behaviour change strategies – such as goal setting and
self-monitoring of progress – in order to increase patients’ physical
activity levels, and improve eating behaviour or quality of diet.
• Take into account the person’s needs, preferences, social
circumstances, degree of obesity, comorbidities, physical fitness
and any previous or concurrent anti-obesity over the counter (OTC)
and prescribed medication.
• Include exercise (preferably cardiovascular), even if this does not
lead to weight loss, as it has other health benefits such as reduced
risk of type II diabetes and cardiovascular disease.6 Recent studies
suggest that individuals who commute to work by active means
(cycling or walking) have significantly lower body mass index and
percentage body fat than people who use private transport.7
Dietary advice is crucial in this process. As slow weight loss is
associated with more sustainable results, aim for a maximum weekly
weight loss of 0.5 -1kg.8 For this kind of approach, the National Institute
for Health and Care Excellence (NICE) recommends diets that have a
600kcal/day deficit (that is, they contain 600kcal less than the person
needs to stay the same weight), or it is advised to reduce calories
by lowering the fat content (utilising low-fat diets).3 Depending on
the patient, another consideration would be to use low-calorie diets
(1000-1600kcal/day), or very-low-calorie diets (< 1000kcal/day). This
approach may be used for a maximum of 12 weeks continuously,3 or
intermittently with a low-calorie diet (e.g. two to four days/week), if the
person is obese and has reached a plateau in weight loss. Any diet of
less than 600kcal/day should be used only under clinical supervision.
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Pharmacological management
Current treatment of obesity consists primarily of health behaviour
modification (diet, exercise and behavioural therapy) for all patients,
and bariatric surgery for a minority of selected severely obese
people. Because health behaviour modification can be limited in
its effect in many patients, and the availability of bariatric surgery is
restricted, additional adjunctive, effective and safe obesity treatments
are required. To date, anti-obesity drugs have not adequately
filled this therapeutic void. The serotonergic agents fenfluramine
and dexfenfluramine were withdrawn in 1997 due to association
with cardiac valvulopathy and pulmonary hypertension.9 After the
withdrawals of rimonabant (Acomplia) in 2009 for depression and
suicidal ideation,10 and silbutramine (Meridia, Reductil) in 2010 because
of increased cardiovascular risk, 10 orlistat became the only agent
available for long-term weight management. In 2012, two new oral
agents – phentermine and extended release (ER) topiramate (Qsymia)
and lorcaserin (Belviq) – were approved by the US Food and Drugs
Administration (FDA) as adjuvants to health behaviour modification in
patients with a BMI greater than 30, or greater than 27 with an obesity
related comorbidity, such as hypertension, dyslipidaemia, or type 2
diabetes. 10 The European Medicines Agency did not approve either
agent, citing toxicity concerns and a lack of morbidity and mortality
data in 2012.11 NICE has advised that patients with a BMI > 30kg/
m2 should receive treatment. Therefore, pharmacological treatment
of obesity should form a part of a wider assessment of a patient’s
lifestyle and risk factors for cardiovascular disease. In patients who are
motivated to lose weight, drug treatments can increase the amount of
weight loss as part of a diet and exercise programme. Any drugs used
in the treatment of obesity should be prescribed by an experienced
doctor who should comply with NICE guidance on the prevention,
identification, assessment and management of overweight and obese
patients.3 In the UK, all anti-obesity drugs, or ‘slimming pills’, other than
orlistat, are widely known to be in use off license.
Anti-obesity drugs acting on the gastro-intestinal tract
Orlistat
Following the withdrawal of fenfluramine and dexfenfluramine, interest
has focused on orlistat, currently the only licensed anti-obesity drug in
the UK.
• Orlistat inhibits the action of the pancreatic lipase within the gut
lumen. It can be given as an adjunct to diet and exercise in the
treatment of obesity when BMI > 30Kg/m2 or > 28Kg/m2 associated
with other risk factors for cardiovascular disease such as diabetes,
hypertension, hypercholesterolaemia, etc.
• It should be taken with a well-balanced calorie-controlled diet that
is rich in fruit and vegetables and contains an average 30% of the
calories from fat.
• Orlistat can reduce the absorption of fat-soluble vitamins, therefore
long-term treatment vitamin supplementation, especially of vitamin
A (β-carotene), is recommended. Other lipid-soluble vitamins
include D, E and K. Most patients however, are not at risk of vitamin
deficiency.
• No dosage adjustment is usually required in hepatic or renal
insufficiency.
• Orlistat is barely absorbed, so the risk of systemic adverse effects
is low.
• Inhibition of fat absorption commonly causes oily stools, abdominal
pain and faecal incontinence (minimised by reduced fat intake).
Some patients may find them intolerable; therefore need to be
warned in advance.
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• Treatment can be continued beyond three months only if weight
loss since commencement of Orlistat exceeds 5% of initial body
weight (target is lower in Type II diabetes patients).
• Orlistat has been studied in long-term clinical studies of up to four
years’ duration, hence it has a good safety profile.12
• Orlistat 120mg should be taken before, after, or up to one hour after
each main meal. Dose can be omitted if the meal contains no fat.
Maximum dose 360mg a day.
• It is recommended that orlistat treatment should be discontinued
after 12 weeks in patients who lose less than 5% of their initial body
weight. 12
• European prescribing guidelines state that the duration of treatment
with orlistat should not be longer than two years.13
Methylcellulose
• Methylcellulose is a bulk-forming laxative.
• It is claimed to reduce food intake by producing a feeling of
satiety.14 However, there is very little evidence to support its
use in the management of obesity.
Chromium Picolinate
Chromium is an essential trace mineral found in various foods. It has
been used as a dietary supplement as there are claims that it can aid
weight loss through regulating blood sugar levels, thus suppressing
appetite and food cravings. However, studies examining a potential
association between chromium and insulin concentrations have
yielded mixed results.15 In 1999, following a study conducted by the
University of Alabama, initial concerns were raised that chromium
picolinate is more likely to cause DNA damage and mutation than
other forms of trivalent chromium.16 However, in December 2004, the
Committee on Mutagenicity published its findings, which stated that,
“Overall it can be concluded that the balance of the data suggest that
chromium picolinate should be regarded as not being mutagenic in
vitro,” and that, “The available in-vivo tests in mammals with chromium
picolinate were negative.”17 400μg chromium picolinate, preferably at
mealtimes, can be used as a food supplement to suppress cravings
and insulin spikes.
Centrally Acting Appetite Suppressants (CAAS)
There are hundreds of clinics in the UK that use CAAS, among other
anti-obesity drugs, under ‘Specials License’. ‘Specials’ are unlicensed
medicines for human use which have been specially manufactured
or imported for the treatment of an individual patient after being
ordered by a:
• doctor
• dentist
• nurse prescriber
• pharmacist independent prescriber
• supplementary prescriber
By law, private clinics who prescribe CAAS must be registered
with the Healthcare Commission. Patients should be aware of any
‘Specials’ or ‘off licence’ use of their prescribed medication, be given
full explanation of risks and benefits and sign a consent form. Failure
to do so contravenes the General Medical Council’s (GMC) ‘Good
Practice in Prescribing Medicines’.18
Phentermine
• Phentermine is an amphetamine analogue that enhances
satiety by increasing hypothalamic noradrenaline
(norepinephrine) levels.
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Pharmacokinetic data
Bioavailability
Peak plasma levels occur within 1 to
4.5 hours
Absorption is usually complete by 4
to 6 hours
Protein binding
Approximately 96.3%
Metabolism
Hepatic
Half life
16 to 31 hours
Excretion
Urinary elimination
• Phentermine first received approval from the FDA in 1959 as an
appetite-suppressing drug.
• Phentermine Hydrochloride then became available in the early
1970s.
• Phentermine is an appetite suppressant. It can help reduce
weight in obese patients when used short-term and combined
with exercise, diet and behavioural modification.
• Fen-Phen (a combination of Fenfluramine and Phentermine) was
withdrawn from the market in 1997 after 24 cases of heart valve
disease were attributed to the Fenfluramine component of FenPhen. There has been no strong evidence that Phentermine is
also associated with cardiovascular or valvular disease.19
• Phentermine is available on prescription in most countries
including the US and UK (off licence).
• It is a sympathomimetic amine and works by stimulating the
release of norepinephrine.20 In a very small minority of cases
increments of more than 20mmHg in systolic or diastolic BP and
more than 20 beats/min in pulse rate may be shown. Therefore
regular monitoring of BP and heart rate is strongly advised –
every two weeks for the first four months and then monthly
thereafter. If large rises in BP and/or pulse rate are observed then
CAAS should be discontinued.
• Phentermine appears to be well-tolerated, producing mild side
effects consistent with catecholamine-releasing properties
through sympathomimetic pathways.21
Amfepramone
• Amfepramone is commonly known as Diethylpropion in the UK.
• Amfepramone is a sympathomimetic amine.
• Is a stimulant drug of the phenethylamine, amphetamine,
and cathinone chemical classes that is used as an appetite
suppressant.22
• Is a selective norepinephrine-releasing agent (NRAs).
• Is believed to have relatively low habituation potential.23
• Delivered as a regular and extended-release (long-acting) tablet.
Diethylpropion is usually taken three times a day, one hour before
meals (regular tablets, 25mg), or once a day in mid-morning
(extended-release tablets, 75mg).
Sibutramine (Reductil)
• Sibutramine is an inhibitor of the reuptake of serotonin and
noradrenaline.
• Originally developed by Boots as an antidepressant, Sibutramine
was sold as an anti-obesity drug to Knoll and then Abbott (Reductil).
• An interim analysis of the SCOUT (Sibutramine Cardiovascular
Outcome Trial) study found that the drug increased morbidity from
cardiovascular disease.24
• SCOUT does not clarify whether the increased risk was caused by
the specific properties of Sibutramine or by the modest degree of
weight loss achieved.
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• The European Medicines Agency (EMA) decided in 2010 that
Sibutramine must follow the example of Rimonabant (a cannabinoid
receptor antagonist used as an adjunct in metabolic syndrome),
which was withdrawn in 2008 because of safety concerns
including severe depression and suicidal thoughts.2.5
• On 21 January 2010, the Medicines and Healthcare products
Regulatory Agency (MHRA) announced the suspension of the
marketing authorisation for Sibutramine (Reductil).
Topiramate
• Topiramate is approved for epilepsy and migraine prophylaxis.
• Putatively reduces weight by decreasing food intake, decreasing
lipogenesis, increasing thermogenesis, improving insulin sensitivity
and increasing secretion of adiponectin.26
Lorcaserin
• On 27 June 2012, the FDA approved lorcaserin as an adjunct to a
reduced-calorie diet and exercise for chronic weight management
with initial BMI ≥30 kg/m² (obese) or ≥27 kg/m² (overweight),
with one weight-related comorbid condition (e.g. hypertension,
dyslipidemia, type 2 diabetes mellitus).
• Lorcaserin is a selective agonist of serotonin (5-hydroxytryptamine
or 5-HT) 2c receptors.
• It stimulates proopiomelanocortin (POMC), producing neurones
in the hypothalamus, resulting in generation of α-melanocortin
stimulating hormone which acts on melanocortin receptors to
decrease food intake and enhance satiety.27
• Lorcaserin is metabolised in the liver to multiple inactive metabolites
that are renally excreted.
• Lorcaserin appears to be well tolerated in patients and the
most common adverse events reported did not include serious
complications. Common adverse effects include headache (18%),
upper respiratory tract infection (15%), dizziness (8%), nausea (8%),
constipation (7%), dry mouth (5%).28
• Lorcaserin has not been associated with depression or suicidal
ideation.
• The potential for recreational use is low.29
• The safety and efficacy of lorcaserin (10 mg twice daily) for ≥
52 weeks has been evaluated in three separate Phase 3 trials.
Lorcaserin demonstrated a satisfactory safety profile according to
FDA criteria but patient outcomes in the trials failed to achieve the
FDA mean benchmark of patient weight loss.30
Data examining the effect of CAAS on death and cardiovascular
events is not currently available and is needed before the benefits of
these drugs can be fairly assessed.
Drugs with conflicting evidence
Growth hormone
It is believed that Growth Hormone (GH) secretion is markedly blunted
in obesity.31 The role of GH in obesity is complex and somewhat
controversial. Although primary GH deficiency leads to centripetal
adiposity, visceral obesity per se also results in a secondary reduction
in serum GH concentrations. The GH response to pharmacological
(growth hormone releasing hormone, L-Dopa) and physiological stimuli,
such as sleep, physical exercise, insulin-induced hypoglycaemia
and corticosteroids, is impaired in obesity.31 Some of the theories on
the cause of altered GH physiology in obesity involve the increased
concentrations of leptin, insulin, free fatty acids (FFAs) and IGF-1.32
Recent evidence suggests that leptin, the product of adipocyte
specific ob gene, exerts a stimulating effect on GH release in rodents;
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Aesthetics Journal
should the same hold be true in humans, the coexistence of high
leptin and low GH serum levels in human obesity would fit in well
with the concept of a leptin resistance.33 Concerning the influence of
metabolic and nutritional factors, an impaired somatotropin response
to hypoglycaemia and a failure of glucose load to inhibit spontaneous
and stimulated GH release are well documented in obese patients;
furthermore, drugs able to block lipolysis and, thus lowering serumfree fatty acids (NEFA), significantly improve somatotropin secretion
in obesity. Caloric restriction and weight loss are followed by the
restoration of a normal spontaneous and stimulated GH release.
On the whole, hypothalamic, pituitary and peripheral factors appear
to be involved in the GH hyposecretion of obesity. Treatment with
biosynthetic GH has been shown to improve the body composition and
the metabolic efficacy of lean body mass in obese patients undergoing
therapeutic caloric restriction.32 According to Scacchi M et al, GH
and conceivably growth hormone releasing peptides (GHRPs) might
therefore have a place in the therapy of obesity.34 However, the bulk of
studies indicate little or no beneficial effects of GH treatment of obesity,
despite the low serum GH concentrations associated with obesity.
Leptin
Leptin, primarily produced in the adipocytes, acts on receptors in the
hypothalamus where it inhibits appetite by counteracting the effects
of neuropeptide Y and anandamide and promoting the synthesis of
α-MSH (Melanocyte-Stimulating Hormone). The initial studies of leptin in
obese humans suggest that absolute leptin deficiency is an extremely
rare cause of obesity.35 Although leptin is a circulating appetite
suppressing protein hormone, obese people have unusually high leptin
concentrations – said to be resistant to leptin.36 Plasma leptin levels are
elevated in obese patients, and correlate with their increased fat mass.
Messenger RNA levels for leptin are increased in their adipose cells
and also correlate with fat mass. Human obesity is likely to result from
defects in the leptin receptor, in generation of its second messenger
or effector mechanism within the leptin target cells or in other effector
cells further downstream. Studies are currently underway to determine
whether or not partial resistance to leptin can be overcome by sufficient
exogenous leptin therapy.
Surgery
Bariatric surgery was first developed 50 years ago. However, in the
past 20 years, a dramatic increase in the prevalence of severe obesity
combined with improvements in the efficacy and safety of bariatric
surgical techniques has led to a 20-fold increase in the numbers of
procedures performed annually worldwide.37 Bariatric surgery has
increased exponentially in UK over the past eight years with more than
10,000 bariatric surgical procedures performed in 2012.38
In the UK, surgery is considered for people with severe obesity if:39
• They have a BMI of 40kg/m2 or more, or 35kg/m2 < BMI < 40kg/m2
and other significant disease (e.g. type II diabetes, hypertension)
that could be improved if they lost weight.
• All appropriate non-surgical measures have failed to achieve or
maintain adequate clinically beneficial weight loss for at least six
months.
• They are receiving or will receive intensive specialist management.
• They are generally fit for anaesthesia and surgery.
• They commit to the need for long-term follow-up.
Surgery is considered as a first-line option for adults with a BMI of more
than 50kg/m2 in whom surgical intervention is considered appropriate.
Orlistat and/or CAAS (off label) can be prescribed before surgery if the
waiting time is long.
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Types of bariatric procedures
The first bariatric procedure in wide use, performed from the 1950s
through to the 1970s, was known as the jejunoileal bypass, and it
involved an intestinal bypass in which the proximal jejunum was
bypassed into the distal ileum. This resulted in extreme weight loss
by way of profound malabsorption and was eventually abandoned
some years later after many people developed severe proteinenergy malnutrition.40 The next major bariatric procedures to
be introduced were the horizontal gastroplasty and the vertical
banded gastroplasty, which were thought to be purely restrictive
procedures made possible through the development of surgical
stapling devices. Both procedures have now been abandoned
because stoma tended to enlarge, leading to weight regain.38
The gastric bypass was originally introduced in 1969 by Mason
and Ito,41 and it was later modified into a Roux-en-Y gastric bypass
configuration for drainage of the proximal gastric pouch to avoid
bile reflux. The next major procedure to be introduced was the
adjustable form of gastric banding.42 The adjustable gastric band is
a silicone belt with an inflatable balloon in the lining that is buckled
into a closed ring around the upper stomach. A reservoir port is
placed under the skin for adjustments to the stoma size.
Two procedures that use a more extreme intestinal bypass,
along with some modest gastric reduction, are the biliopancreatic
diversion and the biliopancreatic diversion with duodenal switch
operations, which are often used for severely obese patients
(BMI ≥ 50). Biliopancreatic diversion combines a subtotal distal
gastrectomy and a very long Roux-en-Y anastomosis with a short
common intestinal channel for nutrient absorption. Biliopancreatic
diversion with duodenal switch combines a 70% greater curve
gastrectomy with a long intestinal bypass, where the duodenal
stump is defunctionalised or ‘switched’ to a gastroileal anastomosis.
