VOLUME 2/ISSUE 8 - JULY 2015

Clinically proven Obagi - Skin care for everyone

The UK’s Best Cosmeceutical,
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Treating the Hyperpigmentation
Practitioners discuss
Mesotherapy
Juan Lopez shares
Online Reviews
Emily Ross

Forehead CPD the issue of

hyperpigmentation and
his treatment
protocol for
highlights the best
ways to utilise
Mr Dalvi Humzah and Anna Baker offer detail their treatment optimising skin online reviews for
their insight into forehead rejuvenation approaches hydration clinic marketing
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Contents • July 2015
06 News
The latest product and industry news

14 News Special: Consumer Health Reporting

We explore the representation of aesthetics in mainstream media Special Feature
19 On the Scene Hyperpigmentation
Out and about in the industry this month Page 21

CLINICAL PRACTICE
21 Special Feature: Hyperpigmentation
We ask practitioners to share their best tips for treating hyperpigmentation

27 CPD Clinical Article Patient Relations

Mr Dalvi Humzah and Anna Baker detail the anatomy of the forehead area Handling Online Reviews
for aesthetic rejuvenation Page 57
33 Eye Rejuvenation
Dr Maryam Zamani provides an overview of aesthetic treatments for Clinical Contributors
rejuvenating the eyes, and details her ‘Tri Eye’ technique Mr Dalvi Humzah is a consultant plastic recon-
structive and aesthetic surgeon, with a BSc in
36 Aesthetics Awards 2015 anatomy. He is the lead tutor for the award-win-
We look at why you should be attending the Aesthetics Awards 2015 ning anatomy teaching programme, Facial Anat-
omy Teaching.

38 Hyaluronidase Protocol Anna Baker is a dermatology and cosmetic nurse

practitioner. She runs the nurse-led Medicos
Lee Rowe details the importance of hyaluronidase and how to use it
Rx Skin Clinic at The Nuffield Health Hospital
in Cheltenham, and is the coordinator for Facial
41 Treating Acne Scars with Fillers Anatomy Teaching.
Dr Renée Hoenderkamp shares her technique for treating acne scars with
Dr Maryam Zamani is an ophthalmologist,
dermal fillers oculoplastic surgeon and aesthetic doctor. She
qualified at the George Washington University
44 Case Study: Liposuction School of Medicine, later completing her training
Dr Amanda Wong Powell discusses the evolution of liposuction and her at the imperial College London.

own experience of performing VASER Liposuction in clinic Dr Renée Hoenderkamp is a GP registrar in

London. With a special interest in aesthetics and
women’s health, she founded The Non Surgical
49 Mesotherapy for Facial Skin Hydration
Clinic in 2011, focusing on natural looking
Juan Lopez explores the use of mesotherapy to rejuvenate and moisturise solutions for facial ageing and deformity.
the face Dr Amanda Wong Powell is a VASER
liposuction surgeon, founder of Dr. W on Harley
53 Spotlight On: Kybella Street and a member of the Royal College of
We investigate the newly FDA-approved fat reducing injection for the chin Surgeons (Edinburgh). She is also medical
director of medical training platform Meducatus.
55 Abstracts Lee Rowe is an independent nurse prescriber
A round-up and summary of useful clinical papers and aesthetic nurse. Leaving the NHS some years
ago, she set up Innersense Aesthetics with fellow
nurse Lorraine O’brien and now works full time at
IN PRACTICE her York-based clinic.
Juan Lopez is an aesthetic nurse and
57 Handling Online Reviews independent prescriber, with a special interest
in skin health and mesotherapy. Owner of
Emily Ross outlines key ways to manage online clinic reviews
DermaTops.com, he is now launching his clinic,
Skin Medico, in London.
60 Supporting Your Patient
Deborah Vine highlights the importance of working as a team to enhance NEXT MONTH
patient care • IN FOCUS: Augmentation • Filler Retrospective
• CPD: Lower Eyelid Rejuvenation • Building Your Media Profile
63 Social Media Etiquette
Paul Jackson addresses what practitioners should be aware of when
communicating with patients online
Book your tickets now for
66 In Profile: Dr Zein Obagi
Wendy Lewis talks to Dr Zein Obagi about his journey into aesthetics the Aesthetics Awards 2015
www.aestheticsawards.com
68 The Last Word: Titles and Qualifications
Dr Sam Robson argues for better clarification of titles and qualifications in
medical aesthetics

Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical

Subscribe Free to Aesthetics aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228
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Editor’s letter
Finally, some sunshine! It feels deceptively
like summer has arrived as I sit here in the
journal office with the sun beating down on
our backs through the windows. Personally
I love the sun, as those of you who know me
Amanda Cameron
will testify. However, the sun has not been as
Editor kind to me, and my regrettably sun-damaged
skin is the result of summers of abuse in the
70s with little or no SPF. In those days, factor 2 was considered
high, and olive oil gave a much better result in terms of tanning.
If only I knew then what I know now!
These days there is no excuse for having sun-damaged skin, with
increased awareness and high SPF, as well as the improvement
in fake tan for those of our patients who want to be darker. Aside
from the obvious risk of skin cancer, hyperpigmentation is also
a very prevalent area of concern in aesthetics, a subject that we
explore in this month’s Special Feature (p. 21).
One thing is clear, and that is that we do live in a strange and
complex world where half the population want to look darker,
and the other half want to look lighter. Regardless of cultural
preferences, safety in the sun is key, and this message was
reinforced with the recent launch of a new UV app from the British
Association of Dermatologists and MET office. The app provides
the public with a free daily UV-forecast and suggestions on how
best to protect specific skin types. Will you be sharing this new
technology with your aesthetic patients?
It’s not only skin tone and texture that we’ll be exploring in this
issue. Our CPD article this month focuses on the rejuvenation of
the forehead, and provides an extensive overview of this area
of the face, looking at the anatomy in detail (p. 27). Dr Maryam
Zamani presents her technique for rejuvenating the eye area
(p.33), and Dr Renée Hoenderkamp looks at the treatment of acne
scarring using dermal filler (p. 39). This month we also profile the
infamous Dr Zein Obagi, tracing his journey into aesthetics, and his
subsequent brand expansion (p. 66).
As you will all know by now, entries for the Aesthetics Awards are
now closed. We have been overwhelmed by the quality of the
written entries, and we look forward to announcing the finalists in
September. In the meantime, we want to hear your thoughts about
this month’s issue. What are your methods for communicating sun
safety to your patients? Do you have your own technique for eye
rejuvenation? Let’s keep up the conversation.
Email editorial@aestheticsjournal or tweet us @aestheticsgroup
#talkaesthetics

Editorial advisory board

We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s
editorial advisory board to help steer the direction of our educational, clinical and business content
Mr Dalvi Humzah is a consultant plastic, reconstructive and Dr Raj Acquilla is a cosmetic dermatologist with over 11 years
aesthetic surgeon and medical director at the Plastic and Derma- experience in facial aesthetic medicine. UK ambassador, global
tological Surgery. He previously practised as a consultant plastic KOL and masterclass trainer in the cosmetic use of botulinum toxin
surgeon in the NHS for 15 years, and is currently a member of the and dermal fillers, in 2012 he was named Speaker of the Year at
British Association of Plastic, Reconstructive and Aesthetic Surgeons the UK Aesthetic Awards. He is actively involved in scientific audit,
(BAPRAS). Mr Humzah lectures nationally and internationally. research and development of pioneering products and techniques.

Sharon Bennett is chair of the British Association of
Cosmetic Nurses (BACN) and also the UK lead on the BSI
committee for aesthetic non-surgical medical standard. Sharon
has been developing her practice in aesthetics for 25 years and
has recently taken up a board position with the UK Academy of
Aesthetic Practitioners (UKAAP).
Dr Tapan Patel is the founder and medical director of VIVA
and PHI Clinic. He has over 14 years of clinical experience and
has been performing aesthetic treatments for ten years.
Dr Patel is passionate about standards in aesthetic medicine
and still participates in active learning and gives presentations
at conferences worldwide.

Dr Christopher Rowland Payne is a consultant
dermatologist and internationally recognised expert in cosmetic
dermatology. As well as being a co-founder of the European
Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was
also the founding editor of the Journal of Cosmetic Dermatology
and has authored numerous scientific papers and studies.
Mr Adrian Richards is a plastic and cosmetic surgeon with
12 years of specialism in plastic surgery at both NHS and private
clinics. He is a member of the British Association of Plastic and
Reconstructive Surgeons (BAPRAS) and the British Association of
Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards
and has written a best-selling textbook.

Dr Sarah Tonks is a cosmetic doctor, holding dual
qualifications in medicine and dentistry. Based in
Knightsbridge, London she practices a variety of aesthetic
treatments. Dr Sarah has appeared on several television
programmes and regularly speaks at industry conferences on
the subject of aesthetic medicine and skin health.
Dr Maria Gonzalez has worked in the field of dermatology
for the past 22 years, dividing her time between academic work
at Cardiff University and clinical work at the University Hospital
of Wales. Dr. Gonzalez’s areas of special interest include acne,
dermatologic and laser surgery, pigmentary disorders and the
treatment of skin cancers.

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 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Standards

Talk #Aesthetics GMC to develop guidance

for doctors carrying out
Follow us on Twitter @aestheticsgroup
cosmetic procedures
#Psoriasis
The General Medical Council (GMC) has launched a public
Psoriasis Foundation @NPF
People w/mild #psoriasis are just as likely to develop psoriatic consultation on the guidance available to UK-based doctors
#arthritis as those w/ moderate to severe forms of the disease. offering cosmetic procedures. The final guidance, expected to be
#health published in early 2016, will aim to set ethical standards that will be
expected of both surgical and non-surgical UK doctors.
#SPF The GMC hopes the guidance will help patients understand what
Dr Anjali Mahto @DrAnjaliMahto to expect from their doctor and ensure that they undergo cosmetic
Physical #sunscreens reflect UV, chemical sunscreens absorb it
treatments in a safe environment. Key points in the new guidance
#sunprotection #SunSafety #healthyskin
will address, amongst others, the need for doctors to be honest with
patients, ensure doctors market their services responsibly, and give
patients enough time and information before they decide to undergo
a procedure. The GMC is also working with the Royal College of
Surgeons (RCS) of England to publish information about which
surgeons have the right skills to carry out cosmetic surgery.
As the vast majority of cosmetic surgery is currently performed within
the private sector, the law currently allows any qualified doctor to
perform the operations, whether or not they are a trained surgeon,
without any additional qualifications or training. The RCS has already
drafted new standards of training and practice in an attempt to correct
this following the PIP scandal and subsequent Keogh Review. Without
#Training a law in place to give the GMC powers to formally recognise these
Andy Millward @AndyMillward_
qualifications, however, the RCS claim the standards will have limited
Passed assessment & doing my @MARSTE_ACADEMY
Dermagen training with @Marie_Reynolds on June 1st. effect on the industry. The proposed legislation would give the GMC
Needle-ss to say I am extremely excited!! the power to inform both members of the public and prospective
employers which surgeons are qualified to perform cosmetic surgery.
Mr David Ward, consultant plastic surgeon and vice president of the
#NeckLift Royal College of Surgeons, said, “It is very important that the newly
River Aesthetics elected government seizes this opportunity to improve patient safety.
@riveraesthetics
A simple change in the law will allow the General Medical Council
Watching the
Neck lift with Dr to detail whether an individual has the appropriate skills and training
Dorinda Donici from to carry out cosmetic surgery.” Professor Sir Bruce Keogh, NHS
Russia #aesthetics England’s medical director, added, “This consultation is a step in the
@Rosmetics @ right direction to tighten standards and protect people from potential
RealYouClinic risks.” Both the public and practitioners are invited to take part in
the consultation, which runs until September 1. Those interested in
participating can find more information on the GMC website.
#Learning
Sue Ibrahim @SkinSpecialist Skin cancer
With 17 years experience in cosmetic dermatology I have
performed thousands of injectable treatments, but I am still
developing my skills.
Suggested increase in
#Training
melanoma cases
Clare McLoughlin @appearancebased
I’m at the Allergan Master Class 2015 today and tomorrow, New research has indicated that melanoma rates are
with Mauricio de Maio! Look forward to seeing some of you increasing among children and young adults. The research
there too! #allergan indicated that melanoma has increased by more than 250%
among children, adolescents and young adults since 1973.
#Success However, the results also suggest an increase in survival
Dr Tijion Esho @DrTijionEsho rates – from 80% between 1973 and 1980, to 95% in 2011. The
Failure is needed at times of success, it keeps you humble,
surveillance, epidemiology and end results (SEER) data analysed
and that is a quality to maintain while progressing in life
35,762 of melanoma cases, looking at individuals of less than 40
years of age from 1973 to 2011.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Dermal filler Awards

FDA approves dermal filler New sponsors

for hand treatment announced for
The Food and Drug Administration (FDA) has approved the use of dermal filler Aesthetics Awards
Radiesse for volume correction in hand augmentation.
Earlier this year, the FDA Medical Devices Advisory Committee announced a
majority vote of 11 to three in recommending the expanded use of Radiesse
within hand augmentation. Now, the dermal filler, produced by Merz Aesthetics, is
the first to be approved for use in the hand area.
Jim Hartman, vice president and head of US Aesthetics/OTC for Merz North
America told BusinessWire, “Merz is proud to be able to provide patients and
physicians with the first and only dermal filler approved by the FDA for use in the New sponsors have been announced for the
hand.” He added, “This new indication for Radiesse is a result of our focus on Aesthetics Awards 2015. Medical device company
meeting unmet needs in the US aesthetics market, and we are excited to provide Schuco International will now sponsor the Award
our physician customers with this new option to better fulfil the aesthetic desires for Special Achievement, which recognises
of their patients.” the outstanding achievements and significant
Radiesse has been previously FDA approved for the correction of moderate to contribution to the aesthetics profession made by a
severe facial wrinkles and folds. Side effects may include bruising, swelling and particular individual. Previously won by pioneering
redness, which the company state are generally mild and short term. aesthetic practitioner Dr Roy Saleh, this year’s
award will once again celebrate a renowned figure
Skincare in the industry for their dedication to aesthetics.
It has further been announced that Swiss-based
New products launched skincare company Pure Swiss Aesthetics will
sponsor the award for Best Clinic Group UK &
by NeoStrata Ireland (10 clinics or more). This award category
will judge entrants on commitment to excellence
Specialist skincare developer NeoStrata has released in customer services, patient care and patient
new products to join its advanced skincare portfolio.The safety. Teresa Da Graça, chief executive of Pure
new products include Skin Active Dermal Replenishment, and Swiss Aesthetics, said, “Last year’s Aesthetic
Smooth Surface Daily Peel. Awards was Pure Swiss Aesthetics’ introduction to
Skin Active Dermal Replenishment is a night cream, which aims the UK market and that makes our sponsoring this
to deliver optimal hydration and anti-ageing effects for patients year that bit more special.” She added, “We are
with dry skin, using NeoStrata patented technologies that aim to very proud and extremely pleased to be launching
plump, firm and protect the skin. and sponsoring the Best Clinic Group Award with
Smooth Surface Daily Peel is a peel for daily home use, our Swisscode brand.” Entry for the Aesthetics
specifically directed at smoothing fine lines and improving skin Awards 2015 closed on June 30, with the voting
texture. It uses glycolic acid and NeoStrata’s patented Aminofil, process commencing from September 1. The
a tyrosine amino acid derivative (N-Acetyl Tyrosinamide) that awards ceremony will be held on December 5 at
creates a rapid volumising effect, aiming to visibly reduce deep the Park Plaza Westminster Bridge Hotel in London.
facial lines and wrinkles. NeoStrata products are available in the To find out more about the awards, or to book,
UK via AestheticSource. visit www.aestheticsawards.com

Why are Doctors and Nurses switching

T H E A R T O F FA C I A L R E J U V E N AT I O N to VARIODERM HA Dermal Fillers?
• Made in Germany to the highest of standards
• Clinical trials show that it outperforms other major brands for elasticity, longevity
and performance
• Dynamic product range for various indications
• Very competitive pricing
• Very high level of patient satisfaction
Contact info@adareaesthetics.com for further info and pricing.