The most recent major bariatric procedure to be introduced
is the vertical sleeve gastrectomy, and its popularity is rapidly
increasing.43 This technique consists of a 70% vertical gastric
resection, which creates a long and narrow tubular gastric reservoir
with no intestinal bypass component.4
For patients who are severely obese (BMI ≥ 38 kg/m2 for women,
≥ 34 for men) surgery remains more effective than a non-surgical
approach in the longer term (measured up to 10 years after
surgery).45 However, bariatric surgery is not without risks. Despite
the lower mortality rate associated with newer laparoscopic
techniques, the perioperative mortality for the average patient
varies across subgroups, ranging from 0.3% to 2% or even higher in
some patient populations.46
A prognostic risk score for bariatric surgery includes:46
•
•
•
•
•
BMI 50 or greater
Male sex
Hypertension
Known risk factor for PE
Aged 45 years or more
Patients with four to five of these characteristics are at higher risk
of death (4.3%) during the first 90 days postoperatively.
In addition, evidence indicates that vitamin and mineral deficiencies,
including deficiencies of calcium, vitamin D, iron, zinc and copper, are
common after bariatric surgery.48 Interestingly, some observational
studies suggest that some bariatric procedures introduce a greater
long-term risk of substance misuse disorders, suicide and increased
alcohol consumption.49 For instance, pharmacokinetic studies indicate
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that the gastrointestinal anatomy after Roux-en-Y gastric bypass
and vertical sleeve gastrectomy leads to more rapid absorption
of alcohol. This may inadvertently increase the frequency of
physiological binges and subsequent alcohol misuse disorder.50
Aesthetics Journal
applied in the consideration of obesity — health professionals
commonly recommend the same lifestyle-based interventions
to those with overweight or mild obesity as to those with more
severe problems. I am of the belief that obesity should be treated
in a much more protocol-driven manner. On the topic of obesity,
my colleague and aesthetic doctor Dr Richard Brighton-Knight said
that if we were looking at cancer interventions we would be using
studies; entering everyone into follow-up studies and adapting
protocols to improve results. The way obesity is currently treated
is haphazard, without enough long-term population studies. Within
the NHS, the focus is too much on bariatric surgery and not
enough on non-surgical interventions. Non-surgical interventions
can produce successful changes without the need for surgery, but
they do require support from practitioners and crucially, motivation
from the patient’s part. I strongly believe that the NHS should be
running non-surgical programmes with standardised protocols
that are monitored and reviewed; these can then link into surgical
options when needed. The focus of treatment needs to be longterm weight loss, which often requires a change to eating habits
and increased activity levels.
Conclusions
Obesity is a chronic disease and a risk factor for many other
medical conditions, affecting health and longevity. It is a hugely
complex condition, and environmental factors such as automation
and change in working conditions has meant that calorie output
has reduced significantly over the past decades. Combined with
the increased availability of cheap food and disposable income,
obesity rates continue to increase. Prevention is the best public
health strategy, and continued work in communicating the benefits
of a healthy lifestyle is crucial for this. Doctors involved in the
management of overweight and obese patients must be familiar
with NICE protocols and all modalities available in order to be able
to guide patients in the right direction, to ensure optimal long-term
results and to minimise potential complications. Modest weight
loss is achievable and undoubtedly provides health benefits.1
The major challenge, though, is to improve patients’ ability to
maintain whatever weight loss that has been achieved. In order
to be successful, anti-obesity treatments need to reflect the
individual’s needs since methods of weight loss not only contain
physical elements, but also strong psychological and emotional
motivational factors. Unfortunately, clinical logic is not always
Dr Sotirios Foutsizoglou specialises in minor
cosmetic surgery and aesthetic medicine. He is the
founder and medical director of SFMedica, based on
Harley Street in London. In addition to his MBBS he also
holds a BSc(Hons) in mathematics from the University
of Athens and a MSc in Biostatistics and Epidemiology from the
Harvard School of Public Health.
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27. Bays HE, ‘Lorcaserin: drug profile and illustrative model of the regulatory challenges of weigh loss drug development’, Expert Rev Cardiovasc Ther, 9 (2011) 9 p.265-67.
28. Kim GW et al., ‘Anti-Obesity Pharmacotherapy: New Drugs and Emerging Targets’, Clin Pharmacol Ther, 95(1) (2014), pp. 53-56.
29. Smith SR, Weissman NJ, Anderson CM, et al., ‘Multicentre, placebo-controlled trial of lorcaserin for weight management’, N Engl J Med 363 (2010), pp. 245-56.
30. Hess R, Cross LB, ‘The safety and efficacy of lorcaserin in the management of obesity’, Postgrad Med, 125 (6) (2013), pp. 62-72
31. Scacchi M, Pincelli AI, Cavagnini F., ‘Growth hormone in obesity’, Int J Obes Relat Metab Disord, 23 (3) (1999), pp. 260-71.
32. Shadid S and Jenssen MD, ‘Effects of Growth Hormone Administration in Human Obesity’, Obesity Research, 11 (2) (2003), pp. 170–175.
33. Münzer, T, Harman, SM, Hees P, et al, ‘Effects of GH and/or sex steroid administration on abdominal subcutaneous and visceral fat in healthy aged women and men’, J Clin Endocrinol Metab, 86 (2001), p.3604-3610.
34. Scacchi M, Pincelli A I and Cavagnini F, ‘Growth hormone in obesity’, International Journal of Obesity, 23 (1999) p.260-271.
35. Jeffrey M. Friedman, Jeffrey L. Halaas, ‘Leptin and the regulation of body weight in mammals’, Nature 395 (1998), pp. 763-770.
36. Bisht S., ‘Leptin hormone: it’s association with obesity: a review’, International Journal of Drug Formulation & Research, 1 (1) 2010, pp. 204-220.
37. Buchwald H, Oien DM., ‘Metabolic/bariatric surgery worldwide 2008’, Obes Surg 19 (2009), pp. 1605-11.
38. Arterburn D and Courcoulas A, ‘Bariatric surgery for obesity and metabolic conditions in adults’, BMJ, 349 (2014) p.28-32.
39. National Institute for Health and Care Excellence, Obesity: identification, assessment and management of overweight and obesity in children, young people and adults, (www.nice.org.
uk, 2014)
40. Balsiger BM, Murr MM, Poggio JL, Sarr MG., ‘Bariatric surgery. Surgery for weight control in patients with morbid obesity’, Med Clin N Am, 84 (2000), pp. 477- 89.
41. Mason EE, Ito C., ‘Gastric bypass’, Ann Surg, 170 (1969), pp. 329-39.
42. Favretti F, Cadiere GB, Segato G, Himpens J, De Luca M, Busetto L, et al. ‘Laparoscopic banding: selection and technique in 830 patients’, Obes Surg 12 (2002), pp. 385-90.
43. Nguyen NT, Nguyen B, Gebhart A, Hohmann S., ‘Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy’, J Am Coll Surg 216 (2013), pp. 252-7.
44. Welbourn R et al., National Bariatric Surgery Registry: first registry report to March 2010. (Dendrite Clinical Systems: www.e-dendrite.com, 2011)<www.e-dendrite.com/files/13/file/
Pages%20from%20NBSR%202010.pdf>
45. Gloy VL, Briel M, Bhatt DL, Kashyap SR, Schauer PR, Mingrone G, et al. ‘Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials’, BMJ 347 (2013), f5934.
46. Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. ‘Trends in mortality in bariatric surgery: a systematic review and meta-analysis’, Surgery 142 (2007), pp. 621-32.
47. Anterburn DE and Courcoulas AP., ‘Bariatric Surgery for Obesity and Metabolic Conditions in Adults’, BMJ 349 (2014), g3961.
48. Gletsu-Miller N, Wright BN, ‘Mineral malnutrition following bariatric surgery’, Adv Nutr, 4 (2013) p.506-17.
49. Svensson PA, Anveden A, Romeo S, Peltonen M, Ahlin S, Burza MA, et al, ‘Alcohol consumption and alcohol problems after bariatric surgery in the Swedish Obese Subjects study’, Obesity (Silver Spring) 21 (2013) p.2444-5.
50. Maluenda F, Csendes A, De Aretxabala X, Poniachik J, Salvo K, Delgado I, et al. ‘Alcohol absorption modification after a laparoscopic sleeve gastrectomy due to obesity’, Obes Surg 20 (2010), pp. 744-8.
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Aesthetics Journal
Aesthetics
The role of topical
and oral antioxidants
Surgeon Ms Rozina Ali and nutritional therapist Eva Escofet explore the
benefits of topical and oral antioxidants in treating the signs of ageing
INTRODUCTION
The doctor-patient relationship is the keystone
of any therapeutic interaction, and I am a
great believer in patient engagement and
responsibility. This makes for a more rewarding
outcome for the patient, as they know just
how much they have contributed to their own
Ms Rozina Ali
wellbeing. The true ‘transformation’ of aesthetic
surgery is not just a passive change in appearance, but is in fact
the end result of a process of reflection, consultation, absorption of
information and what we hope is a commencement of a therapeutic
doctor/patient partnership, all of which takes places in order for the
patient to arrive at their ‘best self’. As a matter of course, I discuss
skincare with all facial aesthetics patients that I see, regardless of
the treatment, and my two therapeutic mainstays are corrective
(antioxidants to neutralise free-radical damage) and protective
(the use of adequate physical or chemical sun protection). Every
consultation includes a medications and social history – but the best
aesthetic consultations also include the documenting of a lifestyle
and nutrition history. The patient’s diet, exercise regimen and overthe-counter (OTC) supplements are important components
BACKGROUND
An antioxidant is any substance that delays,
prevents or removes oxidative damage to a
target molecule.3 Oxidation reactions produce
free radicals that can start multiple chain
reactions that eventually can cause damage
Eva Escofet
or death to the cell. Therefore, due to their
action of inhibiting free radicals, antioxidants are crucial towards the
prevention of ageing and disease.4
Oral antioxidants
Oral antioxidants can come in the form of dietary supplements or
natural food substances. Although dietary supplements are not
designed to replace a healthy balanced diet, the Food and Drugs
Administration (FDA) explains that supplements help to ensure that
users get an adequate dietary intake of essential nutrients, such
as antioxidants.3 Although a healthy diet often provides a source
of vitamins and minerals, taking dietary supplements on top is,
largely, essential in ensuring your body receives all the nutrients it
needs each day. With a consistent decline in nutrients within food
production over the past 70 years,4,5 combined with age-related
decline in digestive enzymes6,7 and also a reduction in probiotic
of their overall wellbeing, as are their recreational and relaxation
methods. Oral antioxidants are an essential component of a patient’s
therapeutic regimen. Today’s busy lifestyles don’t always allow for
fresh organic green vegetables or a wholly raw food diet, so I hunt
tirelessly for the pills or solutions that provide the richest possible
source of absorbable, active nutrients. I recommend all kinds of age
or hormone-appropriate supplements and am always keen to try
the latest active ingredients. Oral antioxidants exert a generalised
benefit, usually slow, steady and subtle, but undoubtedly profound.
Crucially, they allow for uncomplicated, rapid and strong wound
healing.1 Topical antioxidants are much more localised and specific,
making them feel more like part of the treatment. They rely on
patient compliance as, after all, no cream provides benefit if it
stays in its tube. I strongly encourage topical antioxidants with
any facial procedure, whether surgical or non-surgical, invasive or
non-invasive, since, in my opinion, it allows for better results. Tauter,
tighter skin and a healthy glow2 can be felt and seen by patients and
others alike. The stability, ingredients, consistency, smell and cost
of the products all have an effect on how easy they are to use and,
hence, their overall effectiveness.
gut microorganisms, absorption rates of nutrients post 40 years
of age onwards are certainly compromised.8,9,10 Plus, with adding
everyday stress into the equation, which further reduces digestive
function and absorption,11 the need for dietary supplementation
for all nutrients, especially antioxidants, is crucial. Whilst there
are several assays currently used to assess in vitro antioxidant
activity, the following two are most common. The first is the oxygen
radical absorbance capacity (ORAC) assay, which measures the
decrease in fluorescence decay caused by antioxidants. The
second is the total oxyradical scavenging capacity (TOSC) assay,
which measures the decrease in ethylene gas production, caused
by the inhibition of the thermal hydrolysis of ABAP (2,2-Azobis
[2-methylpropionamidine] dihydrochloride) by KMBA (alphaketo-gamma-methiolbutyric acid) in the presence of antioxidant
compounds.12 There are various oral antioxidants with beneficial
anti-ageing properties. For the purpose of this article, however, we
will review those especially effective for dermal anti-ageing.
L-Ascorbic Acid
L-ascorbic acid is a water-soluble antioxidant that the body is
unable to synthesize, therefore ingestion through supplements and
diet is essential.13 As an antioxidant, it scavenges free radicals and
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Aesthetics Journal
reactive oxygen molecules, which are produced during metabolic
pathways of detoxification. It also prevents formation of carcinogens
from precursor compounds.14 Ascorbic acid (above other forms
of vitamin C, such as ascorbates) has been shown to increase
collagen synthesis in cultured skin fibroblasts by approximately
eight-fold.15 It is also an essential cofactor for lysyl hydroxylase and
prolyl hydroxylase, the enzymes needed for collagen biosynthesis.16
Supplementation doses of 250mg have been shown to be
sufficient and effective.17
Aesthetics
chelate redox-active transition metals, regulate the detoxification of
heavy metals and modulate various signal transduction pathways in
physiological and pathological conditions.29 ALA has a high TOSC
value of 3,380 µmol of trolox equivalents per mg, but a relatively
low ORAC figure of 23,200 µmol of trolox equivalents per mg. ALA
research on human dermal fibroblasts in vitro in cell-culture systems
shows that ALA helps to prevent cellular damage via its antioxidant
properties. It can protect fibroblasts, thus helping to slow down the
ageing process in the dermis, whilst stimulating repair.30
Topical antioxidants
It has long been understood that the skin is able to produce
antioxidants. As we age, however, not only does the skin’s ability
to synthesise antioxidants (such as ascorbic acid glutathione,
alpha-tocopherol and superoxide dismutase) decrease, but our
susceptibility to reactive oxygen species (ROS) increases.31 In 2001
Dreher stated, “Regular application of skin care products containing
antioxidants may be of the utmost benefit in efficiently protecting
our skin against exogenous oxidative stressors occurring during
daily life. Furthermore, sunscreening agents may also benefit
from combination with antioxidants resulting in increased safety
and efficacy of such photoprotective products.”32 A study also
showed topical application of antioxidants reduced UVA-induced
dermatoses, and an increased exposure to UVA is required to
induce hyperpigmentation in skin exposed to topical antioxidants.32
Simply placing an ingredient with antioxidant capacity on to the skin
Green Tea
Green tea polyphenols (mainly catechins) have been shown to have will not necessarily protect against ROS. Antioxidants need to be
absorbed into the skin in their active form and remain stable for long
cancer preventative effects in vivo.23,24 Catechins scavenge ROS by
enough to achieve the intended antioxidant functionality. Oxidation
generating more stable phenolic radicals. The ORAC assay scores
could be described as a flaw in topical antioxidant therapy; for
green tea as providing an extremely high figure of approximately
example vitamin C is susceptible to damage from exposure to
120,000 µmol of trolox equivalents per mg of dried tea leaves.25 It
light and oxygen. This has led to a search for intelligent delivery
also has a high TOSC value of 3,780 µmol of trolox equivalents per
mechanisms and packaging solutions, such as airtight metallicised
mg. Green tea has more than five times the amount of catechins
containers.33 Topical antioxidants can be divided into two main
as black tea.26 Oral green tea catechins are shown to protect skin
against harmful UV radiation, improve overall skin quality and boost
categories – water soluble (eg. glutathione, silymarin, vitamin C,
oxygen flow to the skin.27
resveratrol, grape seed extract) and fat soluble (eg. curcumin,
coenzyme Q10, idebenone). A few antixoidant ingredients are both
water and lipid souble, such as alpha lipoic acid.34
Alpha Lipoic Acid (ALA)
ALA is an organosulfur compound derived from octanoic acid,
Many other additional ingredients used in anti-ageing skincare
essential for aerobic metabolism in the body. Naturally occurring
have dual or multiple actions. For example, polyhydroxy acids
lipoic acid is always covalently bound and not readily available
(PHAs) and bionic PHAs are recognised as powerful antioxidants.
from dietary sources, and is also only present in very low doses
Gluconolactone, a PHA, has been shown to inhibit elastin promoter
within dietary foods.28 Dietary or drug supplementation is therefore
gene by 50%, decreasing solar elastosis by reducing the over
production of elastin.35 The Bioinc PHAs lactobionic acid and
necessary for therapeutic doses. Both in vivo and in vitro studies
demonstrate that ALA exhibits the ability to scavenge free radicals,
maltobionic acid have both shown powerful metal chelating
capacity. Lactobionic acid has been used
VERBASCOSIDE
for many years as a component of organRosmarinic Acid
preserving solutions, limiting reperfusion injury
Quercetin
in isolated ischaeimc organs.36 Maltobionic
acid
is also a powerful metal chelator, directly
Ascorbic Acid
reducing damage from free radicals.37
Rutin
Maltobionic acid has also been shown to
Alpha-tocopherol
reduce the production of malondialdehyde and
Trolox
therefore reduce oxidative damage to lipids in
Resveratrol
the cell membrane and the mitochondria.38 An
alpha
hydroxyacid, citric acid is synergistic to
0
0,5
1
1,5
2
2,5
3
3,5
TEAC Value (mM)
the known antioxidant vitamin E. It enhances
vitamin E’s antioxidant action towards radiationFigure 1: Relative Trolamine Equivalent Absorbance Capacity of selected potential antioxidants
Grape Seed Extract (GSE)
GSE is known as a powerful antioxidant that protects the body
from premature ageing, disease and decay. Grape seeds contain
mainly phenols such as proanthocyanidins. Studies have shown that
oral administration of GSE lowers reactive oxygen species (ROS)
generation and plasma protein carbonyl groups, while enhancing
the activity of the endogenous antioxidant systems.18,19,20,21 GSE has
an impressive ORAC figure of approximately 63,000 µmol of trolox
equivalents per mg, and also a high TOSC value of 3,200 µmol of
trolox equivalents per mg. Research suggests that GSE is beneficial
in many areas of skin health because of its antioxidant ability to
bond with collagen, promoting youthful skin, cell health, elasticity
and flexibility. Other studies have also shown that GSE helps to
protect the skin from sun damage.22
@aestheticsgroup
induced peroxidation and, as well as being an antioxidant in its own
right, it inhibits lipid peroxidation and scavenges superoxide anion
free radicals, which can form peroxynitrite – a known detrimental
oxidant.39,40,41 Resveratrol and verbascocide are both curently
attracting attention for their potent antioxidant effects. Verbascoside,
a phenylpropanoid glycoside is a natural plant agent, usually derived
from phytostem lilac leaf cell culture or buddleia davidii meristematic
Aesthetics Journal
cells, with known antioxidant, anti-inflammatory and photoprotective
actions.42 In comparison, using the trolamine equivalent absorbance
capacity (TEAC) scale, verbascocide showed strong antioxidant
activity in comparison to ascorbic acid, alpha tocopherol and
resveratrol; verbascocide induces a dose dependent decrease
of expression of pro-inflammatory chemokines on human
keratinocytes, as demonstrated in Figure 1.43
CONCLUSION
The effective use of oral antioxidants requires a lifestyle shift; it takes discipline and thought on the patient’s part. Using
topical antioxidants can be a very enjoyable and constructive ritual every morning and night. In reality, each patient has
to decide which regimen matches their personality, lifestyle or budget and is suitable to their everyday commitments.