Adare Aesthetics Ltd, 26 Fitzwilliam Square South, Dublin 2, Ireland.

Mob: +353 (0)85 711 7166 | Tel: +353 (0)1 676 9810
Email: info@adareaesthetics.com | Skype: ivanlawlor | Web: www.adareaesthetics.com
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Lips Body contouring

SkinCeuticals introduces Eden Aesthetics to

new lip product distribute new skin
Advanced skincare company SkinCeuticals tightening system
has announced the launch of its new lip
product, Antioxidant (AOX) Lip Complex. Eden Aesthetics
The product, to be released later this month, has acquired the UK
is the latest addition to the company’s distribution rights
‘Correct’ product range. It aims to treat to the Novaestetyc
damaged or ageing lips, with a combination Lift-Shape system.
of pure antioxidants, vitamin E, silymarin and The skin tightening
active ingredients. To be incorporated into a and fractional
daily care routine, SkinCeuticals claims the resurfacing system
AOX Lip Complex delivers three key benefits: aims to improve the
restores hydration, refines and smoothes the appearance of skin
appearance of the lip tissue, and protects through the use of
against environmental damage. Dynamic Quadripolar
It also claims to offer significant benefits when radiofrequency.
offered as part of pre- and post-procedure According to the
care following lip filler augmentation, company, this new
providing relief from common after-effects concept allows the
such as dryness, tightness and swelling. practitioner to focus
“This is a fantastic treatment which I believe the radiofrequency
will quickly become an integral part of my energy where it is
patients’ skincare routine because of how needed most for optimum results. Erika Galtarossa,
it rejuvenates and replenishes lip tissue,” training manager for Novaestetyc, said, “This system
said aesthetic practitioner Dr Sarah Tonks. is based on radio frequency (RF) technology, but it
“AOX Lip Complex delivers an anti-ageing, is a dynamic quadrapolar radiofrequency, which is
protective treatment which I will use in my something specific from us. It means that it is very
clinic both as a preventative option and as effective, but, at the same time, very comfortable to be
an advanced lip therapy for patients with received, and very safe.” Additional handpieces are
premature lip damage.” available to treat larger areas of the body such as the
abdomen, buttocks and thighs.
Botulinum toxin
Technology
Regular Botox may reduce
Consumer gadgets
number of treatments needed
launched to
A study carried out by Dr Alastair Carruthers and his team has revealed that
in patients who regularly received Botox treatments for more than five years, promote sun safety
the time between treatments increased over 22 treatments for glabellar
and crow’s feet lines. The retrospective study looked at data received from The general public are being encouraged to use
multiple centres internationally, covering 194 patients who had received a total gadgets such as mobile apps to protect their skin
of 5,112 Botox treatments. Researchers further found that the average annual from sun. Alongside the Met Office, the British
dose used to treat glabellar lines decreased by 9% as years of treatment Association of Dermatologists (BAD) has produced
increased, with the biggest change happening in the first three years. a mobile app called WORLD UV, which uses GPS
The number of days between Botox injections for glabellar lines went up from technology to calculate local UV levels, and suggest
129 days to 176 days over the course of 22 treatments. For crow’s feet lines, how best users can protect their skin type.
the number of days between treatments also increased from 136 to 209 over In addition, Swedish company Smartsun has
the same period. developed paper wristbands that measure a user’s
Patients further reported positive outcomes, with 98.3% of those aged under UV exposure and changes colour when they need
50 being very satisfied or mostly satisfied with the result of Botox treatment, to reapply sunscreen, while Electronic device
and 86.9% of all patients treated reported looking younger than their actual developer Netatmo has released a bracelet called
age. Dr Carruthers is a consultant for Allergan and has received research JUNE. It communicates with a user’s phone to
grants from the company. The full study, with a full list of disclosures, was recommend adequate SPF and alert users when
published in volume 41, issue 6 of Dermatologic Surgery, in June 2015. they have reached their daily UV limit.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Industry
Vital Statistics
Allergan set to acquire
Kybella manufacturer
Global pharmaceutical company Allergan has announced that it will
acquire Kythera Biopharmaceuticals for $2.1 billion. The news comes
following the recent Food and Drug Administration’s approval of Kybella,
a non-surgical treatment aimed at reducing the appearance of submental
fat, manufactured by Kythera. The acquisition has been agreed as a case 46% of patients use social media
and equity transaction valued at $75 per Kythera share, to be received to look for information about a
as 80% in cash and 20% in Allergan shares, subject to certain customary treatment prior to a consultation
conditions which include the need for approval from Kythera’s stakeholders. (Aesthetic Plastic Surgery)
Brent Saunders, CEO and president of Allergan, said of the news, “The
acquisition of Kythera is a strategic investment that strengthens our leading
global position in aesthetics and continues to position us for long-term Each year,
growth.” The acquisition is subject to expiration or termination of the waiting
54% of the UK
period under the Hart-Scott-Rodino Antitrust Improvements Act 1976. This
states that parties must not complete certain mergers, acquisitions or population is affected
transfers of assets until a detailed filing has been made with the US Federal by skin disease
Trade Commission and the Department of Justice, in order to ensure the (British Association of Dermatologists)
transaction will not adversely affect US commerce under the antitrust laws.
Keith Leonard, CEO and president of Kythera, said, “Allergan’s world-

125 million
class medical aesthetics, global footprint, history and commitment to
developing leading aesthetic products makes them ideally suited to
realise the maximum commercial potential of Kybella.” He continued, “We
An estimated 125 million people
look forward to working with Allergan to ensure a successful US launch of
Kybella, as well as to secure additional approvals globally.” worldwide live with psoriasis
(National Psoriasis Foundation)

Skin cancer

Trial suggests positive outcome 45,506 surgical

procedures were carried
of treating skin cancer with out in 2014
herpes-based drug (British Association of Aesthetic
Plastic Surgeons)

A phase three trial has indicated positive results after a new

herpes-based drug was used to treat skin cancer patients. Dubbed
72% of British people
‘virotherapy’, the new drug, called T-VEC, works by using ‘neutered’ virus
cells to attack the cancer cells, and could become more widely available admitted to being
to cancer patients by next year. sunburned in 2014
More than 400 patients with aggressive melanoma undertook the trial, (British Association of Dermatologists)

which showed one in four had responded to treatment. The trial found
that 16% were still in remission after six months, and 10% of patients
treated had ‘complete remission’ with no detectable cancer remaining.
Members of the control group were treated with a protein designed to
Last year, 44%
of
stimulate the immune response against cancer, but did not include the UK men took steps to
virus component of the treatment. All patients were treated by injection lose weight 44%
and received a dose every two weeks for up to 18 months. (Mintel)
The trial indicated that side effects remained mild compared to
those experienced with chemotherapy drugs, and patients typically
experienced mild flu-like symptoms. Regarding the promising outcome Women under 24 years
of the trial, the authors of the study hope the new drug will offer an
alternative to those with few options.
of age show 45% more
Kevin Harrington, professor of biological cancer therapies at the Institute interest in rhinoplasty than
of Cancer Research London, who led the research, told the Guardian, those between 25 and 34
“This is the big promise of this treatment. It’s the first time a virotherapy (RealSelf)
has been shown to be successful in a phase 3 trial.”

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


Events diary
7th – 9th July 2015
British Association of Dermatologists (BAD)
Meeting, Manchester
www.bad.org.uk/events/annualmeeting
31st July – 2nd August 2015
International Master Course on Aging Skin
(IMCAS), Asia
www.imcas.com/en/asia2015/congress
19th – 23rd August 2015
American Academy of Dermatology (AAD)
Summer Meeting, New York
www.aad.org/meetings/2015-annual-
meeting/general-information
25th – 26th September 2015
F.A.C.E2F@ce conference 2015, Cannes
www.face2facecongress.com/en
26th September 2015
British College of Aesthetic Medicine
Conference, London www.bcam.ac.uk
3rd October 2015
British Association of Cosmetic Nurses
Conference, Birmingham
www.bacn.org.uk/events/bacn-annual-
conference-exhibition
5th December 2015
The Aesthetics Awards 2015, London
www.aestheticsawards.com
Skincare
DMK to introduce
new product range
Skincare manufacturer Danné Montague-King
(DMK) has announced it will be introducing a new
skincare range to its product portfolio. The new
range, DMK Fundamentals, will include three skincare
kits: Acne Control, Age Management and Pigment
Balancing. According to the company, the products
in each kit work to support the skin’s own natural
function. Presented in ‘Home Prescriptive’ packs,
each kit includes a 30-day supply with initial treatment
starting in-clinic. Packs include premium DMK
products such as Enzyme masques, Quick peels
and Fibromax C, with specific products to treat acne,
ageing and pigmentation.
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Fat reduction
SculpSure receives FDA 510(k)
clearance for non-invasive
fat reduction
Medical device manufacturer Cynosure has announced that its hyperthermic
laser treatment device, SculpSure, has received 510(k) clearance from the
Food and Drug Administration for non-invasive fat reduction. The 510(k)
clearance means that the company will now be able to market the device for
the non-invasive treatment of fat. Using a 1060 nm laser with a flexible applicator
system to treat multiple areas of the body, Cynosure claims the SculpSure system
works by disrupting subcutaneous fat cells. “SculpSure represents an entirely
new approach to non-invasive lipolysis, one that is safe and highly effective in
reducing adipose tissue and does so in significantly less time than other current
treatments,” said Cynosure chairman and CEO Michael Davin.
Body countouring
Invasix launches new
MiniFX application
Israeli-based medical device company
Invasix Limited has launched its new
MiniFX application to expand its multi-
treatment platform, InMode.
The new application, now available in
the UK, will be added to the range of
applications for the InMode system,
which aims to allow practitioners to treat
a number of indications on one device.
Invasix claim the new application will allow practitioners to treat smaller and harder
to reach areas, such as the neck and arms. Like its larger counterpart, BodyFX,
MiniFX is a non-invasive contouring and cellulite treatment which uses four
technologies; radiofrequency, high amplitude, vacuum and skin temperature. Other
applications for the InMode platform include FRACTORA (for fractional resurfacing
and rejuvenation), FORMA PLUS (for face and body remodelling), LUMECCA (for
internsed pulsed light rejuvenation) and DIOLAZE (for laser hair removal).
Industry
BACN appoints new vice chair
The British Association of Cosmetic Nurses (BACN)
has appointed a new vice chair, as aesthetic nurse
prescriber Lou Sommereux steps down from the
position. The BACN has announced that Andrew Rankin,
aesthetic practitioner and trainer, will now take over the
vice chair position.
BACN chair Sharon Bennett said, “Andrew has given
enormous amounts of his time working with HEE and
with education. He is sensible and balanced, has been
on the board for a number of years and so understands the business and the input
required from this demanding, time-consuming position.”
On taking up his new position, Rankin said, “I am proud to be given this opportunity,
as I am to support Sharon as chair, to work alongside my peers and to represent our
members so that we can make a difference, which we surely can.”
aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

60
Skin cancer

Trial suggests cancer drug

combination could shrink
Roger Bloxham, Managing Director
nearly 60% of melanomas at AesthetiCare
An international trial of 945 people has indicated that taking a combination of The new AesthetiCare adverts
two cancer drugs can have a significant impact on shrinking tumours in patients talk about being ‘Together on
with advanced melanoma. The results of the trial have suggested that treating the journey to better looking
patients with both ipilimumab and nivolumab stopped the cancer from advancing for skin’ and say, ‘Let’s do things
nearly a year in 58% of cases, with tumours either stable or shrinking over a period differently’. What does all this
of 11.5 months. For ipilimumab alone – a product that was approved by the NHS last mean?
year as an advanced melanoma treatment – the figures were 19% and 2.5 months. We are saying that we want to develop a
long-term partnership plan with clinics and
Dr James Larkin, a consultant at the Royal Marsden Hospital and one of the UK’s
practitioners that will really make a difference to
lead investigators, said, “By giving these drugs together you are effectively taking
their clinical and business results, not just in the
two brakes off the immune system, rather than one, so the immune system is able short term, but for years to come. We are also
to recognise tumours it wasn’t previously recognising and react to that and destroy saying that we have the means to do this with
them.” He continued, “For immunotherapies, we’ve never seen tumour shrinkage the comprehensive product range, skin devices
rates over 50% so that’s very significant to see. This is a treatment modality that I and treatments that make up the AesthetiCare
think is going to have a big future for the treatment of cancer.” ‘Aesthetic System Portfolio’, and through the
superior clinical and business support we
Dermal fillers provide. ‘Let’s do things differently’ is a way of
summarising this approach. ‘Together on the
FDA releases safety notice journey to better looking skin’ describes and
defines our collective passion and focus for
on filler injections better looking and healthier skin, and reflects our
strong dermatology and clinical heritage.