I advise all my patients that the maintenance and often even enhancemment of the results of any plastic surgery
treatments requires their input. The plethora of data available regarding the effectiveness of key antioxidant ingredients
Ms Rozina Ali
in both skincare ingredients and supplements is indisputable. It is heartening to learn of the objective, scientific, biopsyproven benefits of these various ingredients, as well as the clinical synergies within products. The current trend towards layering various
products to effect the best outcome is proven in our own clinics. My erstwhile refrain of ‘yes, but, does it work’ has been answered with a
resounding yes, so I strongly believe we should all be including both oral and topical antioxidants in our treatment recommendations for
our aesthetic patients, to ensure the best possible outcome of any procedures we recommend.
Ms Rozina Ali is a highly trained and experienced consultant
reconstructive and aesthetic surgeon with an interest in facial
aesthetic surgery.
REFERENCES:
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2. Dreher F, Maibach H, ‘Protective effects of topical antioxidants in humans’, Curr Probl Dermatol, 29 (2001) p.157-64.
3. B Halliwell and JMC Gutteridge, ‘The Definition and Measurement of Antioxidants in Biological Systems’, Free Radical Biology and Medicine, Vol. 18, No. 1 (1995), p.125-126.
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6. Mayer, AM, ‘Historical changes in the mineral content of fruits and vegetables: a cause for concern?’ in Agriculture Production and Nutrition: Proc, (USA: Tufts University, 1997). p 69-77
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9. Morley JE, ‘The aging gut: physiology’, Clin Geriatr Med,;23(4) (2007), p.757-7.
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15. Jialal I, Grundy SM, ‘Preservation of the endogenous antioxidants in low density lipoprotein by ascorbate but not probucol during oxidative modification’,Journal of Cl. Invest, 87 (2) (1991), p.597.
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18. Pinnell SR, ‘Regulation of collagen biosynthesis by ascorbic acid: a review’, Yale J Biol Med, 58(6) (1985), p.553-9.
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20. M Balu, P Sangeetha, G Murali, and C Panneerselvam, ‘Age-related oxidative protein damages in central nervous system of rats: modulatory role of grape seed extract’, International Journal of Developmental Neuroscience, 23, (6) (2005), p.501–507.
21. M Balu, P Sangeetha, D Haripriya, and C Panneerselvam, ‘Rejuvenation of antioxidant system in central nervous system of aged rats by grape seed extract’, Neuroscience Letters, 383, (3) (2005), p.295–300.
22. A Devi, AB Jolitha, and N Ishii, ‘Grape seed proanthocyanidin extract (GSPE) and antioxidant defense in the brain of adult rats’, Medical Science Monitor, 12 (4) (2006). p.124-129.
23. Busserolles, E Gueux, B Balasińska et al., ‘In vivo antioxidant activity of procyanidin-rich extracts from grape seed and pine (Pinus maritima) bark in rats’, International Journal for Vitamin and Nutrition Research, 76, (1), (2006) p. 22-27.
24. Shi J, Yu J, Pohorly JE, Kakuda Y, ‘Polyphenolics in grape seeds-biochemistry and functionality’, J Med Food, 6(4) (2004) p.291-9.
Eva Escofet is a highly established nutritional therapist with 12
years of clinical experience. She owns a busy multidisciplinary
clinic, where she mentors a team of nutritionists.
25. Cui Y, Morgenstern H, Greenland S, Tashkin DP, Mao JT, Cai L, Cozen W, Mack TM, Lu QY, Zhang ZF, ‘Dietary flavonoid intake and lung cancer’, Cancer, 112 (2008), p.2241-2248.
26. Uan JM, Koh WP, Sun CL, Lee HP, Yu MC, ‘Green Tea intake, ACE gene polymorphism and breast cancer risk among Chinese women in Singapore’, Carcinogensis, 26 (2005), p.1389-1394.
27. Chandra S, de Mejia EG, ‘Polyphenolic compounds, antioxidant capacity, and quinone reductase activity of an aqueous extract of Ardisia compressa in comparison to mate (Ilex paraguariensis) and green (Camellia sinensis) teas’, J Agric Food Chem, 52 (2004) p.3583–3589.
28. Lu QY, Jin YS, Pantuck A, Zhang ZF, Heber D, Belldegrun A, Brooks M, Figlin R, Rao J, ‘Green tea extract modulates actin remodeling via Rho activity in an in vitro multistep carcinogenic model’, Clin Cancer Res, 11(4) (2005), p.1675-83.
29. Heinrich U, Moore CE, De Spirt S, Tronnier H, Stahl W, ‘Green tea polyphenols provide photoprotection, increase microcirculation, and modulate skin properties of women’, J Nutr. 141(6) (2011) p.1202-8.
30. Reed, LJ, ‘A trail of research from lipoic acid to alpha-keto acid dehydrogenase complexes’, Journal of Biological Chemistry, 276 (42) (2001) p.38329-36.
31. Salinthone S, Yadav V, Bourdette DN, Carr DW, ‘Lipoic acid: a novel therapeutic approach for multiple sclerosis and other chronic inflammatory diseases of the CNS’, Endocr Metab Immune Disord Drug Targets, 8(2) (2008), p.132-142.
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34. Dreher F, Maibach H, ‘Protective effects of topical antioxidants in humans’, Curr Probl Dermatol, 29 (2001) p.157-64.
35. Bauman L, Allemann IB, ‘Cosmetic Dermatology: Principles and Practice’, 2nd edn. McGraw, 34:298 (2008).
36. Cliff S, PRIME International Journal of Aesthetic and Anti-Ageing Medicine, December 2013.
37. Briden ME, Green BA, ‘The Next Generation Hydroxyacids’, Draelos Z, Dover J, Alam M, eds. ‘Procedures in Cosmetic Dermatology: Cosmeceuticals’, Philadelphia, PA: Elsevier Saunders (2005) p.205-212.
38. Charloux C, Paul M, Loisance D, Astier A, ‘Inhibition of Hydroxyl Radical Production By Lactobionate, Adenine and Tempol’, Free Radical Biology & Medicin, 19 (5) p.699-704
39. Brouda I, Edison BL, Weinkauf RL, Green BA, ‘Maltobionic acid, a powerful yet gentle skincare ingredient with multiple benefits to protect and reverse the visible signs of agin’, Am Acad of Dermatol Poster Exhibit: Chicago, (2010).
40. Brouda I, Edison BL, Weinkauf RL, Green BA, ‘Maltobionic acid, a powerful yet gentle skincare ingredient with multiple benefits to protect and reverse the visible signs of aging’, Am Acad of Dermatol Poster Exhibit: Chicago, (2010).
41. Wills ED, ‘Effects of antioxidants on lipid peroxide formation in irradiated synthetic diets’, Journal Int J Radiat Biol Relat Stud Phys Chem Med. 37(4) (1980) p.403-14.
42. Van den Berg AJ, Halkes SB, van Ufford HC, Hoekstra MJ, Beukelman CJ, ‘A novel formulation of metal ions and citric acid reduces reactive oxygen species in vitro’, J Wound Care, 12(10) (2003), p.413-8.
43. Higashi-Okai K, Ishikawa A, Yasumoto S, Okai Y, ‘Potent antioxidant and radical-scavenging activity of Chenpi – compensatory and cooperative actions of ascorbic acid and citric acid’, J UOEH 31(4) (2009) p.311-24.
44. Vertuani S, Beghelli E, Scalambra E, Malisardi G, Copetti S, Dal Toso R, Baldisserrotto A, Manfredini S, ‘Activity and stability studies of verbascocid, a novel antioxidant, in dermocosmetic and pharmaceutical topical formulations’, Moleculs, 16(8) (2011), p.7068-80.
45. Data on file: Resources Of Nature, 801 Montrose Avenue, South Plainfield, NJ 07080.
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Immediatefatcelldestruction•Localizedreductionoffatdeposits
• Sublative®-FractionatedBi-polarRadioFrequencyTechnology
Improvementofstriaeandtexturalirregularities•Smoother,rejuvenated
appearanceoftheskin
*elōstechnologycombinesbi-polarradiofrequencyandopticalenergiesfordeeperdermalpenetrationand
amoresafe,effectivetreatmentthanwithopticalenergyalone.
www.syneron-candela.co.uk | [email protected] | Tel. 0845 5210698
*TheVelaShapeIIIisindicatedfornon-invasivetreatmentforbodycontouringviatemporarycelluliteandcircumferencereduction.ThisbrochureisnotintendedforuseintheU.S.market.
©2014.Allrightsreserved.Syneron,theSyneronlogo,VelaShape,UltraShape,SublativeandelōsareregisteredtrademarksofSyneronMedicalLtd.andmayberegisteredincertainjurisdictions.Candelaisaregisteredtrademarkofthe
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Aesthetics Journal
Aesthetics
The latest
advancements
in laser
Laser specialist Dr Elizabeth Raymond Brown gives an overview of the
latest technological advancements in the field of aesthetic lasers
Introduction
The concept of the laser traces back to the theory of stimulated emission
proposed by Albert Einstein in 1917.1 The first experimental laser, using a synthetic
ruby crystal, was demonstrated in 1960 by Theodore Maiman.1 According to
Hecht,2 the development of the laser was ‘neither simple nor easy’, but in the
intervening 55 years, lasers impacted every aspect of life, including surgical and
non-surgical cosmetic interventions. The UK market for cosmetic interventions
(consumer value) was worth £2.3bn in 2013, and it is estimated to rise to
£3.6bn by 2015. Non-surgical procedures (injectables, laser/light therapies) are
estimated to account for 90% of procedures and 75% of the market value.3 Rarely
can medical aesthetic clinics afford to invest in laser technology unless it offers a
wide range of treatment modalities or unique features, with superior performance
and benefits over other modalities and devices. What could be considered good
examples of customisable laser and intense light devices for multi-applications
include: the Alma Harmony XL, the Lumenis M22, Lynton Lumina and the Cutera
Xeo (Figure 1). These systems offer versatile and expandable ‘platforms’ with
as many as 24 different treatment modalities from a single platform, helping to
grow practice treatments and revenue. Devices offering fewer, but more specific
applications, such as body contouring or treatment of hyperhidrosis include; the
10600 nm output of the Syneron-Candela CO2RE for ablative rejuvenation or the
1565 nm fibre laser of the Lumenis ResurFX (Figure 2), offering fractional nonablative skin rejuvenation.
Figure 1. Cutera Xeo treatment hand-pieces
Figure 2. Lumenis ResurFX
An established marketplace
The economic downturn and subtle changes in customer demands resulted in
some key mergers and acquisitions, which has brought benefits to companies,
investors and consumers alike. With companies extending their product
portfolios, research and development (R&D) bases, and customer support
services, practitioners expect suppliers to offer reliable, high performance
devices, limited or zero consumable costs, on-going clinical education and
‘on-call’ service support. Lasers are designated as ‘Medical Devices’, and thus
must be CE marked and comply with applicable European Medical Device
Directives (within the EU).4 Unlike the United States, the UK is not required to
register laser products, but it is a legal requirement
to meet the ‘Essential Safety Requirements’ of the
applicable European Directives, ie. BS EN 60601-222:2013.5 Laser products are classified according
to the accessible laser emission, and if this exceeds
limits defined in BS EN 60825-1,6 the product
must be accurately labelled and must incorporate
engineering features such as key switches and
interlocks. Manufacturers must also provide
adequate instructions for safe and appropriate
use. Laser eye protection has to be CE marked
and comply with BS EN 207:2009,7 the ‘European
Directive on Personal Protective Equipment’. As
a certified laser protection advisor (LPA), I would
strongly advise those purchasing equipment
directly from non-European websites, or pre-used
devices to seek independent advice on product
safety compliance, output calibration and suitability
of treatment protocols and protective eyewear.
Extending treatment opportunities
All aesthetic laser and light-based therapies
exploit the concept of selective absorption of
incident radiation by a given chromophore or
target, as described by the theory of Selective
Photothermolysis.8 To achieve an efficacious and
safe clinical outcome, specific device variables
must be selected and controlled according to the
presenting condition to be treated and patient
factors such as skin type, hair colour etc.
These variables include:
Wavelength (nm / µm) – determining absorption
by a given chromophore, and depth of penetration
into tissues.
Pulse duration (ms / µs / ns / ps) – determining rate
of heating of target tissues and thus interaction
mechanism, eg. photochemical, photothermal,
photomechanical.
@aestheticsgroup
Energy, power, fluence (J, W, J cm-2 according to output)
– determining amount of energy/power delivered to the tissues.
·
Treatment area (mm, cm-2) – affecting depth of penetration into
tissues, thermal diffusion of heat and treatment time.
It is the subtle but significant refinement of these variables that
offer further opportunities to improve clinical efficacy, reduce
treatment times and enhance patient comfort. For example, the
introduction of ‘fractional’ technology – delivering energy in microspots rather than over a full beam area – had a significant impact
on extending both ablative and non-ablative treatments.9 Other
innovative advances are outlined below:
Wavelengths – adding more and ‘mixing’ them up
A number of devices offer multiple wavelengths and interesting
ways of delivering them:
·
·
Independent wavelength delivery – eg. Syneron-Candela
GentleMax Pro, offers an Alexandrite (755 nm) and an Nd:YAG
(1064 nm) output for hair reduction, allowing treatment of all
skin types and pigmented and vascular lesions. Sequential wavelength delivery – eg. Cynosure Cynergy
Multiplex technology emits a pulsed dye (585 nm) beam
milliseconds before the Nd:YAG (1064 nm) output for increased
absorption by methemoglobin and enhanced treatment of
vascular lesions.
Rarely can medical
aesthetic clinics afford to
invest in laser technology
unless it offers a wide range
of treatment modalities
Figure 3 Quanta Duetto
MT Laser
Figure 4 SyneronCandela PicoWay
Aesthetics Journal
Simultaneous wavelength delivery – eg. The Quanta System
Duetto MT laser (Figure 3), distributed by Lynton Lasers, can
emit Alexandrite (755 nm) and Nd:YAG (1064 nm) wavelengths
in a single emission in varying proportions. Mixing the efficacy
of the Alexandrite with the safety of the Nd:YAG offers treatment
for challenging conditions such as reducing fine hair in darker
skin types.
Pulse durations – ever shorter
Some of the most recent product advances have come from the ability
to produce reliable and repeatable ultra-short picosecond (ps, 10-15 s)
pulses of energy, previously the reserve of the research laboratories.
Picosecond pulses induce photodisruption – a physical effect
associated with optical breakdown that results in plasma formation
and shock wave generation.10 Photodisruption is a well-known tool of
minimally invasive surgery such as posterior capsulotomy and laserinduced lithotripsy of urinary calculi.
The nanosecond pulses (ns, 10-9 s) of Q-switched lasers are
successfully used for tattoo removal and treatment of pigmented
lesions. However, picosecond pulses can produce incredibly high
peak powers from lower pulse energies – still causing optical
breakdown but with less disruptive effects to surrounding tissue.10
Devices exploiting this technology include:
·
·
·
Cynosure PicoSure, dual wavelength (755 nm / 532 nm) laser:
Cynosure has exploited the laser-induced optical breakdown
in tissues via their FOCUS lens array to include treatment
of acne scars and wrinkles. Brauer et al11 have shown new
collagen and elastin production, similar to fractional ablative
lasers, but without the side effects and downtime.
Syneron-Candela PicoWay (Figure 4), dual wavelength (1064
nm / 532 nm) laser: claimed to remove multi-coloured tattoos,
recalcitrant tattoos and pigmented lesions.
Cutera enlighten: This is a dual wavelength (1064 nm / 532
nm) laser offering both nanosecond and picosecond pulse
durations (fixed), in one device, which with their variable spot
sizes claimed to offer removal of both epidermal and dermal
pigmented lesions.
Treatment areas – bigger, faster, cooler
Patients not only expect great results, but also want fast and
comfortable treatments, especially with hair reduction. Increasing
Figure 5 Alma Lasers Soprano
Figure 6. GME Linscan 808 Diode laser
@aestheticsgroup
Aesthetics Journal
To achieve an efficacious
and safe clinical outcome,
specific device variables
must be selected and
controlled according to the
presenting condition to be
treated and patient factors
such as skin type, hair
colour etc.
treated area, scanned beams and comfort cooling are the
industry’s response to these demands. For example:
·
·
·
Soprano from Alma Lasers (Figure 5) is well known for its
SHR hair removal (high repetition of short pulses to achieve
high average power) and their in-motion treatment technique.
Extending this technology further is the Soprano Ice diode
laser, with large spot size and ICE contact cooling designed
to enhance patient comfort.