The Food and Drug Administration (FDA) has published a safety
communication in relation to the unintentional injection of soft tissue fillers
into facial blood vessels. After reviewing information that suggests unintentional
injection of soft tissue fillers into blood vessels in the face can result in rare,
but serious, side effects, the FDA are now urging practitioners, and those
contemplating filler treatment, to be aware of the risks. Risks can include
blocking of blood vessels, resulting in embolisation, visual impairment, strokes
and necrosis. It can also cause damage to underlying facial structures. The FDA
has advised practitioners to thoroughly warn patients of the risks associated
with treatment, and to ensure that they are aware of any signs and symptoms
associated with injection into blood vessels, with a detailed plan for adverse
reactions. Following the review, the FDA is working with manufacturers to update
their labelling with additional warnings, precautions and other statements about
the risk of unintentional injection into blood vessels.
Industry
Ferndale Pharmaceuticals
and Aesthetic Technology
strengthen collaboration
Ferndale Pharmaceuticals has acquired 30% of Aesthetic Technology shares in a
joint commercial venture. Aesthetic Technology is the developer and manufacturer
of the Dermalux LED phototherapy systems, whilst Ferndale Pharmaceuticals is a
specialty dermatology company. Upon the collaboration, Dermalux will be integrated
into AesthetiCare, Ferndale’s aesthetic division, with the aim of Aesthetic Technology
expanding into the professional beauty and spa sectors. The companies hope that
Ferndale can provide Aesthetic Technology with enhanced financial strength and
operational infrastructures, particularly with its developing international presence.
What is the AesthetiCare ‘Aesthetic System
Portfolio’, mentioned above?
This is the portfolio of medigrade skincare and
skin devices and treatments that we are constantly
working on developing and assembling. The
AesthetiCare focus is always on evidence base
and technologies and formulations that deliver
high-level clinical results. When it comes to skin the
portfolio addresses the majority of the needs of an
aesthetic skin clinic, and crucially, the products and
devices all complement each other, and can be
used in evidence-based synergistic combinations
to deliver fantastic results.
What’s the main focus and which indications
does the portfolio combat?
The focus is always better looking and healthier
skin. The indications are rejuvenation of aged
and photo-damaged skin, prevention of the
acceleration of skin ageing and providing
resolution to skin problems such as acne, acne
scars, pigmentation, rosacea / red and flushed
skin. We also, through individual technologies
and combinations, provide great enhancement
to lax and sagging skin, including body shaping
and inch loss. This breadth and synergy enables
us to truly consult and build long-term clinical and
business partnership.
This column is written and supported by

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Skincare
News in Brief
AesthetiCare launches new Harley Street doctor offers eight-
hour lip filler treatment
product range Aesthetic practitioner Dr David Jack is
offering patients a lip-plumping procedure
that lasts six to eight hours.
Instead of injecting traditional filler, Dr Jack
injects saline solution to the surrounding
area of the lips to produce shorter-term
results. According to reports, the treatment,
dubbed ‘Cinderella Lips’, is becoming
popular amongst people seeking temporary
lip enhancements before committing to
traditional lip fillers.

Waterhouse Young appoints new

doctor to join team
Aesthetic practitioner Dr Saira Vasev has
Skincare and device manufacturer AesthetiCare has launched BiRetix, a new joined the team of clinical staff at the non-
cosmetic range geared at treating spot-prone skin. Included in the range is BiRetix surgical aesthetic practice, Waterhouse
Duo, which contains RetinSphere Technology, (a combination of cosmetic retinoids Young. Previously, Dr Vasdev has
that aim to clear pores and clarify skin. It also contains BOIPEP.15, a botanical complex worked for the NHS where she studied
with Oligopeptide 10, a bioactive peptide containing naturally occurring amino acids recovery procedures for facial injuries. A
to fight P. acnes, and salicylic acid. According to the company, clinical studies have spokesperson for Waterhouse Young stated
indicated that each ingredient works to improve the appearance of comedones, that Dr Vasdev has proven to be a valuable
spots and redness. The BiRetix Micropeel and BiRetix Mask are also included in the member of the team and feedback from her
skincare range. The Micropeel contains a clarifying and exfoliating cleanser with first clients has been exceptional.
botanical extracts and exfoliants that aim to clear pores and stimulate cell renewal,
while the clay mask contains mineral, anti-oxidants and RetinSphere technology, EF MEDISPA opens in Canary Wharf
which aim to control sebum and reduce shine. The new range is part of the Resolve Aesthetic clinic chain EF MEDISPA is set
category of AesthetiCare’s SKINSYNERGY medi-grade skincare portfolio, which also to open its fourth London clinic in Canary
includes products for treating pigmentation and redness. Wharf later this year. The new clinic, which
will be situated on Admiral’s Way, will open
Skincare in August and aim to offer patients the latest
advances in medical aesthetics, with a
AestheticSource announced as particular ethos to cater to Canary Wharf’s
time-short executives. The company’s
headline sponsor for ACE 2016 current clinic portfolio includes clinics in
Kensington, Chelsea and St John’s Wood.
Skincare distributor AestheticSource
has been announced as the official Irwin Mitchell launches new
headline sponsor for the Aesthetics cosmetic tracker app
Conference and Exhibition (ACE) 2016. Specialist cosmetic surgery lawyers at
Following its success as the headline Irwin Mitchell have developed an app
sponsor at ACE 2015, the company that assists those going through cosmetic
is now looking forward to next year’s procedures to track their journey. The new
premium UK aesthetic conference event. app, ‘BeautyTracker’, allows patients to
“AestheticSource are proud to be the headline sponsor at the Aesthetics Conference track their journey with practitioners and
and Exhibition 2016,” said Lorna Bowes, director of AestheticSource. “This year’s clinics in an attempt to improve safety in the
conference was a real success for our team, and we look forward to returning industry, following a rise in patients affected
in 2016 as we take on the headline sponsorship once again.” She added, “The by negligent treatments. Allowing patients
conference always provides fantastic exposure for AestheticSource, and the to keep a log of treatments and details of
extensive agenda really supports our view of the importance of ongoing education practitioners, the app will further provide
within the aesthetic industry. We can’t wait to see what next year’s event will bring to access to expert advice if a treatment goes
the educational table!” ACE 2016 will feature a broad agenda, with in-depth clinical wrong. Users will also be able to access
content on the latest innovations, best practice, advice and demonstrations from independent sources of help and advice
leading professionals in the aesthetics industry. To keep up to date with all the if they have an unsatisfactory outcome
latest announcements regarding Aesthetics events, sign up to receive our weekly following treatment.
e-newsletter at www.aestheticsjournal.com

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Botched Bodies and Cosmetic

Surgery Cowboys: The representation
of aesthetics in mainstream media
Aesthetics explores the prevalence of negative
reporting on our industry, and talks to media
professionals about how it can be improved
Introduction
‘Trout pout’, ‘pillow face’ and the ‘Bride of Wildenstein’ are all terms
synonymous with the representation of medical aesthetics in the
media. Type ‘cosmetic surgery’ into any search engine and results
generate news of celebrity treatments, botched procedures and, at
worst, death following surgery. While ‘scare stories’ can of course
encourage the public to think carefully about the risks of procedures
and the importance of seeking treatment from a safe practitioner, some
aesthetic professionals argue that they can have a negative impact on
the industry. Many practitioners are also quick to criticise the reporting
of potentially unsafe treatments and procedures, which often have little
to no safety data supporting their use as aesthetic treatments. Stories
derived from clinical studies can be exaggerated and sensationalised,
claiming new cures and promising immediate, pain-free aesthetic
results. So who is to blame for these hyped-up stories? Many are
quick to point the finger at newspapers, competing for sales figures
and desperate to win the widest readership. Yet the two journalists
interviewed for this report highlight the challenges of deciphering
scientific jargon and the need for more support from the aesthetics
and cosmetic surgery industries to secure accurate reporting. In this,
public relations officers (PRs) and the academics approving scientific
press releases have an important role to play. Research published
in the British Medical Journal suggests that exaggeration in news is
strongly associated with exaggeration in press releases. The study has
indicated that 40% of press releases on biomedical and health-related
science contain exaggerated advice, 33% contain exaggerated casual
claims, and 36% contain exaggerated inference to humans from
animal research.1
Mr Rajiv Grover, plastic surgeon, former president of the British
Association of Aesthetic Plastic Surgeons (BAAPS) and member
of the BAAPS press committee, also notes that it is important that
practitioners take some of the responsibility for the amount of
undesirable stories in the media. He says, “Those negative stories
didn’t just come out by accident – there have been negative things
happening. It’s important that we have high standards everywhere
so there’s less negativity to report.” As such, it seems apparent that
aesthetic professionals, PRs and media representatives need to work
together to improve the representation of aesthetics and cosmetic
surgery in the media, but how can this be done effectively?
The Public Interest
‘If it bleeds, it leads’ is an old adage adopted by many media outlets
to explain the sales value of a negative news story in comparison to a
positive one. Despite many people’s objection to this approach, it does
provide an explanation as to why so much aesthetic and cosmetic
surgery news focuses on the undesirable results and negative
connotations associated with the industry. Along with this, journalists
are obliged to report stories that are ‘within the public interest’. The
Editors’ Code of Practice, which all members of the press have a duty
to maintain, defines the public interest as including, but not being
confined to:2
• Detecting or exposing crime or serious impropriety.
• Protecting public health and safety.
• Preventing the public from being misled by an action or statement
of an individual or organisation.
With such a prominent lack of regulation and a high prevalence of
un-qualified practice taking place in the UK, it is inevitable that the
aesthetic and cosmetic industry ticks the ‘public interest’ box, and
captures the attention of the media.
Misreporting
“We are contacted by PRs on a daily basis,” explains Barney Calman,
health editor of the Mail on Sunday. “We have to treat everything with
caution – our journalists always request studies, safety data and the
proof that something works before writing about it,” he says. Calman
exemplifies one case in which a journalist on his team was sent a
press release announcing that a particular brand of lip filler could now
be used for vaginal rejuvenation. “The reporter had done her due
diligence and asked for safety data, which they had sent to her. The
filler had received a CE mark based on the fact it is safe to be used
in the body, however there was certainly nothing to note that it was
indicated for use in that area,” he explains. “It turned out there was
nothing to support its safety for vaginal rejuvenation.”
Calman notes that following 11 years of reporting healthcare news,
he is now adept at spotting anything untoward. “But obviously, if we
are lied to or misled then incorrect or unsafe information can get out
there,” he says.
The Value of PR
It is common practice for both aesthetic organisations and individual
practitioners to employ the support of PR officers to promote their
services and spread their messages within the media. Julia Kendrick
has recently established her self-titled PR consultancy business
following years of representing large pharmaceutical companies.
To minimise the risk of sharing misleading press releases, Kendrick
ensures anything she sends out is to a pharmaceutical standard. “The
companies I work with are focused on ensuring that all material they
send out is extremely accurate, well referenced, and adheres to the
standards set out by the ABPI,” she explains. The Association of the
British Pharmaceutical Industry (ABPI) Code of Practice sets standards
for promoting appropriate use of medicine to the public. It states that,
“Companies must ensure that their materials are appropriate, factual,
fair and capable of substantiation and that all other activities are
appropriate and reasonable.”3
Kendrick encourages her clients and other PR companies to adopt

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

 @aestheticsgroup
this approach and suggests that, “If you’re conducting yourself and
your business to the highest possible standards in the industry, you’re
setting yourself up in a way that’s going to be successful, credible
and ethical.” While ensuring the accuracy of the content you share
is essential, it is sometimes beneficial to inject some fun into press
releases, suggests Tingy Simoes, especially when fighting for news
space amongst negative reports. Mr Grover agrees, “Journalists in
mainstream media are getting hundreds of press releases per day.
Unless you make it interesting for them and stand out, there’s no
reason for them to read it because they have no time.”
As the managing director of Wavelength Marketing Communications
and Cacique Public Relations, Simoes is known amongst journalists
and practitioners for her eye-catching email subject lines and inventive
treatment captions. She’s coined phrases such as, ‘The Miami Thong
Lift’, which she says generated international press coverage, and
‘The Smile Transplant’, which refers to the treatment available to facial
palsy sufferers. Associating the phrase with the news that the NHS
wasn’t routinely funding ‘smile transplants’4 garnered a hugely positive
response from the UK media, according to Simoes. “If you give
something a name that people can automatically understand and tie
it to something current, you’ll get something that’s very well respected
and sometimes makes global news,” she explains. From a journalist’s
perspective, Calman adds, “There’s certainly a harmonious respect
to be had – if PRs come up with fun ways of selling things, and can
project a treatment onto a fun theme, then it can often work really well
in terms of selling a page.” Simoes also highlights the importance of
PR officers understanding the topic they are trying to promote to the
media. “I find it sad that some PR agencies are cheapening aesthetics
by not understanding it,” she says, adding, “I work so hard on our
press releases, ensuring all the information is in there; statistics, detail,
layman’s terms – we’re trying to educate people and find the things
that are fascinating about the industry.” Freelance journalist Beatrice
Aidin agrees, noting that she deletes any ambiguous press releases
she receives. “PRs have a tough job to do, especially in terms of
medical PR. I think, though, that if the PRs haven’t understood the story,
how will I? If they don’t know what they’re talking about I have no faith
I’m going to get something accurate.” Calman adds, “I wouldn’t like to
blame PR officers because they’re simply working with the information
that they’re given. Their job is to have connections with journalists, not
to be medical experts.”
Improvement Strategies
Mr Grover explains that the BAAPS has recently formed an
organisation called the National Institute of Aesthetic Research (NIAR)
to address the lack of data on the efficacy and safety of aesthetic and
cosmetic surgery treatments. Working in association with the Healing
Foundation, a charity that supports people living with disfigurement
and visible loss of function, Mr Grover explains that the BAAPS hopes
the NIAR can investigate areas lacking research and produce reliable
data to be shared with the public. He says, “Although the institute’s in
its infancy, it will hopefully gain the trust of the media and inform the
public of aesthetic developments in an appropriate way.”
The fast-paced nature of news also means that the industry
needs to act quickly to comment on breaking stories and provide
knowledgeable and reliable explanations or opinion. As Calman
explains, even journalists who specialise in healthcare reporting are
not likely to be medically trained, let alone journalists working within
a different specialty, leaving clinical studies and press releases open
to interpretation. Being able to help journalists in their enquiries as
soon as possible is beneficial to the industry as a whole, as well as for
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
individual practitioners looking to enhance their public profile. Kendrick
shares some of her best tips for talking to journalists:
• Don’t get drawn into sensationalism; avoid commenting on
rumours, you’ll only fuel the fire.
• Use your own expertise to provide a balanced perspective on the
topic in question.
• Research the journalist’s background and publication prior
to interview; consider who they are, their specialty, who the
publication’s audience is, the tone of the publication, and what you
expect the journalist is looking for.
• Avoid talking in jargon and acronyms – Albert Einstein once said,
“If you can’t explain it simply, you don’t understand it well enough”.
Modify your response so that it’s appropriate to the journalist, the
media outlet and the readership.
Kendrick explains that she hopes these methods will improve the
standard of communication needed between the aesthetics world
and the media. Aidin adds that a practitioner who can explain things
well is invaluable to her reporting. She says, “I’ve learnt a lot from
certain practitioners who are intelligent and great communicators; it’s
very important.”
Looking Forward
While the aesthetic industry remains severely lacking in regulation, and
manufacturing companies continue to innovate and create, it seems
unlikely that the media storm surrounding our industry will die down
any time soon. As a journalist, Calman argues that it is not the job of
media professionals to police the industry. “We’re not medical experts,”
he says. “We’re reporters, and our job is to translate information
we receive into a format the can be readily understood by our
readers.” In addition, any journalist can be taken to the Independent
Press Standards Organisation (IPSO), an independent regulator
of the newspaper and magazine industry, and reprimanded for a
breach of the Editors’ Code.5 Calman says, “We take the code very
seriously and make all of our journalists attend IPSO seminars on their
responsibilities of reporting accurately and not distorting the facts.”
Kendrick notes that you’re never going to be able to chase down
and correct every sensationalist story. As a press officer, she says the
importance lies in communicating at the highest possible standard with
the aim of minimising the risk of inaccurate reporting. “It’s about having
the trust and relationship to follow up with journalists if there’s anything
majorly wrong – it ultimately benefits their reputation, as well as
provides consumers with accurate information.” Mr Grover highlights
the work of associations such as the British College of Aesthetic
Medicine and the British Association of Cosmetic Nurses, which are
regularly campaigning for higher standards of regulation within the
industry. To conclude, he reiterates his first point; “It’s important that we
have high standards everywhere, so there’s less negativity to report.”
REFERENCES
1. The association between exaggeration in health related science news and academic press
releases: retrospective observational study (UK: British Medical Journal, 2014) <http://www.bmj.
com/content/349/bmj.g7015>
2. Editors’ Code of Practice (UK: Independent Press Standards Organisation, 2015) <https://www.
ipso.co.uk/IPSO/cop.html>
3. Code of Practice for the Pharmaceutical Industry (UK: Association of the British Pharmaceuti-
cal Industry, 2015) <http://www.abpi.org.uk/our-work/library/guidelines/Documents/code_of_
4. practice_2015.pdf4>
5. Rebecca Smith, Smile transplants for stroke sufferers ‘not routinely funded’ by NHS (UK: The
Telegraph, 2012) <http://www.telegraph.co.uk/news/health/news/9683290/Smile-transplant-for-
stroke-sufferers-not-routinely-funded-by-NHS.html>
6. About IPSO (UK: Independent Press Standards Association, 2015) <https://www.ipso.co.uk/
IPSO/index.html>
 COMPOSED • CONFIDENT • MY CHOICE
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 medical.information@merz.com 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.
1183/BOC/DEC/2014/DS Date of preparation: December 2014
PURIFIED1• SATISFYING2,3,4 • CONVENIENT5
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aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Meet the Expert to Expert

Experts
Evening,
London
Skincare distributor
AestheticSource hosted
a ‘Meet the Experts
Evening’, chaired
by dermatologist Dr
Sandeep Cliff, at the Royal Society of Medicine in London on June 3. Professor
Beth Briden, medical director and CEO of the Advanced Dermatology and
Cosmetic Institute in Minnesota, began the sessions by detailing new active
ingredients in skincare, and introduced new products from skincare specialists
NeoStrata. Dr Uliana Gout, chairperson of the International Chemical Peel Society,
then addressed the need for evidence-based skincare, which was followed by
dermatologist Dr Mukta Sachdev’s presentation on the importance of pre-peel
preparation in order to avoid pigmentation issues in skin of colour.
To conclude the presentations, Dr Stefanie Williams discussed the effects of
sugar on skin. She advised practitioners to urge patients to monitor their starch
intake – a major contributor of sugar in food – and highlighted that those with
diabetes appear to age quicker. “It was a very, very good evening,” said attendee
and aesthetic practitioner Dr Jamshed Masani, following the final Q&A session.
“Especially Dr Mukta Sachdev’s lecture on skin of colour, how she handles
peels with pre-peel regimes, and then doing the peels and still getting good
results. We in Britain are so frightened to treat skin of colour for the reasons of
hypopigmentation and hyperpigmentation.”
Day, London
Featuring live
demonstrations,
lectures and Q&A
sessions, Lifestyle
Aesthetics hosted
its Expert to Expert
day at the Royal
Society of Medicine
in London on May 30.
Delegates were invited
to a variety of talks with aesthetics practitioners
from across the industry, discussing techniques for
facial rejuvenation. Aesthetic practitioner Dr Fabio
Ingallina began the sessions with a discussion
on understanding anatomical landmarks for facial
rejuvenation, which was then followed by dental
surgeon Dr Lee Walker, who demonstrated effective
ways of contouring the lips and perioral area with
Teoxane’s Teosyal Pen. Later in the afternoon,
delegates were able to question the expert panel,
with renowned practitioner Dr Tracy Mountford
acting as moderator for the event. Of the day, Sue
Wales, co-founder of Lifestyle Aesthetics, said, “It is
inspiring to see so many experienced practitioners
turning out on a Saturday to gain more tips from our
experts.”

FACE, London Proof in Real

The Facial Anti-Ageing Conference and Exhibition (FACE)
was held from June 4-6 at the Queen Elizabeth II Centre,
London. Throughout the weekend, attendees were invited
to lectures on anti-ageing concerns of the face. Topics
covered the likes of sun protection, treating blonde/white
hair and pigmentation. The event also incorporated the
annual BODY Conference into its programme, with one
session by aesthetic practitioner Dr Uliana Gout discussing
hand rejuvenation procedures and the importance of careful
injecting for this area. On Saturday afternoon, Dr Stefanie
Williams joined the programme to demonstrate medical
needling with PRP, offering key advice on procedure
protocol to ensure optimal results. Andrew Morris, country
operations manager for Sinclair Pharma, said, “The FACE
conference was very busy for Sinclair with lots of interest
in Silhouette Soft and ELLANSÉ, particularly in their
combination use. There was standing room only at our
training workshops which reinforces Sinclair’s commitment
to quality training.”
Life Reveal,
Berlin
The treatment of 10 identical twins was announced as the secret behind
Galderma’s Proof In Real Life campaign at the Reveal event in Berlin on May
28. One sibling from each pair of twins had been treated with both Restylane and
Restylane Skinboosters, or just one of the products, with the aim of demonstrating
natural-looking results achieved through aesthetic treatment. Global
pharmaceutical company Galderma created the Proof In Real Life campaign with
the hope of challenging misconceptions that aesthetic treatments create extreme
results. Actress Sharon Stone was announced as the global ambassador for the
campaign at the Aesthetic & Anti-Aging Medicine World Congress in March, and
later hosted the Reveal event alongside plastic surgeon Mr Per Hedén, who
detailed how the patients had been treated. In her opening speech, Stone said,
“Tonight’s a very special night, not just for Galderma, but for the world of beauty.
We all know that the aesthetic world is famous for showing extreme looks and
images of aesthetic treatments, which, as many of us know, are not true. The
only way to change this perception is to be bold and to be honest.” The sets of
twins were welcomed to the stage to showcase their results and, following the
Reveal, mingled with guests to discuss their experiences. Dr Kuldeep Minocha,
lead aesthetic practitioner at Absolute Aesthetics in London, treated all but two
sets of the twins. He said, “We worked with the individuals as I would in a normal
consultation – it was important to me to treat the participants like any other patient.
It’s a very unique campaign and it’s been quite amazing to see the results.”

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

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aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Colour me youthful:
the problem with
hyperpigmentation
Sun damage, hormones, inflammation – the
causes of hyper-pigmented skin are almost as
numerous
numerousas asthe
thetreatments
treatmentsononoffer
offerto
tocorrect
correctit.
it.
Allie Anderson talks to practitioners to find out how
to
todeal
dealwith
withthe
thecommon
commonaesthetic
aestheticconcern
concern
If there’s one presentation in the world of medical aesthetics associate hyperpigmentation with the health of their skin. “Patients
that continues to challenge practitioners, it’s hyperpigmentation. come to see me because they’ve reached a point in their lives
Yet, evidence suggests that patients are increasingly seeking when they’re bothered by hyperpigmentation,” Miss Balaratnam
consultation and treatment for the problem. “Whether that’s because adds. For example, someone with many freckles on their face
it’s become a bigger issue, or that it’s always been there but people (caused by increased melanin) may perceive them to be attractive
haven’t been seeking advice from private medical professionals in youth, but less appealing with age. Similarly, dark liver spots on
before, I’m not sure,” remarks Dr Simon Ravichandran, founder of the face may be no cause for concern for one person, and be very
the Clinetix Medispa group. Whatever the reason, he reports that distressing for someone else. Many practitioners, therefore, assess
pigmentation treatments account for around 10-15% of his clinics’ hyperpigmentation not in terms of how severe it is, but the degree to
patient cohort. which it affects the patient.

Cause and effect
Hyperpigmentation – or hyperpigmentation disorders – are caused by
overproduction of melanin by the pigment cells, called melanocytes,
and less commonly, by a greater number of melanocytes.1 The
umbrella term ‘melasma’ is often broadly used to describe
hyperpigmentation disorders of unknown aetiology, associated with
hormonal changes (including pregnancy), certain medications and
sun exposure. Additionally, increased pigment can be caused by
post-inflammatory hyperpigmentation (PIH), such as that left by acne
scarring, psoriasis, and previous aesthetic treatments.
Exposure to sunlight triggers melanin production in order to protect
the skin from harmful ultraviolet (UV) rays.2 Excessive sun exposure
results in increased melanin production, making sun exposure
a major cause of hyperpigmentation. Accordingly, practitioners
report that patients presenting with UV-induced hyperpigmentation
tend to be in their 40s and 50s, having spent many years tanning,
much of that time ill-informed about the risks associated with
sun exposure and sunbeds. Patients seeking treatment for
hyperpigmentation more generally range in age from early 30s to
late 50s, with more than 90% of cases occurring in women.3
Subjective assessment
Miss Sherina Balaratnam, medical director of S-Thetics clinic
and a former NHS trainee plastic surgeon, comments, “Younger
patients – even in their 20s – have less advanced skin damage,
but they’re more conscious of it from an appearance point of view.”
That, she says, is owing to greater appreciation among younger
patients of the dangers of UV damage, which in turn leads them to
Measures of severity can be useful, though. Dr Ravichandran uses
the Melasma Area and Severity Index (MASI), which uses a formula
to calculate an overall score of severity based on the practitioner’s
assessment of:
1. The extent of coverage on four areas of the face (forehead, left
cheek region, right cheek region and chin), each given a score of
0 to 6 based on percentage coverage.
2. Darkness of the hyperpigmentation, where 0 is absent and 4 is
maximum.
3. Homogeneity of the hyperpigmentation, using the same scale as
the darkness measure.4
The usefulness of the MASI score has been disputed on the basis that
it is wholly subjective, but a 2009 study published in the Journal of the
American Academy of Dermatology found it to be a reliable and valid
measure of melasma severity.5 It also serves as a useful evaluation of
treatment outcomes and improvements, says Dr Ravichandran.
According to Aysha Awwad, director of Medico Beauty, many patients
are concerned specifically about premature ageing, focusing on the
appearance of wrinkles rather than uneven pigment. She uses the
Glogau Photo-damage and Ageing Skin Scale (also known as the
Glogau Wrinkle Scale) to determine a patient’s ‘ageing skin type’. This
is determined by the grade of photo-ageing, which is skin damage
primarily visible in the form of discolouration and wrinkles, and which
develops at different ages depending on the degree of exposure
to UV light.6 The scale is used to ascertain which treatments and
products match the patient’s skin type and needs.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

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aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Figure 1: Glogau Photo-damage and Ageing Skin Scale7

Type Description Patient age Indicators

Type 1 Early wrinkles 20s to 30s • Early photo-ageing

• Mild pigment changes
• Minimal wrinkles
• No age spots

Type 2 Wrinkles in motion 30s to 40s • Early to moderate photo-ageing

• Appearance of smile lines
• Early brown age spots
• Skin pores more prominent
• Early changes in skin texture

Type 3 Wrinkles at rest 50s and older • Advanced photo-ageing

• Prominent brown pigmentation
• Visible brown age spots
• Small blood vessels and wrinkles, even at rest

Type 4 Only wrinkles 60s and 70s • Severe photo-ageing

• Yellow-grey skin colour
• Prior skin cancers
• Pre-cancerous skin changes (actinic keratosis)