A new device, recently available in the UK via Aster
International Ltd, is the German Medical Engineering Linscan
808 diode laser (Figure 6). A novel method of linear scanning
across a treatment area of 50 x 15 mm offers high efficacy
and reduced treatment times. Combined with contact cooling,
Motion Control Technology (MCT) and menu driven presets, this compact laser offers all the important features for
safe treatment delivery. Interestingly it also offers treatment
settings for Onychomycosis, as a less painful alternative to
the Nd:YAG 1064 nm wavelength.
Building on the well established Lightsheer technology for
hair reduction is the Lightsheer INFINITY, from Lumenis,
offering diode wavelengths of 805 nm and 1060 nm, with
a unique active pain reduction mechanism using vacuum
assisted (HIT) technology and the ChillTip handpiece for
effective epidermal protection. The INFINITY is a good
example of the enhanced features that manufacturers
need to include for both patient and practitioner with an
advanced graphical interface, intuitive pre-sets and treatment
defaults, benefiting the users and reducing the likelihood of
inappropriate treatment settings.
Going the extra mile – customer support
Aside from the technological advances and refinements, it is
notable that manufacturers now strive to enhance the customer
experience of buying and using a laser. It is no longer acceptable
to take delivery with a half day training session and being left to
‘get on with it’. With such a range of devices available from an
increasing number of suppliers, it can be hard to differentiate
between them, and the decision on system purchase often comes
down to the rapport developed with an individual sales person.
Aesthetics
Whilst perhaps understandable, this can be risky and it is wiser
to focus on company pedigree, product portfolio and customer
support. Reputable and trust-worthy companies offer information
on compliance with safety and licensing requirements, advice
on premises and room layouts, dedicated clinical trainers,
workshops and educational events, webinars and learning
resources, ‘user’ groups, training and business development
support and rapid response to equipment service or break-down.
Companies can also support their customers with contacts for
finance companies, laser protection advisers (LPA) and expert
medical practitioners (EMP).
Conclusion
From the first medical treatment of a retinal tumour with a ruby
laser in 1961,12 to the surgical and non-surgical interventions
available today, lasers have proven themselves as precision
tools for an incredibly extensive range of treatments. Pushing
the boundaries with mid and far infrared wavelengths, beam
delivery methods, faster treatments over bigger areas and
enhanced comfort, will continue to raise expectations of both
patients and users. A word of caution however, advancing
the technology without advancing practitioner education is
dangerous. Just because a laser can remove our wrinkles,
reduce our hair growth and banish our brown spots, it should not
mean that the technology becomes so readily accessible that
anyone can perform such treatments. In my opinion, this is where
manufacturers and distributors have a wider role to play than just
selling the latest technology. But thanks to significant R&D and
investment, it is now possible to deliver medical grade treatments
from the most reliable, efficient and technically-advanced devices
than ever before.
Dr Elizabeth Raymond Brown is an RPA2000 accredited
laser protection advisor and academic lead for the MSc. in
non-surgical facial aesthetics (NSFA) at the University of
Central Lancashire in Preston. She has previously worked
as a laser safety lecturer at Loughborough University and
was head of lasers at Loughborough College.
REFERENCES
1. Hecht, J. (1992) The Laser Guidebook. 2nd edn. USA: McGraw-Hill
2. Hecht, J. Beam: The Race to Make the Laser, (USA: Oxford University Press, 2005)
3. Department of Health (2013) Review of the Regulation of Cosmetic Interventions – Final Report (UK: Department of Health, 2013) Available at: <https://www.gov.uk/government/uploads/system/
uploads/attachment_data/file/192028/Review_of_the_Regulation_of_Cosmetic_Interventions.pdf> [Accessed 17 March 2015]
4. British Standards Institute. European Medical Device Directives (UK: British Standards Institute, 2015) Available at: <http://medicaldevices.bsigroup.com/en-GB/our-services/european-
mdd)> [Accessed 17 March 2015]
5. British Standard Institute. BS EN 60601-2-22:2013: Medical electrical equipment: Particular requirements for basic safety and essential performance of surgical, cosmetic, therapeutic and diagnostic laser equipment (UK: British Standards Institute, 2013)
6. British Standards Institute. BS EN60825-1:2014: Safety of laser products - Part 1: Equipment classification & requirements (UK: British Standards Institute, 2014)
7. British Standards Institute. BS EN 207:2009: Personal eye-protection equipment. Filters and eye-
protectors against laser radiation (laser eye-protectors) (UK: British Standards Institute)
8. Anderson R, Parish J. (1983) ‘Selective photothermolysis: Precise Microsurgery by Selective Absorption of Pulsed Radiation’. Science 220 (1983). p 524-527.
9. Gold, M.H Ed. (2010) ‘Update on Fractional Laser Technology’ J Clin Aesth Dermatol, 3(1): pp.42-50
10. Niemz, M.H. Laser-Tissue Interactions: Fundamentals and Applications. (Berlin Heidelberg: Springer-Verlag, 1996).
11. Brauer, J, Kazlouskaya, V, Alabdulrazzaq, H, Bae, Y, Bernstein, L, Anolik, R, Heller, P, and Geronemus, R. ‘Use of a picosecond pulse duration laser with specialized optic for treatment of facial acne scarring’, JAMA Dermatology, 151(3) (2015) p 278-284
12. Institute of Medicine (US) Committee on Technological Innovation in Medicine; Rosenberg N, Gelijns AC, Dawkins H, editors. Sources of Medical Technology: Universities and Industry. Washington (DC): National Academies Press (US); 1995. PART II, Medical Device Innovation. 3, pp 7.
@aestheticsgroup
Aesthetics Journal
Aesthetics
The importance
of skin texture
Dr Sharon Crichlow analyses the role
and importance of skin texture in
treating the signs of ageing
The Oxford English dictionary defines texture as ‘the feel, appearance or
consistency of a surface or substance’. Is it dry, rough, smooth, grainy, irregular?
Does it reflect light evenly? For practical purposes, Ichibori1 states that ‘skin
texture represents the degree of uniformity of the surface of skin’. It can be
argued that, as it relates to the overall skin surface, anything which affects
the skin either directly or indirectly will affect skin texture. There are many
factors involved in the perception of skin ageing; these include spots, uneven
pigmentation, wrinkles, loss of volume, pore size, erythema and texture.1 Skin
texture is hugely important in skin ageing and in fact, in one Japanese study,
visible skin firmness and texture was found to be the first skin parameter to
decline with age, occurring in participants’ 20s; whereas hyper-pigmented spots
appeared in the 30s and wrinkles in the 40s.2 Therefore if we wish to prevent the
earliest signs of ageing, we must focus on optimising skin texture first.
Historically the focus has predominantly rested on treating wrinkles and volume
loss with muscle relaxing injections, fillers and surgery; treatments that provide
the instant wow-factor that patients crave. Patients, however, are no longer
satisfied with having tightened, plumped-up faces free from wrinkles. In my
experience, patients are now requesting the ‘no makeup, makeup’ look. The
rise of celebrities with flawless looking skin in popular culture, many of whom
now acknowledge the procedures that they have had, has fuelled the demand
for perfection. Skin resurfacing and rejuvenation techniques have experienced
significant advances in the last few decades and new devices are continuously
being introduced.3 This has been facilitated by developments in science and skin
culture laboratories, which have allowed us to test both the safety and efficacy
of anti-ageing treatments on human skin equivalent culture models.4 As a result,
we have been able to develop a wide range of both preventative and corrective
products which are proven to improve skin texture.4
Healthy skin texture should be smooth, evenly pigmented, well hydrated and
overlying a well supported dermis. Unfortunately there is no quick fix to achieving
optimal skin texture; a patient must be committed to an ongoing skincare regime
tailored to their individual skin needs. This starts from the initial consultation.
Practitioners first and foremost need to know the patient’s desires, and assess
whether they are realistic or not. Factors influencing the choice of treatment for
each patient would include their age, skin colour and Fitzpatrick type, whether
their skin is oily/acne-prone or dry/sensitive, and
whether they have undertaken previous treatments,
as well as their medical conditions and medications.
In Ichibori R et al’s study of ageing in monozygotic
twins, it was shown that facial texture ‘is influenced
by environmental factors rather than solely by
genetic factors’.1 In other words, extrinsic factors play
a bigger role than intrinsic ones. This is great news
for those of us not naturally blessed with flawless
skin – it can be nurtured! The two factors that have
been shown to have the greatest impact on skin
texture over time are the use of sun protection
and the avoidance of smoking.1,4 Therefore, it is
imperative to advise the patient of the importance of
these lifestyle choices.
Achieving good skin texture starts with a good
skincare regime and diet. Numerous studies have
demonstrated that Ultra Violet (UV) damage is
the single biggest factor in skin ageing.1,5 The
‘Sunscreen Fact Sheet’ published by the British
Association of Dermatologists in 20136 recommends
the use of a sunscreen of at least SPF 30 and with
UVA rating of 4 or 5 stars as providing adequate
protection against UV damage. We would therefore
advise the same. The use of creams containing the
antioxidants vitamin C (at pH <4 and concentrations
up to 20%) and the vitamin E isomer Tocopherol
potentiates the effect of a sun-block by scavenging
free radicals generated both by body metabolism as
well as by UV damage.1,4 Vitamin C levels are high in
normal epidermis and dermis but the levels fall with
natural ageing as well as environmental and sun
damage.7 Although both of these vitamins should
feature in a healthy balanced diet, significant levels
are often not reached in the epidermis and topical
application of these vitamins may be a more efficient
targeted method for supplying nutrients to the skin,
especially to the epidermis.7
Regular cleansing and exfoliation with fruit enzymes,
alpha- or beta- hydroxy acids and the use of retinoic
acid (the active form of vitamin A in the skin),
increase the turnover of new skin cells and keep the
skin looking luminous. Vitamin A preparations such
as retinol, retinaldehyde or retinyl-propionate, as
well as newer formulations of vitamin A, for example,
nano-particulate tretinoin, optimise topical retinoid
therapy while reducing the skin irritation that often
limits its use.8
A well-hydrated skin ages more slowly.2 The regular
use of moisturisers containing hyaluronic acid,
glycerine and other compounds which help to retain
water in the dermis and reduce trans-epidermal water
loss is therefore essential.
Chronic inflammation leads to the production
of free radicals which damage cell components
and contribute to disease and ageing.4 The role
of inflammation in both skin and body ageing is
becoming increasingly recognised and with it, the
importance of a diet high in essential fatty acids, which
help to reduce skin inflammation.9
@aestheticsgroup
If the skin texture is not
specifically addressed, the
patient will not get the
best outcome from their
treatment and their skin will
remain looking aged
Other products which have been shown to deliver texture benefits to
the skin include Panthenol (which increases skin hydration), N-acetyl
glucosamine (NAG) and Niacinamide, a water soluble derivative of
vitamin B3 which has been shown to reduce pore size.
More recently interest has grown in investigating the role of
epidermal growth factors and peptides – synthetic or naturally
occurring dermal proteins which are involved in wound healing and
have been proven to stimulate proliferation of collagen and elastin in
skin cultures. The palmitoyl derivative of one such peptide (lysinethreonine-threonine-lysine-serine (pal-KTTKS) has demonstrated
significant reductions in wrinkles and general skin appearance.4
Once the patient’s skincare regime, diet and lifestyle are optimised,
more targeted treatments can be added. As mentioned earlier, all
cosmetic skin treatments will affect skin texture, whether directly or
indirectly. Skin peels, wrinkle relaxing injections, fillers, dermarolling,
skin tightening devices and laser treatments will all influence the
skin texture. In general, most patients attending an aesthetic clinic
are initially more concerned with volume loss and wrinkles and so
appreciate the instant gratification produced by fillers and toxins.
However, if the skin texture is not specifically addressed, the patient
will not get the best outcome from their treatment and their skin will
remain looking aged. Sometimes the improvement in the wrinkles
and facial profile paradoxically makes the abnormal skin texture even
more conspicuous. I would therefore recommend offering a suitable
skincare regime alongside toxins and fillers, with more targeted
treatments at follow up. This kind of approach will gain the patient’s
trust as they see the immediate results with the injectable treatment
and therefore, they will hopefully be encouraged to continue with
the valuable skincare regime you have recommended. It is worth
emphasising to the patient that while the results of a good skincare
programme take longer to achieve, they are well worth the wait and
the benefits accumulate over time.
T H E A R T O F FA C I A L R E J U V E N AT I O N
Aesthetics Journal
Specific treatments could include fractional laser devices, which
can work to refine pores and improve skin texture, and can be
used regularly as part of a prophylactic or maintenance regime.
Dermarolling is another widely used rejuvenating treatment which
also enhances the absorption of topical product. Carbon dioxide and
fractional laser can also be used as resurfacing tools, and are usually
reserved for deeper scarring or more intensive rejuvenation. A series
of chemical peels using salicylic acid 20-30%, glycolic acid 40-70%
or trichloroacetic acid 20-30% depending on skin type and indication
will also enhance skin texture and tone.10 Complications of all of these
treatments include scarring, infection and in darker skin types, the
potential for pigmentary problems. Side effects are minimised by
careful patient selection, adequate preparation as necessary (e.g.
reduction of melanocyte activity) and the skill of the practitioner. The
patient will choose a treatment modality that suits their own personal
preference and skin needs, taking account of price, time commitment
for the procedure and the ‘down-time’ required afterward.
In summary, changes in skin texture represent the first signs of ageing
and hence must be targeted at an early age, ideally whilst patients
are still in their 20s. Modern advances in bio-science are making
it increasingly possible to study the ageing process and to keep
it at bay. A good everyday skincare regime, with regular specific
treatments as per patient need, is the basis of achieving a healthy
texture in all types of skin.
Dr. Sharon Crichlow works as a consultant
dermatologist at the Skin to Love Clinic in St. Albans, UK.
Her interests include the treatment of acne scarring and
the pigmentary disorders commonly seen in patients
with skin of colour.
REFERENCES:
1. Ichibori R, Fujiwara T, Taniqawa T et al., ‘Objective assessment of facial skin ageing and the associated environmental factors in Japanese monozygotic twins’, Journal of Cosmetic Dermatology, 13 (2) (2014), pp. 158-63.
2. Kukizo Miyamoto, Yasuko Inoue, Kesyin Hsueh et al., 10 year longitudinal Japanese study tracking facial skin ageing for wrinkles, texture, hyperpigmented spots, radiance and firmness (UK: P&G Beauty and Grooming) <http://pgbeautyscience.com/assets/files/10%20Year%20Longitudinal%20
Japanese%20Study%20Tracking%20Facial%20Skin%20Ageing.pdf>
3. Kirkland EB, Gladstone HB, Hantash BM, ‘What’s new in skin resurfacing and rejuvenation?’ Giornale Italiano Di Dermatologia e Venereologia, 145 (5) (2010), pp. 583-96.
4. P&G beauty and grooming, Innovations in Technology and Clinical testing (UK: P&G Beauty and Grooming)< http://pgbeautyscience.com/fine-lines-wrinkles-texture-influence-self-perception1.php>
5. Maria Celia B, Gail M Williams, Peter Baker and Adele Green, ‘Sunscreen and prevention of skin ageing’, Annals of Internal Medicine, 158 (11) (2013), pp. 781-790.
6. British Association of Dermatologists, Sunscreen Fact Sheet (www.bad.org.uk)<www.bad.org.uk/
for-the-public/skin-cancer/sunscreen-fact-sheet>
7. Alexander J Michels PhD. Vitamin C and skin health (US: Linus Pauling Institute, 2011)<http:lpi.
oregonstateedu/infocenter/skin/vitamin/>
8. Siddharth Mukherjee, Abhijit Date, Vandana Patravale et al., ‘Retinoids in the treatment of skin ageing: an overview of clinical efficacy and safety’, Clinical Interventions in Ageing, 1(4) (2006), pp. 327-348.
9. Giana Angelo PhD., Essential fatty acids and skin health (US: Linus Pauling Institute, 2012)<http:lpi.
oregonstate.edu/infocenter/skin/EFA/>
10. Marta I Rendon, Diane S Berson, Joel L Cohen et al., ‘Evidence and Considerations in the Application of Chemcial Peels in Skin Disorders and Aesthetic Resurfacing’, The Journal of Clinical and Aesthetic Dermatology, 3(7) (2010), pp. 32-43.
Why are Doctors and Nurses switching
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Mob: +353 (0)85 711 7166 | Tel: +353 (0)1 676 9810
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FACIAL ANATOMY
TEACHING FOR
REGISTERED
MEDICAL
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Consultant Plastic, Reconstructive
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Humzah provides independent
bespoke Facial Anatomy Teaching
for registered medical professionals.
These sessions hold a strong practical component
and are entirely focused to meet the learning needs
of the individuals who attend and are tailored to
comprehensively explore facial anatomy in the
context of safely performing injectable treatments.
The teaching holds CPD from The Royal College of
Physicians & Surgeons of Glasgow and has won ‘Best
Teaching Initiative’ at The Aesthetic Awards 2013-14
& 2014-15. In addition, Mr Humzah provides teaching
to focus upon ‘The Management of Non-Surgical
Complications Through Anatomy’ to further explore
the concept of safe injecting and increase awareness
surrounding complications encountered through
botulinum toxin and dermal fillers.
UPCOMING EVENTS
6th May 2015
‘The Management of Non-Surgical
Complications Through Anatomy’
The Royal College of Surgeons Eng - 9am-5pm
3rd June 2015
‘Facial Anatomy Teaching’
The Royal College of Surgeons Eng - 9am-5pm
Call 07739 378 693 to book your place
W - facialanatomy.co.uk T - 07739 378 693 E - [email protected]
@facialanatomy
@aestheticsgroup
Aesthetics Journal
Aesthetics
Case Study: Treating
Filler Complications
Frances Turner Traill shares her experience of
managing a filler complication, and advises
practitioners on how to handle adverse events
As an independent nurse prescriber, I have
been treating aesthetic patients since
2008. In June 2014, a long-standing 36-yearold patient visited my clinic for dermal filler
treatment. The patient had been treated with
botulinum toxin and dermal filler in my clinic
annually for the past four years. She had not
undergone any previous aesthetic treatments
prior to this. I had injected less than 0.5ml of
hyaluronic acid filler into her glabella area four
times previously but with a lower viscosity
HA filler, with no adverse reaction. During
consultation I had followed usual protocol and
outlined the risks associated with treatment,
which I checked were understood by my
patient. A full medical history was also taken,
which indicated that the patient would be
suitable for treatment on this day.