Treatments and techniques Laser therapy for hyperpigmentation

Hyperpigmentation treatments fall into three main groups: topical
agents, peels and lasers. Triple-combination topical therapy
comprising hydroquinone, tretinoin (a prescription-strength retinoic
acid) and a corticosteroid has been found in a number of studies to
be most effective in treating melasma.8,9 Indeed, Dr Ravichandran
describes this as “the gold standard”, and it is his preferred first-line
treatment. Miss Balaratnam also opts for hydroquinone to inhibit
tyrosinase (which causes melanin cells to become more active),
along with tretinoin “to help drive the product deeper into the
cellular layers in order to target deeper discoloration.” This follows
a Visia Skin Consultation imaging session to analyse a number of
contributors’ complexion health and appearance, including UV spots
that indicate sun damage, skin tone variation, pore size and wrinkles.
The results may also indicate exfoliation with a cosmeceutical such
as alpha hydroxyl acid (AHA), forms of which are beneficial in treating
PIH and melasma.10
Retinoids, such as retinoic acid, have been shown to be effective in
treating PIH,11 but can cause skin irritation. A kinder alternative is the
non-prescription vitamin A derivative retinaldehyde, which is well
tolerated.12 Awwad chooses this in a topical formulation, claiming
it’s gentler than skin-bleaching agents like hydroquinone. “We don’t
want to bleach the pigment out of the skin [with hydroquinone];
we want to understand why the melanocytes are behaving in the
way they are, and regulate their behaviour,” she says. Her clinic’s
treatment protocol also incorporates layered topical treatments
applied after deep cleansing of the skin, using a Forao sonic
cleansing device to stimulate blood flow and maximise penetration
of the active ingredients. Chemical peels in various formulations are
employed by some practitioners and there is evidence to support
their use as a second-line treatment in some patient groups.9,13
Common options include alpha hydroxyl acid (such as glycolic and
mandelic acids) and Jessner’s peel (a medium-depth peel containing
salicylic acid, lactic acid and resorcinol). These are typically applied
in the clinic setting, and used in combination with longer-term topical
therapies that the patient uses at home.
Lasers are commonly the last line of defence against
hyperpigmentation, but some practitioners offer laser/light-
based treatment routinely. At River Medical in Ireland, the Fraxel
Dual 1550/1927 laser is used in patients with prematurely aged
and sun-damaged skin. After a topical anaesthetic cream has
been left on the skin for 45 minutes, the laser is applied, with
treatment taking just 20-40 minutes. “The melanocytes down on
the epidermal/dermal junction grow out like branches of a tree,
which appear as freckles or pigmentation on the skin’s surface,”
business manager Aileen Gillic explains. “So the source of the
problem is not always directly beneath the area of pigmentation
– it might be 5-6cm away. For that reason, a full treatment to
the whole area (the entire face, décolletage or hand) – rather
than just to the pigmented spots – is absolutely necessary.” Side
effects of the 1550 and 1927 nanometre light wavelengths include
redness and swelling immediately after treatment, with a dry and
flaky skin appearance for up to 14 days. “It’s not proper clinical
downtime, but it’s social downtime,” Ms Gillic adds.
Chemical peels in various
formulations are employed
by some practitioners
and there is evidence
to support their use as a
second-line treatment in
some patient groups