To begin treatment, I first identified the
supratrocheal artery by the medial crease on
contraction. I adopted an aseptic, standard
technique in which I insert the needle, stop,
aspirate the needle and watch both the
skin and patient’s reaction. I injected slowly,
performing retrograde linear threading whilst
continually observing for signs of vascular
occlusion. I injected 0.5ml medium viscosity
filler into the patient’s glabella area using the
manufacturer’s syringe and needle.
As expected, the treatment went smoothly
– the patient did not complain of any
unexpected discomfort and was happy
with the immediate outcome. There was
no analgesia used, the patient did not
experience any pain at the time of injection,
there was no evidence of bruising or
blanching and the vascular return was
excellent. Three days post treatment,
however, the patient called the clinic to say
that she had developed a “significant bruise
Figure 1: Three days post injection
in the injected area” and was becoming
extremely distressed as a result (Figure 1). I
was acutely aware that I could be dealing with
a potentially delayed skin necrosis. I managed
the distress and psychological issues the
patient was experiencing holistically, using
my general nursing, diagnostic prescribing
and psychiatric nursing skills. It is essential
that, following a complication, patients receive
both verbal and written advice quickly and
clearly. I contacted the patient via telephone,
explained what an impending necrosis
was, and reassured her that I would do my
utmost to control this unexpected reaction.
As an immediate treatment, I instructed her
to take 75mg of Aspirin for two weeks, as
well as over the counter antihistamines. She
was also instructed to use heat pads on
the affected area to encourage the blood
vessels to dilate, resulting in improved blood
flow. I explained to the patient how to test
her blood circulation, which we found was
not compromised. She was then asked to
attend the clinic as soon as possible. After
a face-to-face assessment (Figure 2), I
prescribed 500mg of Clarithromycin tablets
BD for 14 days, and 400mg Moxifloxacin
OD for 14 days as a precautionary measure
against acute infection. My original plan was
to use 1500iu of Hyaluronidase dissolved
with 2.5ml of normal saline for rapid
degradation of the HA dermal filler. The
patient, however, had reported a significant
improvement since she had started taking
the Aspirin and antihistamines. Taking this
into account, we decided to adopt a ‘watchful
waiting’ approach, during which she would
send me regular photographs of the skin’s
developments. Fifteen days post injection,
the complication had significantly improved
Figure 2: Four days post injection
Figure 3: 15 days post injection
and was much less noticeable with make-up
(Figure 3 – no make-up). By September it
had completely subsided but the patient was
left with a deep line on hard expression in
the glabella area (Figure 4). In November, the
area had completely recovered so I treated
it with botulinum toxin, which improved the
appearance of the deep line – making the
patient, once again, a satisfied patient (Figure
5). As soon as the patient reported the
complication, I asked her to take good, clear
photographs of her face and send them to me
immediately. I also took my own photographs
when she came to the clinic. Taking well-lit,
well-positioned photographs regularly is
essential for the successful management
of complications. It allows practitioners to
conduct thorough patient assessment and
enable accurate treatment of the complication
in a timely and visual manner. I ensured that
the patient continued to take her medication
and kept in touch with her regularly. With new
research and innovation presented to us each
day, it is vital that we ensure our patients are
offered the very best levels of competence
available. Reading journals, attending
conferences and communicating with fellow
aesthetic professionals will help ensure
you are confident to deal with and support
patients when faced with any complication
in your practice. To that end, I presented this
case study at the Edinburgh BACN meeting
in November 2014. The main question
asked was why I didn’t use Hyaluronidase to
degrade the HA dermal filler. My diagnosis
was that the patient had post-injection
swelling, causing some compromise of her
supratrocheal artery, which had reduced
significantly following Aspirin, heat, massage
and antihistamine use. I would have
injected Hyalronidase if there had been no
improvement, a deterioration or if necrosis
was impending.
Independent nurse prescriber
Frances Turner Traill runs her
own medical aesthetic clinics
in Glasgow and the Highlands.
She is an active board member
of the British Association of Cosmetic Nurses
(BACN) and continues to lead the Scottish
Regional Group’s educational meetings.
COMPOSED • CONFIDENT • MY CHOICE
INDICATION
PURIFIED1• SATISFYING2,3,4 • CONVENIENT5
Now approved for
crow’s feet lines
Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product
Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of
Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection.
Indications Temporary improvement in the appearance of moderate to severe vertical lines between
the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile
(crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important
psychological impact for the patient. Dosage and administration Unit doses recommended for
Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute
with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml).
Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus
muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and
into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular
injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL
(4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus
major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over
65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to
any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton
syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings
and precautions. Should not be injected into a blood vessel. Not recommended for patients with
a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis
should be available. Caution in patients receiving anticoagulant therapy or taking other substances in
anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases
which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum
toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless
clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with
aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used
with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within
the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness,
itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal
reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or
tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10);
uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown
Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection.
Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common:
headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness.
Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear
and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry
mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity,
dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of
eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders
and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness,
Influenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema,
dry eye. General disorders and administration site conditions; Common: injection site haemotoma.
Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema
(also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness
have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the
injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used
by physicians with suitable qualifications and proven experience in the application of Botulinum
toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002
Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,
60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information
available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire
WD6 3SR.Tel: +44 (0) 333 200 4143
Adverse events should be reported. Reporting forms and information can be found at
www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at
the address above or by email to [email protected] or on +44 (0) 333 200 4143.
1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from:
URL: http://www.medicines. org.uk/emc/medicine/23251.
2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the
treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in
Aging 2013; 8: 449-456.
3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared
with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010;
36: 2146-2154.
4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily
practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58.
5. Data on File: BOC-DOF-11-001_01
Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA.
1180/BOC/OCT/2014/LD Date of preparation: October 2014
PURIFIED1• SATISFYING2,3,4 • CONVENIENT5
Botulinum toxin type A
free from complexing proteins
@aestheticsgroup
Aesthetics Journal
Aesthetics
Perioral Ageing
Dr Souphiyeh Samizadeh outlines how to create
an aesthetically pleasing smile through awareness
of perioral ageing and dental structure
When we start our training to become aesthetic practitioners, the
first things we learn are to fill the nasolabial folds and marionette
lines. But how much do we actually know about perioral ageing?
The lips and the perioral soft tissues play a key role in facial
attractiveness. Lips have physiological functions (protection, eating,
speaking and position of teeth) and are central to non-verbal and
psychological communication. Plump and well-defined lips represent
youth, attractiveness, sexuality and beauty.1,2 Teeth are an integral
part of a beautiful smile, and the dentition and smile are significant
features in determining facial attractiveness.3 Healthy and wellaligned teeth have been shown to have a positive effect on an
individual’s confidence and psychosocial wellbeing.3,4,5 From my own
findings, as well as media reports, ageing of the perioral region (e.g.
thin lips, mouth furrows, and downward corners of mouth) seems to
be amongst the main reasons people seek surgical or non-surgical
aesthetic treatments.6 Understanding the components of facial
ageing will result in a better understanding of the patient’s individual
needs and therefore better-tailored treatment plans.
The perioral region is defined as the lower third of
the face, extending from the subnasale to mentum
(Figure 1). The key perioral landmarks are:
· The philtrum
· Cupid’s bow
· Lips and vermillion border
· Nasolabial folds
· Labiomental folds (Marionette lines)
Skeletal structure and relationships, soft tissue
contours, the dentition and gingival contour, and
the lip framework determine a patient’s lower
face aesthetic. Skin ageing, subcutaneous fat
atrophy and skeletal remodelling are the key
factors that contribute to facial ageing. Other
factors include smoking, stress, lifestyle, work
habits and diet.7,8,9 Treatment and rejuvenation
of this region without an in-depth understanding
of the anatomy and the ageing process can
produce undesirable results. For example, as
we age lower facial volume increases, thus,
the desired ‘inverted triangle’ facial aesthetic
decreases. I also find patients lose fine lip
movement and sometimes require additional dental or surgical
treatment. Dentition and dental treatment play a significant role
in restoring the perioral complex. Conversely, rejuvenation of the
perioral complex will further enhance the aesthetic outcome of
cosmetic or restorative dentistry. When treating perioral ageing, it
is important to bear in mind that facial characteristics are different
in men and women. Men have larger philtrum widths, and total lip
height, wider mouth width, and their pogonion (the most forwardprojecting point on the anterior surface of the chin) is located more
inferiorly than in women.10,11,12
Figure 1 – The perioral
region: Lower third of the face
(indicated by dark blue line).
The width of oral commissures
is equal to the distance
between the medial limbi (light
blue lines). The lips should be
parallel to interpupillary line
(green lines).
Characteristics of ideal lips
· The width of the lips: approximately 40% of width of the lower face16,17
· The ideal lip ratio on the frontal view is 1:1:6; 40% the upper lip and 60% the
lower lip18
· The lips are parallel to the interpupillary line19
· The length of the upper lip from subnasale is approximately half the length of
the lower lip from the chin10,19
· The width of oral commissures is equal to the distance between the medial
limbi17
· Subnasale to the vermilion border of the lip is curved
· There are specific break points on the lips
· There is an anterior projection of the central cutaneous lip10
· The upper lip: well-defined Cupid’s bow with the apexes at the inferior aspect
of the philtral columns20,21
· The lower lip: fuller than the upper lip, with
slight eversion and more vermillion border
show
· On profile, the upper lip will extend beyond
the lower lip by a couple of millimetres21
Figure 2: Youthful lip, full volume, slight eversion of
the lower lip, vertical rhytides are preserved and the
‘wet-dry junction’ of the lower lip is visible.
A: Cupid’s Bow B: anterior projection of the central
cutaneous lip
@aestheticsgroup
The lip framework
When discussing ideal aesthetics and treatment planning
for patients, it is important to recognise the differences in
races, genders, cultures and aesthetic ideas. The position of
lips is affected by the skeletal make up of an individual and
the underlying dental support.13,14,15 Abnormal dental-skeletal
relationships should be recognised.
These patients may need orthognathic surgery or orthodontic
treatment, which is beyond the scope of this article. Regardless of
cultural and ethnic differences, youthful lips are characterised by
fullness and well-defined curvatures.
Lip-teeth relationships
The position and alignment of the dentition influence position of
lips, smile, phonetics and functional balance. The maxillary incisal
edge curvature would be parallel to the curvature of the lower lip in
an ideal smile arc (Figure 4). At rest, there should be 2-4mm vertical
exposure of the maxillary incisors in relation to the upper lip.21,22,23
Evaluation of anterior smile aesthetics must include both static and
dynamic evaluations of profile, frontal and 45° views to optimise
both dental and facial appearance.23,24 Position of the upper and
lower teeth, crowding, lost dentition, discoloured teeth or different
coloured restorations and tooth wear, all affect the aesthetic of a
smile. During advanced facial and smile analysis, tooth proportions
and symmetry, the dental midline, gingival aesthetics, the smile arc,
width of the smile, buccal corridors (the negative space between
buccal surface of upper first premolars and the commissure of lips
when patients smile), contacts, embrasures, and incisal and gingival
display should be taken into consideration.21,25
Figure 4: The ideal aesthetic smile arc has the maxillary incisal edge curvature
parallel to the curvature of the lower lip
Changes with ageing: the hard tissue structures
The hard tissue structures that shape the perioral complex
include the mandible, the maxillary bone and the dentition.
These bony components are central to the overall facial threedimensional contour of the face and suspension of the soft
tissues. The ageing process affects all of these structures.
Genetics, occlusal relationship (the relationship between upper
and lower teeth), dental integrity, midface development and
skeletal maturity are some of the factors that influence skeletal
ageing. Therefore, the rate of skeletal ageing varies in different
individuals.7,26,27
The maxilla
Studies have shown that ageing results in:
· Maxillary retrusion in both dentate and edentulous individuals, in
both men and women16,28
· Changes in the bony contour of maxilla: The maxilla rotates
clockwise26
Decrease in the maxillary angle and height may play a role in the
malar fat pad moving down and forward. This results in a posterior
positioning of the upper lip and deepening of the nasolabial folds.28
The mandible
The mandible is the structural foundation of the lower face. Any
changes in the dimensions of the mandible will affect the overall
Aesthetics Journal
aesthetic of a patient’s face.
Studies have shown that with
ageing:9,16,26,29
· The ramus height and
mandibular body length
decreases significantly as both
Figure 5 – Perioral ageing: Volume
loss, loss of skin elasticity, soft-tissue
men and women get older,
atrophy, loss of bony support and
therefore decreasing chin
projection. Loss of mandibular volume
also means decreased support of the
projection
soft tissues and may contribute to laxity
· The bigonial width does not
of platysma.
change significantly
· The mandibular angle increases in both genders, this may result in
blunting or the loss of jawline definition
· Loss of mandibular volume contributes towards laxity of platysma
and soft tissues of the neck
The dentition
Chronological tooth wear may result in flattening of the incisal
edges, and consequently adversely affect the smile arc. Tooth loss
affects the thickness of cortical bone; edentulous patients suffer from
significant cortical bone loss and maxillary and mandibular alveolar
ridge resorption. This is more pronounced in the mandible than
maxilla, and more in women than men, and results in reduced lower
face height.30 Tooth loss from the lateral areas of the jaw can result
in narrowing of the face and hollowing of the cheeks, whilst loss of
anterior teeth will produce a concave profile.31 Severe tooth wear
can also reduce the vertical dimension of the lower face. Dentures
affect the position of soft tissues and lips, and have a direct effect on
the lower face height.27,29
Changes with ageing: the soft tissue structures
Skin
The most important environmental insult that contributes to the agerelated clinical changes in skin (changes in colour, surface texture,
and functional capacity) is chronic solar exposure. Photoageing
is distinct from intrinsic or chronologic ageing. Chronologically
aged skin shows epidermal thinning, with flattening of the dermalepidermal junction and loss of collagen, which results in increased
water loss and decreased elasticity of the skin. Drier skin is also
the result of reduced water binding capacity and sebaceous gland
activity.9 Loss of skin elasticity and volume, in addition to repeated
perioral muscle activity, contributes to perioral rhytides.5
Fat compartments and the perioral muscles
Facial fat is divided into deep and superficial compartments
and planes. With ageing, the perioral fat compartments become
lipodystrophic and ptotic.8 There is a superficial fat compartment
characterising the philtrum, which has a particular vascular
anatomy.32
With ageing, the malar fat pad descends and overlaps medially and
inferiorly over the firmly attached retaining ligament and creates a
fold.8 Ptosis of the chin pad, mandibular resorption and lip depressor
muscle function, contribute to a prominent labiomental crease.9
The mandibular septum separates the jowl from the submental
fat and is adherent to the body of the mandible. The recession of
this septum with the ageing mandible results in soft tissue rolling
over the border of the mandible.23 Orbicularis oris atrophy, in
combination with thinning of the overlying skin, results in formation of
vertical rhytides above the vermilion border. This is made worse by
smoking.18
@aestheticsgroup
Aesthetics Journal
Ageing of the lip
framework
Structural changes with
age
Changes in lip
morphology during
ageing include the
position of the lip
Figure 6 – Perioral ageing: The upper lip
lines, a decrease in lip
loses its volume, lengthens and inverts; the
lower becomes thinner and rolls inward. The
volume and thickness
intercommissural width becomes longer and
(degeneration of elastic
commissures droop. The vermilion border
and philtral columns become thinner; there
and collagen fibres), lip
is flattening of the vermillion border and
tonicity, changes in lip
partial loss of Cupid’s bow; perioral rhytids
become apparent and the nasolabial folds and
length and retraction
labiomental folds become more noticeable.
of the lips. On average,
there is 2-4mm increase in upper lip length with age.2 It has been
observed that the natural curves of the lips are lost through ageing
and lip dryness is shown to be statistically more marked in aged
women. The lower lip becomes dominant over the upper lip and
is more noticeable in women. Vertical wrinkle lines start to appear
during the fourth decade of life but become more visible during
the fifth decade (there have been some suggestions that this
corresponds to menopause).11 The commissures descend and
inter-commissural distance increases with age.11
Changes in dynamic of lip movement with age
In a youthful and harmonious smile, the maxillary incisors should
be visible and exposed by the upper lip by 2-4mm at rest. On
smiling, the entire crown of the maxillary incisors and up to 2mm of
associated gingiva should be exposed.
Aesthetics
therefore less display of incisors
· We see increased intercommissural width at rest
· The buccal corridor increases
Figure 7: The images depict how, with ageing, the smile becomes wider
transversely and narrower vertically, showing less maxillary teeth. In addition,
the buccal corridor space increases. Older individuals tend to smile with the
lower lip covering the maxillary anterior incisal edges.
Conclusion
The focus of human communication is the face, thus it is key to
social interaction and the perception of attractiveness. The correct
soft-hard tissue balance is important for achieving and maintaining
a pleasing aesthetic appearance and function.
Better understanding of facial ageing leads us towards a threefold facial rejuvenation technique: restoring volume (loss of
bony volume), lifting and reducing the soft-tissues and skin
rejuvenation. Advanced rejuvenation involves multidisciplinary
treatment and may necessitate dental restorations or plastic
surgery. Overfilling and volumising where there is advanced bone
resorption or dental problems may lead to undesirable aesthetic
results. Likewise, perioral rejuvenation without midface correction
is not recommended as this can result in an unnatural look.
Dr Souphiyeh Samizadeh is a dental surgeon with a
special interest in aesthetic medicine. She is an honorary
clinical teacher at King’s College London and the clinical
director of the Revivify London clinic. She has presented
at both national and international conferences, and is
actively involved with research into aesthetic medicine.