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

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aestheticsjournal.com @aestheticsgroup Aesthetics Journal
The laser that has been at the forefront of removing skin pigment
for several years is the Q-switched laser, which uses selective
photothermolysis to target specific areas of hyperpigmentation.
Dermatologist Dr Maria Gonzalez from the Specialist Skin Clinic
uses the ND:Yag (neodymium-doped yttrium aluminium garnet
crystal) 1042 nm laser to treat darker skin, while the 532 nm laser
is indicated in fairer-skinned patients. She chooses laser for
photo-damaged skin in patients who present with solar lentigos,
seborrheic warts and dark freckles, and to treat very extensive or
resistant melasma. “We focus the laser on the area of pigmentation,
but patients are often happier if we treat the whole face as they feel
they’ve got a more even result,” Dr Gonzalez comments. Although
pre-treatment skin preparation does not significantly improve
outcomes, she adds, post-treatment care will usually incorporate an
emollient-based moisturising regime.
Sun protection
Whatever the cause of hyperpigmentation – be it UV damage,
idiopathic melasma, or PIH – exposure to UV radiation generally
exacerbates the condition. Consequently, patients should
take extreme care with sun exposure following treatment for
hyperpigmentation. The primary method of both optimising the
outcomes of the treatment and preventing further photo-damage
and pigmentation is use of a high sun protection factor (SPF) of
at least 30 (some practitioners recommend SPF 50+), applied
liberally throughout the year. “For anybody who embarks on
[hyperpigmentation] treatment, we insist on a homecare regime,
because without that, patients are wasting our time and their
money,” comments Gillic. “As well as year-round SPF 50, I almost
always suggest some vitamin C in the regime to help the sun
protection to work that bit harder.”
Dr Ravichandran promotes sun avoidance. “It’s an absolute must
for all groups of pigmentation disorder,” he says. “I advise patients
against sun beds and sun exposure, and recommend a high SPF
that covers both UVA and UVB, along with a hat and dark glasses,
and covering up in the sun.”
The development of treatment and techniques
In darker-skinned individuals, an almost-ghostly white complexion
with very clear demarcation lines was once a tell-tale sign of
hyperpigmentation treatment. “The only solutions years ago were
harsh chemicals that bleached the skin, and fully ablative laser
treatment,” explains Miss Balaratnam. “Now, we have skin-lightening
agents that are so much kinder to the skin, and they’re becoming
increasingly more sophisticated. From fully ablative to fractionally
ablative lasers, it’s interesting to see how this will develop in the
coming years.”
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
Developments will likely continue to be aimed
at minimising side effects, which – paradoxically
– include increased hyperpigmentation. Dr
Ravichandran believes that advancements in
topical products like liquorice extract will lead
the way, as well as mandelic acid, which “are
showing some promise in the management of
pigmentation”. There is some emerging evidence
of the efficacy of combination salicylic and
mandelic acid peels in treating melasma and PIH,14
with more research needed.
Dr Gonzalez, however, cites more advanced and
targeted lasers as the panacea in pigmentation solutions. “Lasers
have to be seen as the pinnacle in treating hyperpigmentation.
The technology has improved over the last decade or so and is
improving all the time,” she remarks. The biggest development
in recent years has arguably been the picosecond laser, which
effectively delivers a high-energy, very short-wave pulse of light
to a highly targeted area with minimal collateral damage to the
surrounding skin. “I believe there is an advancement of that already
waiting in the wings, so strategic and precise use of lasers is very
much the treatment of the future.”
Greater understanding of the mechanisms that cause melasma
may help to channel future research into effective remedies for this
condition. In general, however, a wider acceptance of the damaging
effects of the sun’s UV radiation – and importantly, adequately
protecting ourselves against the risks of damage – remains the first
defence in staving off and dealing with this ever-challenging complaint. 
REFERENCES
1. C.B. Lynde; J.N. Kraft; C.W. Lynde, ‘Topical Treatments for Melasma and Postinflammatory
Hyperpigmentation’, Skin Therapy Letter, 11(9) (2006), pp. 1-6 
2. World Health Organization, The known health effects of UV (www.who.int, 2015) <http://www.who.int/
uv/faq/uvhealtfac/en/index2.html>
3. Rendon M, Berneburg M, Arellano I, Picardo M., ‘Treatment of melasma’, J Am Acad Dermatol, 54
(2006), pp. 272-81
4. BMJ Best Practice, Melasma Classification (London: BMJ Best Practice, 2015) <http://bestpractice.bmj.
com/best-practice/monograph/627/basics/classification.html>
5. Pandya AG et al. ‘Reliability assessment and validation of the Melasma Area and Severity Index (MASI)
and a new modified MASI scoring method’, Journal of the American Academy of Dermatology, 64(1)
(2011), pp. 78-83.
6. Richard G. Glogau, MD, & Associates, Glogau Wrinkle Scale (San Francisco: SFDerm, 2015) <http://
www.sfderm.com/glogau-wrinkle-scale/>
7. Table adapted from ref. 6.
8. Rivas S and Pandya AG, ‘Treatment of melasma with topical agents, peels and lasers: and evidence-
based review’, American Journal of Clinical Dermatology, 14(5) (2013), pp. 359-76.
9. Shankar K et al, ‘Evidence-based treatment for melasma: expert opinion and a review’. Dermatology
and therapy, 4(2) (2014), pp. 165-86.
10. Van Scott EJ, Yu RJ., ‘Alpha hydroxy acids: Procedures for use in clinical practice’, Cutis, 43 (1989),
pp. 222–8; Van Scott EJ, Yu RJ., ‘Hyperkeratinization, corneocyte cohesion, and alpha
hydroxy acids’, J Am Acad Dermatol, 11 (1984), pp. 867–79; Goodman GJ, Baron JA., ‘Postacne
scarring: A qualitative global scarring grading system’, Dermatol Surg, 32 (2206), pp. 1458–66. Cited
in BS Chandrashekar et al, ‘Retinoic acid and glycolic acid combination in the treatment of acne scars’,
Indian Dermatology Online Journal, 6(2) (2015), pp 84–88.
11. Schmidt JB, Donath P, Hannes J, Perl S, Neumayer R, Reiner A. ‘Tretinoin-iontophoresis in atrophic
acne scars’, Int J Dermatol, 38 (1999), pp. 149–53; Rossi AB, Leyden JJ, Pappert AS, Ramaswamy
A, Nkengne A, Ramaswamy R, et al. ‘A pilot methodology study for the photographic assessment
of post-inflammatory hyperpigmentation in patients treated with tretinoin’. J Eur Acad Dermatol
Venereol. 25 (2011), pp. 398–402. Cited in BS Chandrashekar et al, ‘Retinoic acid and glycolic acid
combination in the treatment of acne scars’, Indian Dermatology Online Journal, 6(2) (2015), pp.
84–88.
12. Saurat JH et al, ‘Topical retinaldehyde on human skin: biological effects and tolerance’, Journal of
Investigative Dermatology, 103(6) (1994), pp. 770-4.
13. Rashmi S et al, ‘Chemical Peels for Melasma in Dark-skinned Patients’, Journal of cutaneous and
aesthetic surgery, 5(4) (2012): 247–253.
14. Garg VK, Sinha S, Sarkar R. ‘Glycolic acid peels versus salicylic-mandelic acid peels in active
acne vulgaris and post-acne scarring and hyperpigmentation: A comparative study’. Dermatol
Surg. 2009;35:59–65, cited in Rashmi S et al, ‘Chemical Peels for Melasma in Dark-skinned Patients’,
Journal of cutaneous and aesthetic surgery, 5(4) (2012), pp. 247–253.
 47
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aestheticsjournal.com @aestheticsgroup Aesthetics Journal
Forehead
rejuvenation
and contouring
strategies
Mr Dalvi Humzah and Anna Baker discuss
anatomically-sound approaches to treating
and re-contouring the forehead
The aesthetic practitioner is able to address and successfully
treat many of the senescent changes of the upper face, in
particular the forehead and glabellar, through a variety of non-
surgical injectable modalities. To achieve an effective result, a
current and accurate anatomical awareness, as well as a detailed
understanding of product suitability is imperative in order to reduce
complications and yield an excellent cosmesis. In this article, a
variety of techniques will be analysed in terms of their suitability to
refine skin texture and re-contour this region.
Key Words
Dermal filler, botulinum toxin A, anatomy, forehead, re-contouring
Introduction
When considering a ‘beautiful’ face, the forehead, in terms of height,
contour and appearance, is accepted as one of the seven keystone
areas to acknowledge.1 In this article, the anatomy of the forehead
and glabellar will be reviewed with regard to the application of
specific non-surgical cosmetic treatments. It is acknowledged
that botulinum toxin is used to effectively reduce and soften the
appearance of static and dynamic rhytides at the forehead and
glabellar.2 The use of dermal fillers to re-contour this region can
provide exceptional results.3 The current literature covers varied
injection techniques to treat the upper face using botulinum toxin,
Figure 1: SCALP
Layer one: Skin
Layer two: Subcutaneous layer
Layer three: Aponeurotic layer, commonly referred to as the
SMAS layer; a strong musculo-aponeurotic sheet, encasing the
whole face
Layer four: Loose areolar tissue; a gliding plane to allow for
mimetic expression
Layer five: Periosteum/ deep tissue (muscle/fascia)
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
one
point
Aesthetics
but little is available in the context of forehead re-contouring. In
this article, the authors will share their specialised techniques,
underpinned by regional anatomy, with discussion of approaches
described within the current literature available. The acronym
in Figure 1 (used by many medical students) will be alluded to
throughout the article, to allow the reader to clearly visualise the
anatomical planes described for product placement.4
The Forehead
Topographically the forehead may be defined as the area bounded
laterally by the superior temporal septum which arises from the
temporal crest, inferiorly by the orbital rims with the supra orbital
adhesion and nasion and superiorly the hairline (a variable which is
difficult in those who are follicularly challenged).5 When describing
the regional anatomy, many texts will address the course and
details of individual structures, which while correct, fails to provide
a three-dimensional description of the areas of interest for a non-
surgical practitioner.
A different view is required when treating an area with what is
essentially a blind approach, as the practitioner can not see the
structures under the skin whether using a needle or cannula. The
five-layered approach outlined above will enable a practitioner
to quickly determine the position of product placement, and
also understand where important structures are in relation to
the approach utilised. It is, however, imperative when using this
approach that the practitioner has an in-depth knowledge of the
named structures in each area.
Layer One: Skin
A lot of vital anatomical information can be learnt by examination
of this important structure. Apart from the overall appearance of
the skin and the ageing changes, superficial arterial and venous
structures may be visible that will alert the injector to avoid
puncturing these – and, in doing so, avoid adverse events. The
dynamic lines in the glabellar region define the underlying median/
 @aestheticsgroup
Forehead 1
MF ST
LT
M P
M: Median forehead
ST: Supratrochlear vessels
MF: Middle forehead fat pad
LT: Lateral temporal cheek compartment
central fat compartment (see layer two). The glabella line also
indicates the line of the supratrochlear vessels located near the
subdermis, and the deep insertion of the medial portion of the
corrugator. The lateral dermal attachments of the corrugator are
often seen as a semicircular depression laterally.6 The horizontal
forehead lines represent septal dermal attachments to the
underlying frontalis, and when running horizontally indicate the
contiguous nature of the frontalis muscle.7 The midline dip and
lateral appearance of the forehead lines indicate the point of
separation and lateral position of the muscle. This approach to
injection, named the ‘objective-muscle-identification approach’,
will help the injector to accurately and effectively tailor toxin
placement.8
Layer Two: Subcutaneous
This is an important layer as many structures are located here and
understanding this area in detail will allow a practitioner to reduce
adverse events. Prior to the seminal work by Rohrich and Pessa,
the subcutaneous fat was viewed as an amorphous structure under
the skin. However, these authors identified three compartments.7
The (median) central compartment is located in the midline region
of the forehead. It has a consistent location that abuts the middle
temporal compartments on either side with an inferior border at the
nasal dorsum (supratrochlear artery). The lateral boundary is possibly
a septal barrier and could be referred to as the central temporal
septum. The middle temporal fat compartments lie on either side of
the central forehead, the inferior border is the orbicularis retaining
ligament, and the lateral border corresponds to the superior
temporal septum. The lateral temporal-cheek compartment connects
the lateral forehead fat to the lateral cheek and cervical fat. The
separation between the middle temporal compartment and lateral
temporal compartment may occasionally be seen as an oblique
depression on the skin in some patients. While these are important
anatomic concepts, it is interesting to note that we are unclear as
yet what their role is in the ageing of the forehead, unlike other
regions that have been examined, for example, the mid-face fat
compartments as described by Gierloff et al.9
Other important structures are the nerves and vessels. The
Trigeminal nerve (Cranial nerve V) branches supply the sensory
innervation to the forehead.5 Lateral to the medial end of the upper
margin of the orbit, the supraorbital nerve indents the bone into a
foramen. The nerve passes superiorly and penetrates the frontalis
around the superior orbital adhesion and runs superiorly in the
forehead fat supratrochlear to supply the scalp and vertex. The
smaller supratrochlear nerve passes up on the medial side of the
supraorbital nerve penetrating frontalis similarly to innervate the
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
Forehead 2
SOM SOL
ST
ROOF
P: Procerus
ST: Supratrochlear
SOM: Supratrochlear medial
SOL: Supratrochlear lateral
ROOF: Retro orbicularis orbital fat
medial forehead and the infratrochlear nerve supplies skin on the
medial eyelid(s), passing above the medial palpebral ligament.10
Frontal branches of the facial nerve transition subcutaneously in the
temple to innervate the frontalis segmentally in the subcutaneous
plane (layer two).11
Accompanying the nerves, the arteries follow a similar course.
The skin of the glabellar and forehead region is mainly supplied
by branches from the bilateral supratrochlear, supraorbital and
superficial temporal arteries.12 The supratrochlear artery branches
from the ophthalmic artery in the orbit and emerges by piercing
the orbital septum above the medial canthal tendon.10 It runs in the
vicinity of the procerus and corrugator muscles in the nasal root
and the glabellar area, passing subcutaneously in level two on its
superior path. The artery has several branches during its course and
anastomoses with the supraorbital artery and supratrochlear artery.10
Within the corrugator complex, the artery is vulnerable to injury from
needle puncture from toxin needle placement and caution is advised
here due to its superficial path. The main artery runs in the glabellar
line often just under the subdermis in layer two.12
The supraorbital artery is the larger of the two; it divides into a
superficial and deep branch, and the former penetrates the frontalis
and enters layer two; then anastomosing with the superficial
temporal artery and lacrimal artery. It thus connects the internal and
external carotid systems.12 Due to these anastomoses within this
layer, the injector must approach layer two with a high degree of
caution to reduce potentially irreversible complications. The deep
branch runs on the deep surface of the frontalis and runs obliquely
laterally – often leaving an indentation on the bone. Occasionally
the deep branch will separate in the orbital cavity and enters the
forehead through a separate bony canal approximately one cm
above the midportion of the orbital rim.13 Deep injections of toxin
in this region may spread down this canal and enter the orbital
contents, resulting in ptosis.13
The venous return from the face is usually superficial; the
supraorbital and supratrochlear veins traverse to the medial
canthus where they unite to form the angular vein.14 This becomes
the facial vein, which pursues a straight course behind the facial
artery, just below the border of the mandible. Blood from the
upper lateral forehead is also collected into the tributaries of the
superficial temporal vein.14
Layer Three: Frontalis
The occipito-frontalis is an exceptionally thin muscle, fusing with
the galea aponeurotica from the lateral two thirds of the highest
nuchal line of the occipital bone, extending its fine fibres anteriorly
to fuse with the procerus muscle at the nasal bone.15 It is part of
aestheticsjournal.com @aestheticsgroup Aesthetics Journal
a group of musculoaponeurotic muscles, which elevate the brow
with medial fibres blending inferiorly with the corrugator supercilli
and orbicularis oculi muscles blending laterally with orbicularis oculi
over the external frontal bone.
The occiptofrontalis muscle represents the third layer in the scalp,
which equates to the superficial musculoaponeurotic system
(SMAS) layer in the face. Spiegel et al established that superiorly
to the nasion, the frontalis fibres are contiguous for a variable
distance before an aponeurosis is apparent in the space between
the bilateral muscles, which may vary considerably between
individuals.16 Male subjects may display a wide variation in the
medial muscle border as a ‘W’ shape with a variable attenuation
point. Female subjects demonstrate a less irregular central
dehiscence shape with a continuous frontalis and ‘V’ shape
dehiscence. The dynamic forehead lines may indicate the muscle
configuration (see layer one). These findings are key in analysing
the frontalis muscle activity accurately, to treat effectively and
administer botulinum toxin judiciously.
Appropriate patient selection for botulinum toxin is crucial. Patients with
brow ptosis are poor candidates for correction of forehead ryhtides
with toxin.1 This needs to be assessed prior to considering treatment.
If present, in the authors’ experience, dermal fillers (including skin
boosting or intradermal blanching) may provide superior results, and
may additionally subtly enhance the position of the brows.
Layer Four: Loose Areolar Tissue
This layer represents a gliding plane – essentially an avascular
plane. The frontalis glides over this layer and is a safe plane to
place dermal fillers for deep forehead contouring (see below), as
an avascular plane does not comprise any vessels or structures to
compromise.
Layer Five: Periosteum
The final layer is anatomically the point where the ligaments that
define the forehead arise. Moss et al5 describe the following
arrangement of ligamentous attachments in the upper face: the
temporal ligamentous adhesion supports the region immediately
superior to the eyebrow at the junction of its middle and lateral
thirds. Located at the intersection of the temporal, frontal and
Figure 2: Principle retaining ligament defining
the forehead and temporal boundary
Superior temporal
septum
Inferior temporal
septum
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
periorbital regions are the superior temporal septum, the inferior
temporal septum and the supraorbital adhesion. The temporal
ligament arises from the frontal bone as an expansion at the
anterior end of the superior temporal septum, inserting into the
superficial fascia at the junction of the superficial temporal fascia
and galea, on the deep surface of the frontalis muscle. The base
is located parallel to the arcus marginalis of the orbital rim at a
distance of 10mm above it. The superior temporal septum arises
from the periosteum along the superior temporal line of the
skull and inserts into the line of junction between the superficial
temporal fascia and the galea. Anteriorly, this line of junction
occurs between the superficial temporal fascia and the galea,
lining the deep surface of the lateral border of the frontalis muscle;
the expanded end is the temporal ligamentous adhesion. The
supraorbital ligamentous adhesion arises from the frontal bone
above the orbital rim, extending between the temporal ligament
and the origin of the corrugator muscle. The inferior border
is located approximately 6mm above the deep attachment of
the periorbital septum; the ligament is condensed around the
branches of the supra-orbital nerve and corrugator muscle origin.
The periorbital septum originates from three-quarters of the
circumference of the orbital rim, extending from the corrugator
origin around to the inferomedial boney origin of the orbicularis
oculi. The origin and boundaries of these attachments are
significant in terms of re-contouring the forehead with dermal fillers
within the supraperiosteal plane; placement with a blunt cannula
does not permit dissection of these fixed attachments, thus,
product remains safely enclosed within the desired plane and
anatomical boundary (Figure 1).
Anaesthesia
For optimum patient comfort when re-contouring the forehead, it may
be preferable to block the supratrochlear and supraorbital nerves
respectively. 3% mepivicaine or 2% lidocaine may utilised for this
purpose, with small volumes used to specifically block these nerves
low in the supraorbital region.17 Lidocaine mixed with the dermal filler
may also be used, although the injection technique is slower and
may still be uncomfortable for the patient.
Topical anaesthesia is insufficient for this advanced deep technique,
despite the use of a blunt cannula as the supraorbital nerves
innervate the underside of the frontalis and periosteum.17
Deep Correction
Re-contouring the forehead using a supraperiosteal
approach is gaining popularity.13 Redefining this
anatomical region provides a youthful contour,
and facilitates deep support in counteracting the
morphological age-related bone resorbtion noted in
both male and female individuals at the glabellar angle.15
Restoring the boney support to the frontal eminence, as
well as the lateral brow, achieves a subtle redraping of
the overlying tissues and the procedure is popular within
certain ethnic populations who strive achieve a rounded,
convex appearance to the forehead.3 Facial mapping
prior to treatment, along with baseline photography, is
key for practitioner and patient to agree on the expected
outcome from treatment.
Once the full face has been thoroughly cleaned with
chlorhexidine and hair tied back, re-contouring may be
achieved by commencing an entry point medial to the
 @aestheticsgroup
A male patient may
favour augmentation of
the supraciliary arch to
enhance a masculine
brow in conjunction with
the frontal eminence,
with threads placed
supraperiosteally
temporal fusion line, utilising a 25g needle entry point to the depth
of the supraperiosteal plane (layer four). Calcium hydroxylapatite
with its highly viscous, elastic and cohesive properties without
additional lidocaine provides an ideal product to use in this layer.
A 25g cannula is inserted along the supraperiosteal plane to
deposit linear threads of product to augment the right and left
frontal eminences from the lateral entry points. The volume of
product required to achieve the desired result will vary between
individuals, depending upon the degree of correction required. A
cannula length of 38mm or 50mm is preferable, depending on the
dimensions of the frontal bone; within the supraperiosteal plane,
the cannula will glide with ease without risk of injury to nerves or
vascular compromise. Busso and Howell describe this technique
as ‘horse shoe’ placement of product, which achieves a subtle
lift across the length of the brow. 3 A male patient may favour
augmentation of the supraciliary arch to enhance a masculine
brow in conjunction with the frontal eminence, with threads
placed supraperiosteally. Following correction, the product is
then moulded into the desired contour, and the patient advised to
withhold from applying makeup for 48 hours.
Loghem et al concur that a cannula approach is preferable,
and also advocate an entry point from the temporal crest.18 The
ligamentous attachments in the upper face aid in retaining the
product supraperiosteally, facilitated further by cannula placement.18
Superficial Correction
To further enhance the result of the deep correction, it is possible
to combine the use of botulinum toxin A to soften dynamic
ryhtides across the forehead and glabellar complex. For more
established ryhtides, a cohesive, polydensified matrix hyaluronic
acid dermal filler may be combined through a ‘blanching’
technique using a 30g needle, described by Micheels et al, who
postulate that blanching is not caused by vasoconstriction, but
instead by the transparent and transient appearance of the gel in
close proximity to the skin’s surface.19 A superficial or intradermal
depth may be established by ‘tenting’ the needle to visualise the
outline in the skin, with the bevel placed downwards, depositing
multiple bead-like punctures, just under the skin until the rhytide
has been eliminated. The product is gently massaged following
correction, providing exceptional levels of correction for static
and/or superficial rhytides.
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
Conclusion
The content of this paper has been compiled to equip the clinician
with current evidence and knowledge pertaining to non-surgical
forehead re-contouring. The key to successfully and safely treating
this region is a current and accurate anatomical knowledge and in
particular an understanding of the layered concept in relation to the
forehead (SCALP). Anatomy is a dynamic and three dimensional
subject; as anatomical awareness develops, it is imperative that
practitioners keep abreast of this specialist subject. Didactic and
interactive practical teaching courses will enable an in-depth
analysis in respect to important facial structures. Once this view
is appreciated, it will enable practitioners to develop safe and
effective techniques in treating facial zones.
Mr Dalvi Humzah is a consultant plastic reconstructive
and aesthetic surgeon, with a BSc in anatomy. He has
been a tutor for the Royal College of Surgeons of England
and is an examiner for the Intercollegiate MRCS for the
Royal College of Surgeons of Glasgow. He is the lead
tutor for the award-winning teaching programme, Facial Anatomy
Teaching, and actively teaches and lectures internationally.
Anna Baker is a dermatology and cosmetic nurse
practitioner. She runs the nurse-led Medicos Rx Skin
Clinic at The Nuffield Health Hospital in Cheltenham,
and is the coordinator for Facial Anatomy Teaching.
Baker runs nurse-led photodynamic therapy clinics for
non-melanoma skin cancer and is currently studying post-graduate
Applied Clinical Anatomy at Keele University.
REFERENCES
1. Little A.C., Jones B.C., DeBruine L.M., ‘Facial attractiveness: evolutionary based research’, Trans P.,
Soc B., 366 (2011), pp. 1638-1659.
2. Dubina M., Tung R., Bolotin D., Mahoney A.M., Tayebi B., Sato M., Mulinari-Brenner F., Jones T.,
West D.P., Poon E., Nodzenski M., Alam M., ‘Treatment of forehead/glabellar rhytide complex
with combination botulinum toxin a and hylaruronic acid versus botulinum toxin A injection alone:
a split-face, rater-blinded, randomized control trial’, Journal of Cosmetic Dermatology, 12(4) (2013),
pp. 261-6.
3. Busso M., Howel J.D., ‘Forehead Recontouring Using Calcium Hydroxylapatite’, Dermatologic
Surgery, 36 (2010), pp. 1910-1913.
4. Smith A.G., Irving’s Anatomy (4th Ed.) (Churchill Livingstone, 1972)
5. Moss J.C., Mendelson B.C., Taylor G.I. ‘Surgical Anatomy of the Ligamentous Attachments in the
Temple and Periorbital Regions’, Plastic And Reconstructive Surgery, 105 (4) (2000), pp. 1475-1489.
6. Weider J.M., Moy L.R, ‘Understanding botulinum toxin surgical anatomy of the frown, forehead and
periocular region’, Dermatological Surgery, 24 (1998), pp. 1172-1174.
7. Rohrich R.J., Pessa J.E. ‘The Fat Compartments of the Face: Anatomy and Clinical
Implications for Cosmetic Surgery’, Plastic And Reconstructive Surgery. 119(7):2219-2227.
8. Guerrerosantos J., Eduardo P.G.C., Arriola J.M., Manzano A.I.V.,Villarian-Munoz B., Benavides
L.G., Vazquez M.G., ‘Effectiveness of Botulinum Toxin (Type A) administered by the fixed-site dosing
approach versus the muscle area identification’, Aesthetic Plastic Surgery, 39 (2015), pp. 243-251.
9. Gierloff M., Stohring C., Buder T., Gassling V., Acil Y., Wiltfang J., ‘Aging Changes of the Midfacial Fat
Compartments: A Computed Tomographic Study’, Plastic And Reconstructive Surgery, 129(1) (2012),
pp. 263-273.
10. Sinnatamby C.S. (2006) Lasts Anatomy Regional & Applied. 11th Edition. Churchill Livingstone
Elsevier.
11. Agarwal C.A., Mendenhall S.D., Foreman K.B., Owsley J.Q., ‘The Course of the Frontal Branch of the
Facial Nerve in Relation to Facial Planes: An Anatomic Study’, Plastic And Reconstructive Surgery,
125(2) (2010), pp. 532-537.
12. Shimizu, Y., Imanishi N., Nakajima T., Nakajima H., Aiso A., Kishi K., ‘Venous Architecture of the
Glabellar to the Forehead Region’, Clinical Anatomy, 26(2) (2013), pp. 183-195.
13. Carruthers J.D.A., Fagien S., Rohrich., R.J., Weinkle S., Carruthers A. (2014). Blindness Caused by
Cosmetic Filler Injection: A Review of Cause and Therapy. Plast Reconstr Surg 134(6):1197-1201.
14. Imanishi N., Najajima H., Minabe T., Chang H., Aiso S., ‘Venous Drainage Architecture of the
Temporal and Parietal Regiosn: Anatomy of the Superficial Temporal Artery and Vein’, Plastic And
Reconstructive Surgery, 109(7) (2002), pp. 2197-2203.
15. Lorenc Z.P., Smith S., Nestor M., Moradi A. ‘Understanding the functional anatomy of the frontalis
and glabellar complex for optimal aesthetic botulinum toxin type A therapy’, Aesthetic
Plastic Surgery, 37(5) (2013), pp. 975-83.
16. Spiegel J.H., Goerig R.C., Lufler R.S., Hoagland T.M., ‘Frontalis midline dehiscence: An anatomical
study and discussion of clinical relevance’, Journal of Plastic, Reconstructive & Aesthetic
Surgery, 62 (2009), pp. 950-954.
17. Zide B.M., Swift R., ‘How to block and tackle the face’, Plast Reconstr Surg, 101(3) (1998), pp. 840-51.
18. Loghem J., Yutskovskaya Y.A., Werschler W.P., ‘Calcium Hydroxylapatite: Over a Decade of Clinical
Experience’, The Journal of Clinical and Aesthetic Dermatology, 8(11) (2015), pp. 38-49.
19. Micheels P., Sarazin D., Besse S., Sundaram H., Flynn T.C. ‘A Blanching Technique for Intradermal
Injection of the Hylauronic Acid Belotero’, Plastic And Reconstructive Surgery, 132(4S-2) (2013), pp.
59S-68S.
 LIFT, CONTOUR &
REJUVENATE
with long-term collagen stimulation