As a result of ageing:11,32,33
· The smile gets narrower vertically and wider across
· There is a decreased display of maxillary anterior teeth
· Exposure of mandibular anterior teeth increases
· There is a reduction in the muscles’ ability to raise the upper lip,
REFERENCES
1. Wollina, U., ‘Perioral rejuvenation: restoration of attractiveness in aging females by minimally invasive procedures’. Clin Interv Aging, 2013. 8: p. 1149-55.
2. Van der Geld, P., P. Oosterveld, and A.M. Kuijpers-Jagtman, ‘Age-related changes of the dental aesthetic zone at rest and during spontaneous smiling and speech’. The European Journal of Orthodontics, 2008. 30(4): p. 366-373.
3. Robinson, P.G., ‘Summary of: The influence of tooth colour on the perceptions of personal characteristics among female dental patients: comparisons of unmodified, decayed and ‘whitened’ teeth’. Br Dent J, 2008. 204(5): p. 256-257.
4. AL-DREES, A.M., ‘Oral and perioral physiological changes with ageing’. Pakistan Oral & Dental Journal, 2010. 30(1): p. 26-30.
5. Desai, S., M. Upadhyay, and R. Nanda, ‘Dynamic smile analysis: changes with age’. American Journal of Orthodontics and Dentofacial Orthopedics, 2009. 136(3): p. 310. e1-310. e10.
6. Ferrario, V.F., et al., ‘Sexual dimorphism in the human face assessed by euclidean distance matrix analysis’. Journal of Anatomy, 1993. 183(Pt 3): p. 593-600.
7. Coleman, S.R. and R. Grover, ‘The anatomy of the aging face: volume loss and changes in 3-dimensional topography’. Aesthet Surg J, 2006. 26(1s): p. S4-9.
8. Rohrich, R.J. and J.E. Pessa, ‘The fat compartments of the face: anatomy and clinical implications for cosmetic surgery’. Plastic and reconstructive surgery, 2007. 119(7): p. 2219-2227.
9. Zimbler, M., M. Kokoska, and J. Thomas, ‘Anatomy and pathophysiology of facial aging’. Facial plastic surgery clinics of North America, 2001. 9(2): p. 179-87, vii.
10. Klein, A.W., ‘In search of the perfect lip: 2005’. Dermatologic surgery, 2005. 31(s4): p. 1599-
1603.
11. Leveque, J.L. and E. Goubanova, ‘Influence of age on the lips and perioral skin’. Dermatology, 2004. 208(4): p. 307-13.
12. Masood, Y., et al., ‘Impact of malocclusion on oral health related quality of life in young people’. Health Qual Life Outcomes, 2013. 11: p. 25.
13. Naini, F.B. and D. Gill, ‘Facial aesthetics: 2. Clinical assessment’. DENTAL UPDATE-LONDON-, 2008. 35(3): p. 159.
14. Ahmad, I., ‘Anterior dental aesthetics: Dental perspective’. Br Dent J, 2005. 199(3): p. 135-141.
15. Ahmad, I., ‘Anterior dental aesthetics: Dentofacial perspective’. Br Dent J, 2005. 199(2): p. 81-88.
16. Mendelson, B. and C.H. Wong, ‘Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation’. Aesthetic Plast Surg, 2012. 36(4): p. 753-60.
17. Prendergast, P., ‘Facial Proportions’, in Advanced Surgical Facial Rejuvenation, A. Erian and M.A. Shiffman, Editors. 2012, Springer Berlin Heidelberg. p. 15-22.
18. Penna, V., et al., ‘The aging lip: a comparative histological analysis of age-related changes in the upper lip complex’. Plastic and reconstructive surgery, 2009. 124(2): p. 624-628.
19. Perkins, S.W. and H.D.t. Sandel, ‘Anatomic considerations, analysis, and the aging process of the perioral region’. Facial Plast Surg Clin North Am, 2007. 15(4): p. 403-7, v.
20. Klein, A.W., ‘In Search of the Perfect Lip: 2005’. Dermatologic Surgery, 2005. 31: p. 1599-1603.
21. Naini, F.B. and D.S. Gill, ‘Facial aesthetics: 2. Clinical assessment’. Dent Update, 2008. 35(3): p. 159-62, 164-6, 169-70.
22. Sarver, D.M., ‘The importance of incisor positioning in the esthetic smile: the smile arc’. Am J Orthod Dentofacial Orthop, 2001. 120(2): p. 98-111.
23. Frese, C., H.J. Staehle, and D. Wolff, ‘The assessment of dentofacial esthetics in restorative dentistry: a review of the literature’. J Am Dent Assoc, 2012. 143(5): p. 461-6.
24. Sarver, D.M., ‘The importance of incisor positioning in the esthetic smile: The smile arc’. American Journal of Orthodontics and Dentofacial Orthopedics, 2001. 120(2): p. 98-111.
25. Ahmad, I., ‘Anterior dental aesthetics: Facial perspective’. British dental journal, 2005. 199(1): p. 15-21.
26. Shaw, R.B., Jr., et al., ‘Aging of the mandible and its aesthetic implications’. Plast Reconstr Surg, 2010. 125(1): p. 332-42.
27. Wulc, A.E., P. Sharma, and C.N. Czyz, ‘The anatomic basis of midfacial aging’, in Midfacial Rejuvenation. 2012, Springer. p. 15-28.
28. Shaw Jr, R.B. and D.M. Kahn, ‘Aging of the midface bony elements: a three-dimensional computed tomographic study’. Plastic and reconstructive surgery, 2007. 119(2): p. 675-681.
29. Bartlett, S.P., R. Grossman, and L.A. Whitaker, ‘Age-related changes of the craniofacial skeleton: an anthropometric and histologic analysis’. Plast Reconstr Surg, 1992. 90(4): p. 592-600.
30. Bodic, F., et al., ‘Bone loss and teeth’. Joint Bone Spine, 2005. 72(3): p. 215-221.
31. Sveikata, K., I. Balciuniene, and J. Tutkuviene, ‘Factors influencing face aging. Literature review’. Stomatologija, 2011. 13(4): p. 113-6.
32. Garcia de Mitchell, C.A., et al., The philtrum: ‘anatomical observations from a new perspective’. Plast Reconstr Surg, 2008. 122(6): p. 1756-60.
33. Van der Geld, P., P. Oosterveld, and A.M. Kuijpers-Jagtman, ‘Age-related changes of the dental aesthetic zone at rest and during spontaneous smiling and speech’. Vol. 30. 2008. 366-373.
Advertorial
NeoStrata
@aestheticsgroup
Aesthetics Journal
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“Our research goes
on in our labs for
ingredients we plan
to use for the next five,
ten, fifteen years”
Leigh Ann Catlin
Catherine Mueller
NeoStrata’s Vice President of International Business Development
Leigh Ann Catlin, and Executive Director of International Markets
Catherine Mueller, explain why an evidence-based approach is central
to the skincare company’s ethos
What makes NeoStrata stand out as a skincare company?
Leigh Ann Catlin (LC): NeoStrata is totally unique as a cosmetic
company for a couple of reasons. One is that we have several
laboratories in our offices. We have a cell culture lab where we
screen for various ingredients to measure their efficacy in treating
the conditions that we want them to treat – this is where we actually
grow and foster cells. We also have a standard research lab, where
we do research on ingredients that we’re interested in using. We also
have our own formulation research and development laboratory, with
a full team of scientists that carry out research on our formulations.
So although a small cosmetic company, we research the active
ingredients that we want to use and we also develop our own
formulations. NeoStrata is also unique in the way that we do extensive
testing on our products. A doctor recommending our product, or a
consumer using our product, can feel very confident that the claims
that we make about our products and the things that we say that they
do, they do. And we have the clinical studies, the data, and the before
and after pictures to back up and support the claims that we make.
How important is continuous research and development
for NeoStrata?
Catherine Mueller (CM): That’s extremely important. Historically we
are known worldwide as the AHA (Alpha Hydroxy Acid) brand, but
although we continue to use AHAs in our formulations, we have
researched other new compounds. We’ve gone from AHAs to Poly
Hydroxy Acids, and, specifically, Gluconolactone. We then went
to Complex Poly Hydroxy Acids, later using Lactobionic Acid and
now Maltobionic Acid. In the past five years, we’ve started to use
NeoGlucosamine, which is a non-acid anti-ageing ingredient with great
plumping and pigment-evening properties. In our latest technologies,
we’ve used the amino acid Amino Fill, which is a non-acid technology
– we’ve used this in our latest Skin Active Line Lift for targeted
treatments to further enhance the plumping, the collagen building and
the production of GAGs (Glycosaminoglycans) in the skin. And these
are just the ingredients we’ve commercialised over the past 27 years
as a company; our research goes on in our cell culture lab and our
54
standard lab for ingredients we plan to use for the next five, ten, fifteen
plus years.
LC: Research is really the heritage of NeoStrata. It’s really important
to Dr Van Scott and Dr Yu (NeoStrata founders Dr Eugene J. Van
Scott and Dr Ruey J. Yu, who discovered AHAs back in the 1970s) to
continue researching and to discover new ingredients that can help
people’s skin.
Why does NeoStrata appeal to aesthetic professionals?
LC: I think aesthetic professionals can see that NeoStrata has a base
of clinical studies and effective products that really work. We have a lot
of doctors that say they use the products themselves, so they feel very
comfortable recommending them to their patients.
CM: They embrace the science that’s behind it. When the doctors
ask the questions, we have the answers, and we can prove it. They
also then feel confident that if they’re going to use our products and
recommend them to somebody, they fully understand them as well.
What’s the future for NeoStrata?
CM: Dr Van Scott always says that we have great formulations and
they do great things, but he says the best is always yet to come. And
he’s so excited about that! Helping people improve whatever condition
they’re trying to improve in their skin, helping them feel more confident
in themselves, that’s a great place to be in. What’s great is that our
brand really does cross all ages, all generations and all conditions,
from pigmentation, acne, fine lines and wrinkles, to dry skin, sensitive
skin and rosacea.
LC: The one thing that’s for sure is that NeoStrata Company will
continue its research. There are many things in the pipeline; there
are lots of ingredients and substances that we are researching now
that will be used in future products. NeoStrata Company is a really
exciting thing to be a part of.
NeoStrata is distributed in the UK by AestheticSource.
For more information contact [email protected] / 01234 313130
Aesthetics | April 2015
@aestheticsgroup
Aesthetics Journal
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A summary of the latest
clinical studies
Title: Evolving Perspectives on the Etiology and
Pathogenesis of Acne Vulgaris
Authors: LF Eichenfield, JQ Del Rosso, AJ Mancini, F
Cook-Bolden, L Stein Gold, S Desai, J Weiss, D Pariser, J
Zeichner, N Bhatia, L Kircik
Published: Journal of Drugs in Dermatology, March 2015
Keywords: Acne, development, topical/oral antibiotics
Abstract: As the pathophysiology of acne is complex and
multifactorial, the continued influx of new basic science and
clinical information requires careful analysis before drawing
conclusions about what truly contributes to the development
and progression of this chronic disease. Our objective is
to review the latest evidence and highlight a number of
important perspectives on the pathophysiology of acne.
An improved understanding of acne pathogenesis should
lead to more rational therapy and a better understanding
of the role of P acnes opens new perspectives for the
development of new treatments and management. Further
research may be directed at targeting receptors, adhesion
molecules, cytokines, chemokines or other pro-inflammatory
targets implicated in the activation of immune detection
and response (i.e., toll-like receptors [TLRs], proteaseactivated receptors [PARs]) that appear to contribute to the
pathophysiology of acne. Therapeutic options that reduce the
need for topical and/or oral antibiotic therapy for acne are
welcome as bacterial resistance to antibiotics is a clinically
relevant concern both in the United States and globally.
Title: Laser treatment of periocular skin conditions
Authors: B Yates, SK Que, L D’Souza, J Suchecki, JJ Finch
Published: Clinics in Dermatology, March 2015
Keywords: Lasers, lesions, periocular, resurfacing
Abstract: Advances in laser technology in recent
decades have increased the options for the treatment of
dermatologic conditions of the eye and eyelid. Benign
tumors can be laser-ablated with relative ease, and vascular
and melanocytic lesions can be precisely targeted with
modern lasers. In this contribution, we review treatment of
periocular pigmented lesions, including melanocytic nevi
and nevus of Ota; vascular lesions including telangiectasias,
port wine stains, and infantile hemangiomas; hair removal;
eyeliner tattoo removal; laser ablation of common benign
periocular tumors, such as syringomas, xanthelasma, milia,
and seborrheic keratoses; and laser resurfacing. The recent
advent of fractionated laser technology has resulted in
dramatically decreased healing times for periocular skin
resurfacing and fewer adverse effects. Fractionated laser
resurfacing has now nearly supplanted traditional full-field
laser resurfacing, and safe treatment of rhytides on the thin
skin of the eyelids is possible. Proper eye protection is, of
course, essential when using lasers near the eye. Patient
preparation, safety precautions, and risks-intraocular and
extraocular-are discussed herein. As laser technology
continues to advance, we are sure to see improvements
in current treatments, as well as development of new
applications of cutaneous lasers.
Title: Fractionated carbon dioxide laser therapy as
treatment of mild rhinophyma: report of three cases
Authors: AA Meesters, MM van der Linden, MA De Rie, A
Wolkerstorfer
Published: Dermatology and Therapy, March 2015
Keywords: Rhinophyma, rosacea, laser therapy
Abstract: Rhinophyma is a bothersome condition of the
nose that is regarded as a manifestation of rosacea (subtype
3). Whereas the efficacy of medical treatments, including
antibiotics and retinoids, is often dissatisfying, conventional
invasive procedures are limited by their unfavorable side
effect profile. We present three patients who were treated
by a minimally invasive approach using fractionated carbon
dioxide (CO2 ) laser therapy, showing variable response.
We observed that fractionated CO2 laser therapy may
improve patient-reported outcome in some patients with
mild rhinophyma and is associated with a relatively favorable
side effect profile compared with conventional surgical
techniques.
Title: A randomized, controlled clinical study to investigate
the safety and efficacy of acoustic wave therapy in body
contouring
Authors: AH Nassar, AS Dorizas, A Shafai, NS Sadick
Published: Dermatologic Surgery, March 2015
Keywords: Body contouring, acoustic wave therapy, lateral
thigh
Abstract: There is an increased demand for the reduction
of localized adipose tissue by noninvasive methods. The
objective of this study was to determine the safety and
efficacy of noninvasive lipolysis of excess adiposities
overlying the lateral thigh region using acoustic wave therapy
(AWT). This study incorporates 2 mechanical waves with
varying properties in the same session: radial and planar
AWT. The treatment was performed using AWT on the
lateral thigh areas of 15 female patients. The study was
performed using the planar and radial pulse handpieces,
with 8 sessions performed within 4 weeks. Follow-up visits
were performed 1, 4, and 12 weeks after the last treatment.
Reduction in both thigh circumference and subcutaneous fat
layer thickness, measured through ultrasound, was observed.
This study demonstrates that AWT is safe and efficacious
for the treatment of localized adiposities in the saddlebag
area. However, the results obtained were not statistically
significant. Larger studies will be needed to further access
the effects of AWT on thigh circumference reduction.
Furthermore, the authors also found an improvement in
the appearance of both cellulite and skin firmness after the
treatments.
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other clinics and capture the consumer’s attention. The simplest way
to do this is through package names and creatively named treatments
or treatment zones. For example, if you simply say, “Get in Shape for
Summer with the Latest Body Contouring Treatments” it’s bland, but
if you created a ‘Bikini Beach Body Menu’ of treatments, it engages
readers and suddenly comes to life. For example:
Creating a
Summer
Marketing
Campaign
Charlotte Moreso explores the
benefits of seasonal marketing
and shares practical tips on how
to entice patients into your clinic
during the summer months
Summer provides a huge opportunity to enhance your aesthetic
practice, but your marketing must be planned well in advance. Miss
the season by a week or two and your competitor might just snatch
up your potential business. Methods of marketing are boundless, and
it’s often a minefield to decipher which of these might work best for
your business and within your budget. This guide aims to help you
decide which avenues might be best for enticing new patients to
your clinic, whilst capturing the attention of your current patient base
and extending their treatment preferences. Above all, though, your
communication methods must be creative. Patients respond best to
interesting tag lines, innovative treatments and eye-catching imagery
as much as if they were exploring the latest fashion.
Marketing preparation
Timing: Forward planning is critical in order to capture business. Reach
patients with your messaging and offers in the spring, when they are
starting to think about ‘bikini-body’ season, then consistently target
them with updated information and messaging.
The Science: You may respond to the intricacies of the latest aesthetic
technology, but the average patient will not. They will want to know
how it works, how long until they see results, whether it will it hurt,
and prices – so don’t blind them with science. Think of those beauty
adverts that proclaim, ‘The Science Bit’ at the end of the advert and aim
for the same level of information when marketing to your patients.
The First Steps: Before you do anything, look at your treatments and
list what aspects of the body patients will be hoping to improve this
summer. Your list will usually include laser hair removal, sun protection,
body contouring, fat reduction, cellulite treatments, stretch mark
treatments and facial treatments to even out the complexion so that
they can ‘go bare-faced’ on the beach. Once you have your definitive
treatment list, it’s time to get creative. You need to stand out from the
The Bikini Bottom Treatment: Let us sculpt your derriere into the
perfect beach peach with just six pain-free radio frequency treatments
The Bikini Belly Treatment: Just two fat freezing treatments will
have you ditching your swimming costume and dusting off your
favourite bikini
The Beachy Bingo Wing treatment: Wave without the wobble in just
six weeks
Lovely Lasered Legs: Want to be smooth and fuzz free this summer?
Ditch the razor and love the laser!
Being creative with language does not undermine the seriousness of
the treatments; it’s a way of capturing attention and enticing patients
to enter your clinic, where they will then receive thorough consultation
and can be provided with any relevant literature on the treatment in
question.