The Lifting Filler

LESS
Call Merz Aesthetics Customer Services now
INTACT to find out more or to place an order
COLLAGEN

P
Tel: +44 (0) 333 200 4140
S TO
RAD144/0215/LD Date of preparation: February 2015

Email: customerservices@merz.com
REDUCED LACK OF www.radiesse.co.uk
COLLAGEN STRUCTURAL
SYNTHESIS SUPPORT

LOSS OF
FIBROBLAST
ACTIVITY
The Lifting Filler
aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

move away from removal of excess skin and towards a trend to

replace volume and induce collagen stimulation. Restoration of the
periorbita is multifaceted and entails smoothing of the lower eyelid,
often using a combination of different modalities, such as botulinum
toxin, fillers, lasers, radiofrequency and ultrasound technology, to
achieve the best aesthetic outcome.
Increased collagen degradation and decreased collagen synthesis
means the adult skin loses approximately 1% of its dermal collagen
content on an annual basis.5,6

Treatment Options
Technological advancements have been made to increase collagen
synthesis. Skin rejuvenation can be categorised into two main
categories: invasive and non invasive. In the last decade, there
has been increased demand for noninvasive procedures for skin
rejuvenation and a simultaneous explosion of new non-surgical

Tri Eye techniques and combinations of such treatments to improve and

rejuvenate the skin around the peri-orbita. These modalities include
Intense Pulsed Light (IPL), fractionated laser treatments, radiofrequency
and ultrasound technology. The evolving list of nonablative lasers

Treatment
and light systems also includes broadband infrared light, dual yellow
laser, pulsed dye (585, 595 nm), Nd: Yag (1064, 1320nm), Diode
(910, 1450 nm) and Er: Glass (1540 nm lasers).7 IPL is a non-coherent
light that covers a large wavelength to be absorbed by the desired
chromophores. It works by causing reversible thermal damage to
collagen in the dermal layer and helps fibre remodeling without
Dr Maryam Zamani provides ablation to the epidermis.8 Regia et al showed improvement in flaccid
an overview of the aesthetic skin related to the increase of collagen in the deep reticular dermis,
promoting a skin tightening effect with IPL.8 Periorbital and facial
treatments available for rejuvenation treatment with IPL may help those patients with Fitzpatrick Skin types
of the eye, and details her ‘Tri I-IV with pigmentation and vascular issues with secondary benefits of
mild collagen induction.9
Eye Rejuventation’ and ‘Tri Eye Radiofrequency is another nonablative skin rejuvenation modality used
Transformation’ techniques to cause shrinkage of dermal collagen and promote the formation

The eyes are the aesthetic centre of the face and are often Figure 1
referred to as the ‘window to the soul’. The periorbita is an area
where we can often see the first signs of ageing and is cause for
common requests for rejuvenation in aesthetic practices. Complaints
include excess skin, fine lines and wrinkles, puffiness around the
eyes and pigmentation issues. To understand these issues we need f
to understand the process by which they occur. g

Starting in the third decade of life, redundancy of upper eyelid skin a h

begins and continues to progress until that skin rests on the upper i
b
eyelid lashes. This results in a hooded appearance that can also c
d
be accentuated by the descension of the brow and underlying fat
e j
pads. In the fourth decade of life, the lateral canthal rhytids and
accentuation of the lower eyelid folds are apparent at rest. This
is followed by the herniation of fat pads in the upper and lower
eyelids (Figure 1).1
With age, the cheek, periorbita and subobicularis fat atrophy while the Lid cheek segment
orbital retaining ligament relaxes. The process results in a downward Malar segment
Nasolabial segment
displacement of the lid-cheek junction and an indentation between
the lower eyelid and the cheek, also known as the tear trough.2
Other factors can influence the appearance of the tear trough as
well. Volume loss accentuates the nasojugal grove and the inferior a Dermatochalasis g Central fat pad
b Pelpebromalar groove h Lacrimal gland
orbital rim creating a hollow appearance (Figure 1).3 Some individuals c Malar mound i Fat herniation
are predisposed to having lower eyelid fat prolapse that can further d Mid cheek groove • Lower medial fat pad
e Tear trough • Lower central fat pad
accentuate the loss of volume directly inferior.4 Bone resorption in (Nasojugal groove) • Lower lateral fat pad
facial ageing in conjunction with soft tissue atrophy has created a f Medial fat pad j Malar fat pad (descent)