Create a consistent campaign
Create the strap line for your summer treatment campaign and stick to
it. Use this throughout all communication. A strap line is the title of the
campaign that would be used in press releases and in all marketing
materials. This could be something like, ‘xx Clinic Beach Body Beautiful
Treatments’. Public Relations (PR) and marketing tools could comprise:
• A window sticker for your clinic
• Posters
• Leaflets that display the treatment menu
• Roll-up banners
• Press releases for journalists
How to reach new patients
Post office mailings, a marketing service provided by the Royal Mail
that sees your marketing materials delivered to the door of selected
recipients, can offer a very good return on investment and are
straightforward to carry out. You are able to pick exact postal drop
zones, targeting people in exactly the area you wish, for what is
essentially a nominal amount of money. Once you have selected the
area it is critical that the promotional material looks good and stands
out from other free post. Make it beautiful and something patients
will want to pick up and not just throw away. An aesthetically pleasing
image one side and treatment menu on the reverse with your clinic
details is sufficient. Offer a free taster treatment and the phones will
start ringing. You can send materials in envelopes or alone, but placing
it in a good quality coloured envelope could become more enticing to
the recipient, and is a unique idea if the budget allows.
Summer treatment open days
I have witnessed immense success from open days, with patients
queueing to pay for bookings – but open days only work if you get
them right. Here’s the magic formula for filling the diary with bookings:
What: Open your clinic for a day or afternoon and evening to all your
patients and potential new patients, offering free taster treatments from
your summer treatment menu. Also ensure you have a few ‘models’
to perform demonstrations on in quieter spells, as this often attracts an
audience. When conducting these tasters, leave treatment doors open
so people can see what is going on inside. It soon draws a crowd.
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Botulinum toxin and its
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Dates: Tuesday 2 June and Wednesday 8 July
Venue: Royal Society of Medicine, London
CPD: 6 credits
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Non members £799
Botulinum toxin and dermal fillers
course – intermediate (Manchester)
Dates: Saturday 13 - Sunday 14 June
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Venue: Manchester (Venue TBC)
CPD: 12 credits (6 per day)
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Non members £649 - £1,399*
*please note, one and two day rates available
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Contact details:
Telephone: 0207 290 3928
@aestheticsgroup
Aesthetics Journal
When: April or May is a good time, but avoid school holidays as
potential patients who are also busy parents may be unable to attend.
Deals: Create good value package offerings, redeemable only if they
book on the day. This ensures immediate booking without the risk of
losing their interest once they have walked away. Of course, it is vital
that you adhere to Keogh’s recommendations when marketing these
clinic ‘deals’. It was stated in the Keogh Review that, “advertising and
marketing practices should not trivialise the seriousness of procedures
or encourage people to undergo them hastily.”1 Offering time-limited
deals, financial inducements, cosmetic procedures as competition
prizes and package deals such as ‘buy one get one free’ or ‘refer a
friend’ should be avoided.
Goody Bag: Contact the suppliers of your brands and ask them to
donate some mini-samples to the goody bag – everyone loves a
freebie!
Adding Luxury: Serve canapés, sparkling wine when appropriate and
healthy juices.
How: Create a postcard-sized flyer with details of the event on the
front, and treatment menu on the reverse, that can be mailed out to
homes in your local area. Go online and buy a stock image (from a
stock photography website) of a good bikini body to capture attention,
and ensure your flyer contains the following information:
• Invitation to preview/experience the Must-Have Summer Bikini Body Menu at your clinic
• Menu of Taster Treatments
• Complimentary Taster Treatments
• When and where
• Special Offers
• Goody Bag for every attendee
• RSVP to reserve your place
Press Reviews: Use the same menu of treatments to invite your local
press to try out full-length versions for reviews in the local magazines
and newspapers. If possible, avoid inviting them to the consumer open
day, as they like to be treated on a one-on-one basis and expect the
full treatment or a course of treatments in order to write a thorough
review. If you advertise with local magazines or newspapers you should
try and use this to your advantage in order to secure editorial reviews.
Depending on the publication, try and negotiate editorial reviews when
you book any advertising; alternatively, develop a good relationship
with the editorial team at the publication and they will naturally be more
inclined to write about your event and the treatments you provide.
What not to do
When creating your summer marketing campaign, don’t…
Sell too hard: We all know when we are being sold to,
so keep it subtle and targeted towards what patients
really need
Do a press launch: Unless you have something 100%
unique to tell journalists about. They are time-poor and
getting them out of the office can be tricky. One-to-one
invites set at a time that is convenient for them often
work better
Devalue your clinic: Too many offers might actually
work against you. You want to be seen as the more
advanced clinic, not necessarily the cheapest
Overwhelm patients with too much science: Just
because it’s a technical device doesn’t mean they want
to read all the techy information
Aesthetics
Successful summer campaigns
A recent summer campaign I was involved with was for a worldleading aesthetic beauty company where we promoted all their
body devices, both existing and new, at a press event in London.
The campaign, entitled ‘Body Beautiful’, was divided into two clear
areas: Skin Perfecting and Body Perfecting. Skin Perfecting included
treatments for stretch marks, veins, tattoo removal and body scars and
Body Perfecting included treatments for fat, cellulite and skin laxity. My
team enlisted leading UK aesthetic doctors and experts to present
both the ‘Facts & Fix’ for each issue at the press event. A Little Black
Book of Body Beautiful was written, detailing each presenter’s topic,
and this was given to the UK’s top 500 health and beauty writers as
a resource for their articles. The event took place mid-January, when
editors and journalists were working on their early summer issues.
To add theatre to the event we had a male and female model spray
painted gold and silver to signify the concept of ‘Body Beautiful’.
This doubled up as a social media tool, where journalists tweeted
novelty shots of themselves with the models. The most successful
summer-themed PR and marketing campaign we have created
was for a leading laser hair removal device. Their Unique Selling
Point (USP) was that all skin colours and most hair colours could be
treated. We therefore created a consumer-focused campaign called,
‘No Shades Barred’. Creative marketing materials were developed
using a block of facial images illustrating all the different skin and hair
colours on their laser spectrum. This eye-catching image was placed
onto roll-up banners, posters, leaflets and window stickers. A press
pack was created and included in a marketing guide sent to all the
clinics using the laser. This enabled the clinics to send the pre-written
press releases to their local newspapers and magazines, and refer
to our guide on how to best communicate with journalists. The pack
also detailed how to order the different marketing materials. The
campaign materials were up-taken by many clinics and the campaign
images were used online as well. This campaign won Best Consumer
Campaign 2013 at the Aesthetic Awards.
And don’t forget…
Use any press coverage you receive to best effect. Consumers love to
see your name in the media, so scan it and post on Facebook, Twitter
and your website or if the piece is particularly good, produce an e-mail
flyer and send to your patient list. Many clinics also produce coverage
books or create montages of their coverage as a poster or postcard,
which can be displayed in reception. Also see what support the PR
agencies that represent the aesthetic device companies can offer you.
They may provide you with press releases or ideas on how to market
the treatment to patients.
The three C’s
In summary, be creative, consistent and think consumer, consumer,
consumer. Tell patients what they’d want to know, rather than what
you’d want to know.
Charlotte Moreso is managing director of True Grace PR.
Charlotte has worked as a PR and marketing consultant
in the health and beauty industry for more than 20
years, running highly successful campaigns for global
commercial brands, smaller UK beauty brands and in more
recent years, creating news for the UK’s leading aesthetic treatments,
doctors and clinics. Her work has won several industry awards.
REFERENCES
1. Department of Health, Review of the Regulation of Cosmetic Intervention (England: GOV.UK, 2013) https://www.gov.uk/government/publications/regulation-of-cosmetic-interventions-government-
response [accessed 23 March 2015].
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Aesthetics Journal
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went, but you can rectify the situation. Use marketing strategies
to attract them back to your clinic: an exclusive, limited-time offer
with free taster sessions that showcase treatments needing regular
clinic visits for optimum results. Provide results-driven treatments
that patients can see and feel instantly – this will keep them
coming back for more, and encourage them to book a course of
treatments. Provide these ‘taster treatments’ on a usually quieter
day, give it an appealing name and encourage them to bring
friends to your new, say, ‘Love Your Skin Days’.
Maintaining
Patient Loyalty
Pam Underdown extols the value
of offering VIP service to encourage
patients back into your clinic
“You are the best and I will recommend you to everyone!”
These are the words practitioners should want to hear from every
patient. To achieve such acclaim, it is vital that you put the time
and effort into making sure your patient experience is beyond
compare from beginning to end. This patient has chosen you and
your clinic because, in an increasingly busy, stressful world where
time is precious, you are able to connect with them simply by
listening and caring enough to give them what they really want – a
treatment and service that makes them feel valued and special. The
aesthetic patient that feels a bond with you and your clinic is your
walking, talking testimonial. Retaining this bond is crucial. This can
be done in a multitude of ways, primarily through rewarding existing
patients for their continued loyalty, providing unparalleled service
and reconnecting with past patients. The best way to maintain this
relationship is by enhancing the patient experience; giving them the
‘wow’ factor that keeps them coming back for more.
Are you a one hit wonder?
If you spend all of your time, money and effort attracting a new
patient and then never see them again, you are doing them and your
business a disservice. If the patient felt confident enough in you to say
yes initially, the hard part is done. The least you can do is reciprocate
by staying in touch and following up with how they are. It’s always
faster, cheaper and easier to reconnect with previous patients than it is
to attract new patients, so do your best to maintain connections.
You are never going to know why you lost patients, unless you
reach out to them
Chances are you lost some patients last year. Perhaps you can’t
say for sure how many you lost, why you lost them or where they
Get all your basics right
There’s a big difference between a ‘need’ and a ‘want’. A need is
just what must be done, and your patient has very little emotional
attachment to it. Meeting his or her needs won’t necessarily turn
the individual into a long-term loyal patient. A want is different.
There’s a reason why your patient desires something and this is
often loaded with emotion. Explore their real reasons for seeking
aesthetic consultations and reflect their own use of emotional words
when presenting their individualised treatment plan. This way, your
patient will know that you have listened and are now offering a
personalised answer and treatment tailored to their wants. Another
way of providing an individualised solution that suits the patient’s
needs is to offer an annual treatment plan with monthly affordable
payments, perhaps using a monthly online recurring direct debit
system. Patients benefit in terms of spreading the cost of treatment,
but to use this type of system your business needs to already be
profitable. You must decide if this is of real value to your particular
patient base and makes business sense for your clinic.
However, ensuring return business is not about doing one or
two big things; it’s doing a hundred little things with care and
consistency, with every single patient and every single visit.
Anything that is meaningful, memorable, fun, unusual or unexpected
will influence how patients feel about you and your clinic. Train your
team to give outstanding service. Don’t accept mediocre results
from your team and before long you’ll be attracting the staff that
don’t want mediocre results either. Motivate your team through
regular meetings, training and team building sessions to keep
morale high and reach your targets, thereby ensuring patients are
consistently satisfied. Training should not just cover the clinical
aspects of an aesthetic practice, but also brush up on business and
customer service skills; skills that guarantee your patients leave
your clinic in high spirits.
Ensuring return business
is not about doing one or
two big things, it’s doing a
hundred little things with
care and consistency, with
every single patient and
every single visit
@aestheticsgroup
Communicate and live by your ‘Patient Promise’
Your promise doesn’t need to be long; it just needs to explain what
patients can consistently expect, why you’re different and how you
keep your promises. Testimonials from existing, loyal patients that
relate to your promise can be used as marketing material for new
patients and reinforce your clinic’s positive image. For consistent
results you need effective systems and processes in place, as well
as the standards and measurements so you know whether your
patient promise is being delivered every single time – regardless
of which staff member your patients sees, what day they have
had or their mood. In order to implement effective systems and
processes (aka protocols) you must first ask yourself what your
goal is with your new ‘Patient Promise’, the vision you are pursuing,
your patients’ expectations, your team’s expectations, what you
do (the system), why you do this and how you do it (the process).
Document each element of your ‘Patient Promise’ using a stepby-step approach and decide which areas need monitoring and
improving (the standards) and how you are going to measure each
one. Will you measure based on emotional benchmarks (so you
know the impact your clinic has emotionally on every patient)? Or
will you measure it by performance (i.e. how quickly your phone
is answered)? Will you measure by financial targets or by patient
feedback? Once fully documented, you can train your team to
The best way to retain
patient loyalty is not to cut
back on costs when times
are tough, but to invest
in the right areas of your
business
implement each standard and ensure that the appropriate team
member is accountable for on-going measurements, improvements
and feedback. You must also include each one in your operations
manual and staff handbook. A simple example of a standard is
the measurement of incoming calls: perhaps your Patient Promise
states that all calls will be answered within two to three rings – in
order to measure that you must carry out the appropriate checks,
either manually or by using call handling software to ensure this
standard is met constantly. Remember, your job as the business
owner is to ensure your team knows what’s expected of them. You
must provide the training, measurement and support to guarantee
each standard is consistently achieved. By sticking to your promise,
your business will reap the benefits. Satisfied patients will not only
come back regularly, but will also be more open to giving back,
which may be in the form of providing consent for their treatment
images to be used within your marketing, or offering honest
feedback on your clinical services.
Discovering your VIP patients
Divide your patient database into those who are loyal, those who
visited and never booked, and those who you treated but never
saw again. People can be inconsistent – things change and people
change. I’m sure you’ve heard that 80% of your profits come from
Aesthetics Journal
20% of your patients. It’s called the Pareto Principle (named after
the Italian economist Vilfredo Pareto) and it works just as well today
as it did decades ago.1 The Pareto Principle is very simple, yet very
important, particularly in business. What was most important about
Pareto’s finding was that this 80/20 distribution occurs extremely
frequently. In addition, the principle also suggests that 20% of
your time produces 80% of your results. Your top 20% of patients
provide a consistent revenue stream, and because of their frequent
custom, they require less set-up time. Look for those who have spent
more with you, visited most frequently, referred more patients than
others or those who are very connected in the community. Then
put a ‘fence’ around them to keep them happy, loyal, returning and
referring. With these select number of patients, you should market
to them in a different way, enhance their experience and reward
them so that they feel appreciated. Make them part of your exclusive
VIP Club so they receive extra perks that other patients don’t. Give
them value-added extras such as: same day appointments, regular
VIP patient appreciation events, or a free makeover after every
procedure so they can go right back to their everyday activities.
Another effective way of rewarding these patients could be by
offering them a free monthly skin treatment, a free skin analysis or a
retail discount card. Be creative; you have many options, just ensure
that whatever you are offering is feasible and realistic; you don’t want
to end up disappointing your best customers by failing to deliver on
a promise.
The end goal of this marketing activity is to make these patients feel
special because they are part of your inner circle. The notion of a
‘VIP club’ has a very similar feel to the airline frequent-flyer clubs.
You have a very different flying experience as part of the club –
you get on first, there’s plenty of room for your luggage and you
get more leg-room. It’s a different industry, but the same concepts
apply. People like to feel special and will invest in that feeling. When
a patient feels like they have been rushed through a treatment to
make room for the next patient, they are less likely to feel special
and will probably visit a clinic elsewhere. Capitalise on the idea of VIP
service to ensure your patients are more than satisfied when they
leave your clinic. This will guarantee verbal recommendations and
ensure their return for their future treatments.
If you look after your patients – they will look after your profits
Return patients and referrals are what make a business successful.
Your loyal patients are your brand advocates and should be treated
like gold. Don’t take them for granted. Acknowledge and appreciate
them for what they are – your positive spokespeople who keep
coming back to you again and again, and bring their friends, family
and colleagues. In simple terms, the best way to retain patient loyalty
is not to cut back on costs when times are tough, but to invest in the
right areas of your business; your patients, staff, marketing, education
and continuous improvements to your patient journey. Do this well
and watch your loyal patient base grow.
Pam Underdown is a business growth specialist and the
owner of Aesthetic Business Transformations. She works
exclusively to help medical aesthetic business owners
improve their marketing, increase their profits, reduce their
costs and build a long term sustainable business asset. Pam
has more than 25 years of business development, sales and marketing
experience, including nine years in the aesthetics marketplace.
REFERENCES
1. Lavinsky D, Pareto Principle: How to use it to dramatically grow your business, (Forbes, 2014) < http://www.forbes.com/sites/davelavinsky/2014/01/20/pareto-principle-how-to-use-it-to-dramatically-
grow-your-business/> Last accessed 19 February 2015.
@aestheticsgroup
Aesthetics Journal
Handling a
Legal Complaint
In the January issue of Aesthetics, Dr Askari
Townshend argued the importance of a skilful
and thorough approach to handling potential
litigation. This month, he shares his personal
experience of managing a legal complaint
Hamilton Fraser, the UK’s largest cosmetic
insurer, include ‘top tips on how to avoid a
potential claim’ in the knowledge centre1
on its website:
1. Keep detailed patient notes
2. Keep hold of your patient notes
3. Assess your clients carefully
4. Obtain a full medical history from the patient
5. Patient consent
6. Follow product guidelines
7. Record settings
8. Encourage patient to follow guidance
9. Patient literature
10. Take before and after photos
All of these are important to follow and will
reduce your chance of facing a claim, but
bear in mind that they will not eliminate the
risk – as I have found out to my cost.
After opening my own clinic in 2008,
patients that I had previously treated
followed me. One lady was happy to
travel a more than 100 mile-round trip for
injectable treatments, which I felt was a
compliment to my skills. After a thorough
consultation with this particular patient,
we agreed on Intense Pulsed Light (IPL)
treatment for her mild rosacea. Before
conducting the procedure I discussed each
aspect of the consent form with the patient,
which she signed, took good photographs
of her condition and performed a test
patch. When she attended the clinic for
her rosacea treatments, photographs
were taken on each occasion and a
questionnaire on change in medical history
was completed.
The first four treatments with incremental
increases in energy produced excellent
results. A very small blister did appear
after the second treatment, but this
resolved without consequence. For the
fifth treatment, I increased the energy by
one joule (the smallest increment) – this is
normal practice as the target chromophore
is reduced by the success of previous
treatments. The next day, my patient
contacted me to report that, after treatment,
her face had felt hotter than usual and had
developed blisters, also experiencing a
significant amount of swelling. Without my
knowledge, she had attended her local
A&E department where she was treated
with prednisolone and a topical antibiotic.
Treating patients that are not local is
challenging when there are complications.
Although using modern technology, such
as smart phones, to send and receive
photographs or video calls are useful,
digital communication is no replacement
for face-to-face assessment, being able to
support and provide necessary treatment
or prescriptions. In addition, it is less likely
that you will have colleagues that you can
call upon or refer to.
I gave my patient lengthy advice over the
phone and asked her to keep me informed
of her progress. The next day things had
not settled and were, perhaps, even worse.
She visited her GP and was referred to a
dermatologist who saw her twice in two
days and prescribed oral antibiotics to treat
the complication. During this time I tried to
keep in touch by phone, text and email,
however, after a few days, she stopped
responding to me completely.
Never before (or since) have I come across
such a violent reaction to a light-based
treatment from such a small change in
settings. It was especially unexpected as
my patient had received several previous
treatments, at greater energies than the
one that had caused her blister, with no
significant problems. My patient was
adamant that there had been no recent sun
exposure, changes in medical history or
medication that could have contributed to
the abnormal response.
I immediately stopped using my IPL system
and cancelled all booked treatments. The
self-test used to diagnose any problems
with the device was uneventful and the
company engineer found no faults after
conducting a full service. I contacted the
company’s trainer and two other national
experts who used the same system but
none could shed any light on why this had
happened. Once my device received the all
clear I started using it again, very cautiously
to begin with, and found no problem with
any other treatments.
I informed the Health Care Commission
(as the Care Quality Commission (CQC)
was known then) and my insurer. With no
channels of communication, there was
nothing more that I could do to help my
patient, which meant I could only wait and
hope that all was healing well.
I received a formal letter of complaint four
months later, to which I replied expressing
my regret at what had happened and
enquired what outcome she hoped for
in order to resolve the complaint. The
patient had seen a dermatologist who
had recommended a course of laser
treatment to correct minor scarring. She
had also discussed the case with a solicitor
and asked for £9,000 in compensation.
Even if I had wanted to, I didn’t have the
money to pay this. Having discussed
this with my insurer I offered a fraction
of this amount, which was declined. The
@aestheticsgroup
excess on my insurance was £1,500, so
offering significantly more than this wasn’t
practical. After the first flurry of solicitor
letters encouraging me to admit liability
(something you must not do without
discussing with your insurer first as it may
be against the policy requirements) we
didn’t hear anything for more than a year.
I thought that perhaps the solicitors had
recognised the quality of my notes and
consent process and had decided not to
pursue the case. This was optimistic as
three years after the procedure had taken
place, her solicitors were in touch once
again.
My solicitors felt that there was a weakness
in our case as I had increased the energy
of the treatment without a prior test patch.
Some practitioners advocate test patches
at the end of each treatment, though, in
reality, this is not a good verification of
treatment response. A single shot is not
comparable to the heat generated from
a full treatment – of course this is not to
be confused with test patches before the
first treatment, or after a significant change
in settings, which are vital. This issue
Aesthetics Journal
Aesthetics
had been discussed at a British Medical
Laser Association (BMLA) meeting I had
attended after the incident, which found
that the majority of members – if not all –
did not routinely test patch before every
minor change of settings. Despite this, my
solicitor felt that a judge may rule that a
test patch could have avoided the injuries
caused – especially as judges are not
always sympathetic towards our speciality.
This was a disappointment as I felt that I
had done all that I could to ensure a safe
treatment, and had not been able to find
any practitioner that felt otherwise.
The result of the process, drawn out across
four years, was a payout to my patient
of £7,000, with an additional £16,000 of
legal costs. The financial cost to me was a
£1,500 excess fee and an increase in my
premiums, which no doubt will take some
years to normalise.
Legal complaints are a stressful time for
all concerned and can last many months,
if not years. During this time it is important
to keep in close contact with your insurer,
especially before communicating with
your patient, to ensure that you do not
do anything to weaken your case or
invalidate your cover. Solicitor letters are
often worrying and use language that may
overstate their position. Try not to take
the process as a personal or professional
attack – a successful claim from a patient
is not always a sign that you have acted
improperly in any way. Treat within your skill
set, with care and diligence, and document
every treatment as if a complication is
expected. Even if you do this, you may
well find yourself having to go through the
claims process – but at least you will have
protected yourself as best as you can.
International trainer and UK
medical consultant for Sculptra
by Sinclair Pharma, Dr Askari
Townshend qualified as a
doctor in 2002 and was awarded
MRCS in 2006. With extensive injectable
experience, Dr Townshend opened his own
clinic in 2008. In 2010, he sold the clinic to
become director of medical services at sk:n
until 2013.
REFERENCES:
1. Hamilton Fraser Cosmetic Insurance, ‘Our top tips on how to avoid a potential claim’, Resources & Guides (2015) <http://cosmetic-insurance.com/wp-content/
uploads/2013/07/hfisc_3721-A52pp-TopTips-v1.pdf> Last accessed: 18 February 2015.
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Aesthetics Journal
“It’s fascinating to see how our
specialty and the industry is
developing across the globe”
Consultant nurse practitioner Constance Campion
tells us about her varied career within aesthetics,
and the values that come first
Hailing from a family of
medical professionals,
becoming a nurse
was a natural career
path for Constance
Campion. “The care of
patients was something
I was often exposed to as a young child,”
she explains, “My grandmother and my
aunt and uncle’s professional standing and
benevolence was particularly noticeable and I
wanted to emulate this.”
In 1972, Campion began her nurse training
at St. Vincent’s University Hospital in Dublin,
after which she studied midwifery at The
Rotunda Hospital. After an early nursing
career, she worked in the private medical
sector and was later headhunted into private
equity. This led to a role as an analyst, where
she became associated with the birth of the
private medical sector in Denmark.
Since 1989, Campion has been a partner
at Plastic Surgery Associates – a plastic,
reconstructive and aesthetic surgery practice
based at Bupa Cromwell Hospital – and went
on to expand this service by founding The
London Wellness Age-Management Centre.
In this time she also founded Medico Beauty
Ltd. and The Medico Beauty Institute, an
aesthetics distribution network and education
company, established in 1998.
Speaking to Campion, it is clear that she
is fiercely passionate about the nursing
profession. “Regretfully, there’s a great
misunderstanding and lack of knowledge
about the specialist nursing role which has
to a great extent undermined the central role
of nurses,” she says. “Nurses are the experts
in patient care and that is not definable or
negotiable in any setting where patients are
placed. As competent nursing care underpins
patient outcomes, it was regrettable that
Keogh did not explore, let alone critically
analyse, the elements of nursing care that
should have been strengthened in the sector.”
Voicing the sentiments and experiences of
aesthetic nurses, says Campion, is something
that needs work. Whilst she is critical of the
Keogh Review, she says the jury is out on the
work of Health Education England (HEE). She
does, however, fully support the work that is
being done by nursing colleagues, who are
representing and piloting the re-validation
work being conducted by the Nursing
Midwifery Council (NMC) and the British
Association of Cosmetic Nurses (BACN).
Campion has recently become the BACN’s
London regional leader, having, alongside
colleagues, first introduced and formally set
out the aesthetic nursing specialism to The
Royal College of Nursing in the early 90s;
subsequently supporting the establishment of
the BACN that followed.
Education, specialist training and ethics are
vital to improving the standing and branding
of our mutual specialism and the aesthetics
industry, argues Campion. “There is a clear
demarcation and distinction between training
and education,” she says. “There is still no
core specialist education available and
aesthetic practitioners have to rely on supply
companies for professional development and
information. There needs to be demarcation
between what constitutes product-training
and what’s generic specialist education.”
Establishing competency standards in
medical aesthetics has been pivotal to
Campion’s work. She chaired the first steering
committee at the Royal College of Nurses
(RCN) and joined her nursing colleagues to
help write registered competencies.
Aesthetic practice is, “A lot tougher than
people think”, she says. “You’re trying to
enhance, rejuvenate, protect and heal – and
this equates to a huge scope of responsibility
to the patient and their family,” she explains.
“You also carry the duty to hold yourself out
as a reliable and competent professional as
a nurse. You really do worry about patients,
about the risks and possible complications,
whilst having to balance this against the
patient’s notion of expectation associated
with their results – it’s always on your mind.”
Reflecting on her career, Campion says,
“Managing to have an entwined career,
where I am an analyst, a businesswoman
and a nurse, has been really rewarding and
interesting. From the perspectives of the
various threads I work in, it’s fascinating to
see how our specialty and the industry is
developing across the globe.” Whilst Campion
acknowledges she is proud of her own
success, she emphasises that her marriage
and family hold more value than anything
else. “My husband and my family have been
pivotal in my make-up and shaped me as a
person,” she says. “I am very grateful and I
don’t deny that hard work and meaningful
choices lead to achievements, but business
and career success can never take away
from the values I am rooted in – my family and
care of my patients are what comes first.”
What treatment do you enjoy giving the
most?
Any treatment related to the skin. I enjoy
facial augmenting and re-contouring. But I
never cease to be amazed by what can be
achieved in the skin.
What technological tool best
compliments your work?
The skin is a very revealing organ and
can be the most amazing tool if you
understand how to assess it. You can
harass its cellular biological regenerative
processes to repair itself. You become far
less reliant on magic wands and devices if
you start first with educating and training in
the cellular aspects of the skin.
What’s the best piece of career advice
you’ve been given?
“When you’ve reached the end of your
rope, tie a knot on it and hang on!”
Do you have any industry ‘pet-hate’?
I don’t like reliance on extrinsic
rejuvenation alone, because it mimics and
limits practitioners to the levels of a beauty
menu. Almost every identifiable issue in
aesthetics that we deal with is also linked
to an intrinsic issue.
What aspects of aesthetics do you enjoy
the most?
Comprehensive-integrated consultation
and assessment, and skin analysis. That’s
one of the busiest processes for us in our
practice, because it sets out the specialist’s
paradigm in patient consultation, which
leads to appropriate treatment choices
and patient care.
@aestheticsgroup
The Last Word
Dr Steven Dayan argues for
patient education in a world of
distorted images
“I’m not happy, look at my phone. My nose is too big.” Are
these words familiar to you? When consulting with a patient, do
we always know which version of the patient we are attempting
to treat – what they see in a mirror, their appearance as we see
it, or their appearance as they see it reflected in the screens of
their phone? Over the last five years, the new craze for ‘selfies’
has exploded in popular culture, sometimes with no regard
for boundaries or borders. It has without a doubt impacted our
consultation process, and maybe even the way we practice
cosmetic medicine. When the president of the US is caught taking
a ‘selfie’ with the prime ministers of Britain and Denmark at a
gathering of global leaders, there is no denying this craze is crosscultural, and adopted by people worldwide.
Yet taking an effective photograph like this is no mean feat.
A photo that is taken close to its object will often enlarge and
distort the portion of the object that is closest to the lens, as
demonstrated when taking a picture with a concave, or ‘fish
eye’ lens. So when the lens of the phone camera is only a few
centimeters away, or the distance of an arm, it makes whatever
feature of the face that it is closest to look biggest. If the camera
is straight on, then the nose looks largest; if from above then the
eyes look greatest; if taken from below then the chin and the
lower one third of the face predominates.
Recent advances in product technology has allowed for the
creation of a device known as a ‘selfie stick’ – a convenient
portrait-pleasing device that is attached to a smart phone to allow
users to take photographs from a distance of one metre. The end
result is a more proportional and flattering facial image. For this
same reason, professional photographs are taken from a distance,
in such a way that all facial features are at a relatively similar
distance from the lens.
In our western society, the female face that is generally considered
attractive is one with a large upper third, one highlighted by
prominent infantile eyes and coupled with a small chin. Our
culture also appreciates sumptuous lips. This is reflected in the
myriad of ‘selfies’ we see, and that are brought to us, where the
patient has taken the photograph from above and is consciously
making the lips seem more prominent. In contrast, patients that
Aesthetics Journal
take a selfie with the camera directly in front of their face notice
a nose appearing bigger and inconsistent to what it is in real
life; a discouraging reality to, say, the recent rhinoplasty patient,
especially when they look in the mirror and are equally discontent
but not sure why. A mirror is a reverse image of what is seen in a
photograph. A bump on the left side of the nose now becomes a
bump on the right side of the nose, and it can get confusing.
Additionally, we tend to be most comfortable with our image in
a mirror because this is the version of ourselves we see most
frequently. But even the physics of a mirror misrepresents from
what others see of us. In a mirror, our facial size is half of what it
is in real life, regardless of the distance you stand from the mirror.
Yet most people believe the dimension of their face is the same
size in the mirror as it is in real life. So our brain compensates,
overestimating facial features.
So we have a mirror and a phone photo that are opposite images
of each other, and both are varied images from what an outside
observer perceives. Therefore when a patient is disappointed
with how they look in a picture, when they tell us that they desire
a smaller nose, which version of the patient are we attempting to
improve? Without clear communication on the shifting parameters of
image taking, this puts us, and the patient, in an Alice in Wonderland
scenario of questioning what is real and who are we treating.
I believe that the best way to address this is to first educate
our patients, pulling out a mirror and a camera phone and
demonstrating the image differences. It’s important to let them
We tend to be most
comfortable with our image
in a mirror because this is
the version of ourselves we
see most frequently
know that while we want to improve their appearance and meet
their expectations, we are also interested in maintaining a natural
appearance, since if we treat only their ‘selfie’ image, we may
inadvertently make their nose too small. We certainly are in a
difficult position where we are tasked with making people look
better naturally, yet also meeting their demands. In my opinion,
part of being a practitioner is to be a teacher, and I think it is
our responsibility to educate our patients, the media and a new
generation of selfie takers about the physics of distorted imagery.
In this evolving modern age, this kind of approach is integral to a
successful consultation, and a successful aesthetic treatment.
Dr Steven Dayan is a facial plastic surgeon who
has had more than 90 articles published in medical
journals and authored five books including Subliminally
Exposed. His accolades include the AMA Foundation’s
Leadership Award. He serves on the scientific and
steering committees of multiple medical congresses, holding an
elected position within his facial plastic surgery society.
REFERENCES
1. Lawson R, Bertamini M. ‘Errors in judging information about reflections in mirrors’, Perception 35(9) (2006) p 1265-88.
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+44 020 8736 4110
[email protected]
www.lumenis.com
colour that will leave skin healthy and radiant.
Soft luminous powder blends effortlessly
Youthful sun kissed glow
Works for all skintones
Boston Medical Group Ltd
Contact: Iveta Vinklerova
+44 0207 727 1110
[email protected]
www.boston-medical-group.co.uk
p
Polaris
Lasers
Medical
Microdermabrasion
From
Contact:
Neil Calder
MATTIOLI ENGINEERING
+44 01234841536
[email protected]
www.polaris-laser.com
Lynton
+44 01477 536975
[email protected]
www.lynton.co.uk
4T Medical
01223 440285
[email protected]
www.4tmedical.com
As featured on
s
m
blowmedia
Creative and Digital Design agency
Contact name: Tracey Prior
[email protected]
0845 2600 207
www.blowmedia.co.uk
needle free
Mesotherapy
Fusion GT
0207 481 1656
[email protected]
www.fusiongt.co.uk
MACOM
Contact: James Haldane
+44 02073510488
[email protected]
www.macom-medical.com
g
c
Tel: 01234 841536
www.polarismedicallasers.co.uk
Med-fx
Contact: Faye Price
+44 01376 532800
[email protected]
www.medfx.co.uk
Galderma Aesthetic & Corrective
Division
+44 01923 208950
[email protected]
www.galderma-alliance.co.uk
Candela UK Ltd
Contact: Michaela Barker
+44 0845 521 0698
[email protected]
www.syneron-candela.co.uk
Services: Adviser (LPA) Services
for the delivery of active
Silhouette
Soft
substances.
Tel. 020 7467 6920
Contact: Emma Rothery
www.silhouette-soft.com
[email protected]
Sinclair Pharmaceuticals
[email protected]
0207 467 6920
www.sinclairispharma.com
z
Cosmetic Insure
Contact: Sarah Jayne Senior
www.cosmeticinsure.com
0845 6008288
[email protected]
70
h
Hamilton Fraser
Contact: Stephen Law
0800 63 43 881
[email protected]
www.cosmetic-insurance.com
Medical Aesthetic Group
Contact: David Gower
+44 02380 676733
[email protected]
www.magroup.co.uk
Aesthetics | April 2015
Zanco Models
Contact: Ricky Zanco
+44 08453076191
[email protected]
www.zancomodels.co.uk
RESTYLANE
SKINBOOSTERS –
SHOW YOUR SKIN
AT ITS BEST
Restylane Skinboosters are a brand new approach to nourishing your skin,
especially designed to deliver lasting moisturisation and improvements in the skin.
Restylane Skinboosters are clinically proven for treating the face, neck, hands,
and décolletage3. Visible improvements to the skin can be seen after a course of
treatments resulting in skin with a radiant glow. A series of tiny injections,
made more comfortable with anaesthetic lidocaine, improves skin
elasticity1, firmness2 and radiance.3
What you and everyone else will notice is fresh and wonderful skin.
IMPROVE YOUR SKIN QUALITY
FOREHEAD AREA
PERIORBITAL AREA
FACE REJUVENATION *
ACNE SCARS
PERIORAL AREA
NECK AREA
HANDS
DÉCOLLETAGE
1. Kerscher M et al. Dermatol Surg 2008;34:1–7
2. Williams S et al. J Cosmetic Derm 2009;8:216–225
3. Streker M et al. J Drugs Dermatol 2013; 12(9):990–994
RES/039/1214 Date of preparation December 2014
Experience all the benefits of VYCROSS™ technology.
Treat various areas of the face using only 3 products.
It’s that versatile.
Instructions and directions for use are available on request.
Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK
Date of Preparation: August 2014 UK/0880/2014

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