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

 @aestheticsgroup
Figure 2: Reticular vessels treated with Nd: Yag 1064 Figure 3: Tri Eye Rejuvenation:
Before
After
Before and two weeks following treatment Before and three months after treatment with Botulinum
toxin A, Volbella and Ultherapy
of new collagen through controlled neocollagenesis without
integumental injury. Radiofrequency devices are able to achieve
greater depths of thermal injury with tissue penetration to the level
of the dermis and subcutaneous layer without producing thermal
burns.5 Such treatments are generally a succession of four to eight
treatments depending on the particular device used.
Nd: YAG 1064 laser and the Norseld Dual Yellow Laser are non-
ablative lasers used for aesthetic rejuvenation of the face. Nd:
YAG 1064 can be used successfully and selectively to target
haemoglobin in reticular vessels seen in the peri-orbita and
temples (Figure 2).10 Norseld Dual Yellow Laser also uses the 578
nm yellow wavelength to target chromphores associated with
oxyhaemoglobin in red telangectatic vessels. The Norseld laser is
highly successful in treating small red telangectatic vessels along
the eyelid margin.11
Fractional resurfacing for aesthetic enhancement continues to
evolve using ablative, non-ablative and fractional technologies
because of their improved safety profile. These three approaches
mainly differ in the mode of thermal damage, degrees of efficacy
and downtime.12 Fractional laser technology has gained increased
popularity in improving scars, fine lines, dyspigmentation, and
wrinkles because of its favourable side effect profile, recovery time
and outcome.12,13 Common indications for both non-ablative and
ablative resurfacing are for periorbital wrinkles, photo ageing and
dyschromias. Laser resurfacing is used to help remove a specific
layer of skin down to a specific depth of skin. In doing so, fine
lines and wrinkles can be softened, pigmentation improved and
skin tightened. Ablative lasers have the advantage of predictable
depth of tissue ablation. Erbium; YAG lasers such as the iPixel
by Alma can represent an improvement over CO2 lasers in
producing less downtime.12,14,15 Fractional resurfacing produces
specific microthermal zones of photothermolysis creating columns
of injury whereas ablative skin resurfacing creates a confluent
area of epidermal and dermal injury.16 Fractional thermolysis
leaves intervening areas of normal skin untouched whereby
re-epithelialisation and repair can occur rapidly. These treated
zones compromise 15-25% of the skin surface per treatment
depending on the machine, wavelength, fluency and stacking
application of the laser. From my experience, generally two to
six sessions are needed to complete a treatment. Similar to
ablative resurfacing, the thermally ablated tissue is repopulated
by fibroblast-derived neocollagenosis and epidermal stem cell
production.12 The advantages of the fractionated laser treatment
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
Figure 4: Tri Eye Transformation
Before Before
After After
Before and one month following treatment
include reduced erythema, oedema, downtime and dyschromic
changes, particularly important in treating Fitzpatrick skin types V
and VI.12 Such treatment modalities have an important role in treating
the delicate lower eyelid skin, particularly in patients that are not yet
candidates for lower eyelid blepharoplasty. In a comparative split-face
trial with fractional Er:YAG and microfractional CO2 laser resurfacing
showed greater efficacy and patient satisfaction for the fractional
CO2 laser,17 however recovery time and risks for CO2 laser were
higher. The spectrum of adverse sequel range from mild (prolonged
erythema, milia) to moderate (transient to permanent dyspigmentation,
local infection) to severe (hypertrophic scarring, ectropian, systemic
infection).1
Ultherapy is another non-invasive treatment modality using
microfocused ultrasound (MFU) with visualisation to create thermal
micro-injuries also known as thermal coagulation points (TCP) in
the dermis and subdermal tissue. Despite its lower energy, MFU is
capable of heating tissue to greater than 60C to a depth of 5mm
within the mid to deep reticular layer of the dermis and subdermis,
while sparing the overlying papillary dermal and epidermal layers
of the skin.18,19 MFU causes collagen fibres in the superficial
musculoaponeurotoic system and deep reticular dermis to contract
and stimulate de novo collagen.18 An ultimate lift is created in the
healing of the TVP resulting in firming, tightening and shrinking
of the dermis and subdermal tissues. The efficacies of Ultherapy
treatments vary on the vector direction of treatment and the total
energy supplied. Off label, Ultherapy has been used for improving
the infraorbital skin laxity by both tightening the obicularis oculi
muscle and the orbital septum.18,20,21 Ultherapy has a reputation of
being painful; however with proper pre-treatment analgesics, this is
well controlled.22 Pain, oedema, headache, numbness, paresis, PIH,
bruising and welts are potential transient risk profiles that need to
be discussed with the patient.23
Botulinum toxin is an effective neuromodulator used in aesthetic
rejuvenation to temporarily paralyse the muscles of facial
expression thereby decreasing wrinkle lines created by muscle
activity. In the periorbita, botulinum toxin has FDA approval for
treatment of the crow’s feet and glabellar lines and can be effective
in treating the lower eyelid lines and elevating the tail of the
eyebrow. As a low risk procedure, botulinum toxin is considered a
relatively safe treatment to help diminish the lines created by facial
expression.24
Hyaluronic acid (HA) fillers are now playing an even bigger role in
treating the ageing eye and face as a three dimensional approach
aestheticsjournal.com @aestheticsgroup Aesthetics Journal
to rejuvenation with particular attention to proportional ideals. In
determining the HA to use in the periorbita it is essential to look
at the viscosity (how the gel flows from the needle) and elastic
modulus (gel stiffness) of the product. In treating the periorbita,
I prefer using products from the Juvéderm Vycross family,
particularly Volbella in the anatomical tear trough because of its
lower HA concentration of 15 mg/ml. A lower HA concentration
means the gel is less hydrophilic and will absorb less water from
surrounding tissue, causing less oedema.25 HA can be injected into
the peri-orbita and malar region with both deep (pre-periosteal and
submuscular) and dermal injections in order to temporarily help
reduce the appearance of lines and wrinkles. While techniques
vary, most incorporate serial depots of HA along the inferior orbital
rim, into the subobicularis oculi muscle either in a ‘haystacking’
or injection-withdrawal technique to layer support. An often
undertreated and neglected area for HA treatment is temporal
hollowing and can have a significant impact on overall facial
rejuvenation. All HA injections in the periorbita carry significant risk
and great care to understand and respect the underlying anatomy
must be taken to minimise potential pitfalls.
Tri Eye Rejuvenation and Transformation
In treating the periorbita, there is a vast array of combination
treatments that can be implemented. I find that often the most
successful aesthetic results come from combining different
modalities together to create a more unified approach to
rejuvenation and improve overall patient satisfaction. Creating a
patient specific treatment plan to combat specific issues is needed
for a complete rejuvenation. The combination of botulinum toxin
type A and hyaluronic acid appear to rejuvenate the periorbital
and temporal areas, glabella, and crow’s feet areas with minimal
adverse effects and with higher rate of patient satisfaction.26 In
my practice, I have created a triad of treatments in two specific
non-surgical protocols called the ‘Tri Eye Rejuvenation’ and ‘Tri
Eye Transformation’ to address the ageing periorbita. I have a
significant number of patients who present in my clinic complaining
REFERENCES
1. Scarborough, D., Herron, J., Khan, A., Bisaccia, E., ‘Periorbital Rejuvenation for Early Signs of Aging:
Exploring Aesthetic Interventions Part 2’, The Dermatologist, (1) (2003)
2. Rebecca Tung, R., Ruiz de Luzuriaga, A., Park, K., Mauricio Sato, M., Dubina, M., Alam, M., ‘Brighter
Eyes: Combined Upper Cheek and Tear Trough Augmentation: A Systematic Approach Utilizing
Two Complementary Hyaluronic Acid Fillers’, Journal of drugs in Dermatology, 11 (9) (2012)
3. Hamman, MS., Fabi, S.,  Goldman, M., ‘Comparison of Two Techniques Using Hyaluronic Acid to
Correct the Tear Trough Deformity’, Journal of Drugs in Dermatology, 11 (12) (2012).
4. S M Salvi, S Akhtar, and Z Currie, ‘Ageing changes in the eye’, Postgrad Med J., 82(971) (2006), pp.
581–587.
5. Elsaie ML., ‘Cutaneous remodelling and photorejuvenation using radiofrequency devices’, Indian J
Dermatol, 54 (2009), pp. 201-5.
6. Chung J, Cho S, Kang S. ‘Why does the skin age? Intrinsic aging, photoaging and their
pathophysiology’, In : Photoaging, Rigel Ds, Weiss RA, Lim HW, Dover JS, editors. (New York: Marcel
Dekker Inc, 2004), p. 13.
7. Choi YJ, Lee JY, Ahn JY, Kim MN, Park MY., ‘The safety and efficacy of a combined diode laser and
bipolar radiofrequency compared with combined infrared light and bipolar radiofrequency for skin
rejuvenation’, Indian J Dermatol Venereol Leprol, 78 (2012), pp. 146-52.
8. Patriota RC, Rodrigues CJ, Cucé LC., ‘Intense pulsed light in photoaging: a clinical, histopathological
and immunohistochemical evaluation’, An. Bras. Dermatol, 86 (2011)
9. Goldberg DJ., ‘New collagen formation after dermal remodeling with an intense pulsed light
source’, J Cutan Laser Ther., 2 (2000), pp. 59–61.
10. Ozyurt, K., Colgecen E., Baykan, H., Ozturk, P., Ozkose, O.,‘Treatment of Superficial Cutaneous
Vascular Lesions: Experience with the Long-Pulsed 1064 nm Nd:YAG Laser’, ScientificWorldJournal,
197139 (2012)
11. Norseld, Laser Treatments: Vascular Lesions (norseld.com, 2014) <http://norseld.com/index.php/
laser-treatments/#tabs-2>
12. Goel A, Krupashankar DS, Aurangabadkar S, Nischal KC, Omprakash HM, Mysore V., ‘Fractional
lasers in dermatology- Current status and recommendations’, Dermatosurgery Specials 77 (3) (2011),
pp. 369-379.
13. Brightman LA, Brauer JA, Anolik R, Weiss E, Karen J, Chapas A, et al., ‘Ablative and fractional
ablative lasers’, Dermatol Clin, 27 (2009), pp. 479-89.
14. Fitzpatrick RE, Goldman MP, Satur NM, Tope WD., ‘Pulsed carbon dioxide laser resurfacing of
photoaged facial skin’, Arch Dermatol, 132 (1996), pp. 395-40.
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
of the appearance of the skin around the eyes but who are not yet
surgical candidates or do not feel ready or willing to have surgery.
The ‘Tri Eye Rejuvenation’ combines botulinum toxin, HA fillers and
Ultherapy in two sessions, ten to 14 days apart, to treat brow ptosis,
crow’s feet and the tear trough in a younger patient generally aged
30-50. In the first visit, Ultherapy is used to treat the brow and the
lower eyelid and to promote lifting and tightening of the periorbita.
10-14 days later patients return for treatment of the tear trough and
temples with HA fillers and toxin to the crow’s feet (Figure 3). All
patients are educated about waiting three to six months to observe
the final improvement from Ultherapy and that botulinum toxin and
HA treatments require maintenance.
Alternatively ‘Tri Eye Transformation’ combines HA filler, laser and
the iPixel to treat patients that suffer more from periorbital volume
loss resulting in fine lines, wrinkles and prominence of vasculature.
This treatment has approximately three to six days of downtime. In
the first visit, Norseld or Nd: Yag is used to target telangectactic and
reticular vessels in the periorbita. On the same visit, iPixel is used to
fractionally ablate the periorbital skin. Three more sessions of iPixel
are completed monthly and upon satisfaction of this resurfacing, HA
filler is injected to help augment the volume loss in the temples and
periorbita, which includes the tear trough and mid cheek segments.
Conclusion
Both these and other combination treatments used for rejuvenation
of the periorbital region have been tested to show relatively
long-lastingefficacy and high patient satisfaction.27, 28 Integrated
treatments for the eye area using variant procedures creates a
greater understanding of the multifaceted changes that occur in the
ageing face.
Dr Maryam Zamani is an oculoplastic surgeon and
aesthetic doctor. Dr Zamani specialises in surgical and
non-surgical aesthetic procedures at the Cadogan
Clinic. A graduate from Georgetown University and
George Washington University School of Medicine,
USA, Dr Zamani completed her studies at Imperial College and
Cardiff University.
15. Alexiades-Armenakas MR, Dover JS, Arndt KA., ‘The spectrum of laser skin resurfacing:
Nonablative, fractional, and ablative laser resurfacing’. J Am Acad Dermatol, 58 (2008), pp. 719-37.
16. Hantash BM, Bedi VP, Sudireddy V, Struck SK, Herron GS, Chan KF., ‘Laser-induced transepidermal
elimination of dermal content by fractional photothermolysis,’ J Biomed Opt, 11 (2006).
17. Lomeo G, Cassuto D, Scrimali L, Sirago P. Er: YAG versus CO2 ablative fractional resurfacing:
A split face study. Abstract presented at American Society for Laser Medicine and Surgery
Conference, April 2008, Kissimmee, FL.
18. Fabi SG., ‘Noninvasive skin tightening: focus on new ultrasound techniques’, Clinical, Cosmetic and
Investigational Dermatology, 8 (2015), pp. 47-52.
19. Kim YS, Rhim H, Choi MJ, Lim HK, Choi D., ‘High-intensity focused ultrasound therapy: an overview
for radiologists’, Korean J Radiol, 2008;9 (2008), pp. 291–302.
20. Suh DH, Oh YJ, Lee SJ, et al., ‘A intense-focused ultrasound tightening for the treatment of
infraorbital laxity’, J Cosmet Laser Ther, 14 (2012), pp. 290–295.
21. Pak CS, Lee YK, Jeong JH, Kim JH, Seo JD, Heo CY., ‘Safety and efficacy of Ulthera in the
rejuvenation of aging lower eyelids: a pivotal clinical trial’, Aesthetic Plast Surg, 38(5) (2014), pp.
861–868.
22. Fabi, SG., ‘Noninvasive skin tightening: focus on new ultrasound techniques’, Clin Cosmet Investig
Dermatol, 8 (2015), pp. 47–52.
23. Hitchcock, T., Dobke, M., ‘Review of the safety profile for microfocused ultrasound with
visualization’, Journal of Cosmetic Dermatology, 13 (4) (2014), pp. 329–335.
24. De Boulle, K., Fagien S.,, Sommer, B., Glogau, R., ‘Treating glabellar lines with botulinum toxin type
A-hemagglutinin complex: A review of the science, the clinical data, and patient satisfaction’, Clin
Interv Aging, 5 (2010), pp. 101–118.
25. Eccelston D., Murphy, DK. , ‘Juvederm Volbella in the perioral area: a 12-month prospective,
multicenter, open-label study’, Clinical, Cosmetic and Investigational Dermatology (2012), pp.
167-172.
26. Beer KR, Julius H., Dunn M., Wilson F. , ‘Remodeling of periorbital, temporal, glabellar, and crow’s
feet areas with hyaluronic acid and botulinum toxin’, J Cosmet Dermatol, 13 (2) (2014), pp. 143-50.
27. Kearney C, Brew D., ‘Single-session combination treatment with intense pulsed light and nonablative
fractional photothermolysis: a split-face study’, Dermatol Surg, 38(7 Pt 1) (2012), pp. 1002-9.
28. Choi YJ, Lee JY, Ahn JY, Kim MN, Park MY., ‘The safety and efficacy of a combined diode laser and
bipolar radiofrequency compared with combined infrared light and bipolar radiofrequency for skin
rejuvenation’, Indian J Dermatol Venereol Leprol, 2012 78(2) (2012), pp. 146-52.
 Aesthetics Awards
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 @aestheticsgroup
Hyaluronidase
Protocol
Aesthetic nurse Lee Rowe outlines the
protocol for administering hyaluronidase
and highlights the importance of
understanding its use in aesthetics
Introduction
The aesthetic community is expanding, with non-surgical treatments now
contributing to 75% of the market, making the industry worth an estimated
£3.6 billion in 2015, in the UK alone.1 Numerous training days are held across
the UK, qualifying delegates to obtain and use hyaluronic acid (HA) dermal
fillers for their patients’ anti-ageing concerns. However, as we know, the art of
injecting is just one aspect of this treatment; other aspects include knowledge
and understanding of anatomy and physiology, consenting issues, aftercare
and, more importantly, complication management. I find practitioners are
frequently raising the issue of how to treat complications on support forums,
networking groups and during study days. It is a worrying sight to see how many
practitioners do not feel confident nor hold the experience to deal with the
adverse reactions that can be so detrimental to a patient. The aim of this article is
to give the reader a valuable insight into the use of hyaluronidase; how it works
and, crucially, when to administer it.
What is hyaluronidase?
Hyaluronidases are a family of injectable enzymes that act as dispersion
agents. These help speed up the natural breakdown of hyaluronic acid through
hydrolysis.2 Licensed for therapeutic indications, such as increasing tissue
permeability to enhance the delivery of drugs or to increase the uptake of
subcutaneous fluids, in aesthetics, it is widely used ‘off license’.3 Off license
does not necessarily mean it is unsafe to use, but that it is being prescribed and
administered in a way that is different to its licensed use. The license is obtained
from the Medicines and Healthcare products Regulatory Agency4 (MHRA) and will
state what the drug can be used for, how much to give and the age of patients
suitable to be treated with it. As long as the practitioner is acting in the patient’s
best interests, their autonomy is respected and the patient has fully consented,
then hyaluronidase can be administered in the event of an adverse reaction.5
Due to this ‘off license’ use of hyaluronidase, practitioners can only seek
guidance from other professionals (as well as use their own expertise) in order
to judge how much hyaluronidase to use and how to reconstitute it, which can
be limiting if one has little experience of using it. Various factors will influence the
administration and dosage – for example, the concentration of HA filler, level of
cross-linking and amount of HA deposit.
Recognising complications with HA fillers
There are, of course, several complications associated with having a HA dermal
filler treatment, such as bruising, mild swelling and tenderness at the injection
site6, which can be easily managed through observation and support on the
patient’s behalf. It is the more serious complications, such as when filler is
injected into a vein or an artery, that will require medical intervention and the
administration of hyaluronidase as part of its management. If HA is injected into
an artery this can cause a clot formation around the filler, or the filler itself may
cause the blockage. If the vessel is significant in supplying blood to the skin,
this can lead to necrosis, an irreversible complication that results in the death of
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
the skin tissue.7,8 This occurs when the skin region
cannot access enough blood and oxygen.8 When
injected into a vein, HA can also cause a blockage,
resulting in blood flowing back into the tissues and
therefore increasing pressure and causing low
grade ischaemia.8
The nose is one of the most feared sites for necrosis
following HA procedures, with the tip being the
most affected.9 To give an example of how serious
a vascular complication can be, injecting dermal
filler into the angular vessels around the nose can
potentially lead to blockage and skin necrosis or,
in extremely rare cases, blindness.10 Fillers injected
into an artery in the face can travel proximally to
the internal carotid system whereby, on release of
pressure, the product travels into the central retinal
artery resulting in possible visual loss or blindness.11
It is therefore imperative that practitioners are able
recognise the signs of an impending necrosis
and have the skills to be able to act quickly,
thus lowering the risk of harm to the patient. Not
only must a policy be in place which allows the
practitioner to deal with the situation, but they must
also be fully competent and confident in what to do.
When should it be used?
Over injection can be a potential risk when injecting
HA fillers, leaving the patient with unsightly lumpiness
or looking ‘pillow-faced’, with large volumes of filler
visible in the mid face.11 Nodules can also occur
following HA anywhere on the face, and those that
start within 48 hours of injection may be inflammatory
– however, those occurring sub-acutely (up to two
weeks post-treatment) or late (after two weeks) are
more likely to involve infection.12 Large haematomas
can also be treated with hyaluronidase.6 The
use of hyaluronidase can improve absorption via
hypodermoclysis, the process of interstitial infusion or
subcutaneous infusion of fluids into the body.13
It is important to stress that if the practitioner suspects
infection then hyaluronidase shouldn’t be used14 and
antibiotics should be prescribed. However, another
side effect that can be resolved with hyaluronidase is
when the Tyndall effect presents itself. This is when
the HA is too superficially placed and creates a bluish
discoloration of the skin.8
Throughout the procedure the practitioner must
observe for signs of blanching of the skin, a change
in appearance that may appear dusky or mottled.6 In
this instance, the patient may complain of pain and
the area might begin to feel cool to touch. If these
signs are ignored then the area may turn blue and
tissue necrosis can occur.8 Hyaluronidase should be
administered as soon as this complication occurs,
and there is good evidence that tissue necrosis
can be prevented or be less severe the sooner the
hyaluronidase is injected.8 Hyaluronidase must be
used early, as its effectiveness in dissolving HA fillers
is reduced after approximately four hours.8 Whether
the situation is an emergency or not, it is imperative
aestheticsjournal.com @aestheticsgroup Aesthetics Journal
that the patient fully understands the implications of why it is being
prescribed, how it will be administered and a consent form should
be signed. Patients must also be made aware of the impending
risks involved with the use of hyaluronidase and that it is being
used off license.
How to use hyaluronidase
A common preparation of hyaluronidase in the UK is made
up of 1500 IU of hyaluronidase in a powder for Solution for
Injection / Infusion.14 This comes as a freeze-dried white
powder in small glass vials or ampoules. As a prescription only
medication (POM), it should only be administered following a
face-to-face consultation with the prescriber.
Below is my technique for preparing hyaluronidase 1500IU:
1. Draw up 10ml of water for injection or 0.9% normal saline in
a syringe.
2. Reconstitute the hyaluronidase 1500IU with 1ml of the 10ml of
normal saline or water for injection.
3. Rotate the vial to ensure the powder is fully dissolved.
4. Draw up the 1ml of hyaluronidase back into the syringe with
the remaining 9ml saline or water for injection thus giving a
concentration of 150IU/ml. Each 0.01ml will then be 1.5IU of
hyaluronidase.
Once the solution is prepared, using a clean non-touch
procedure, inject the hyaluronidase into the affected area
in small aliquots using a 30 gauge needle for superficial
injections and 27 gauge for deeper deposits.
Administration should be extremely accurate and limited
to the affected area. In the case of nodules, they should
be injected directly, and for product that has been injected
into the superficial dermis, injections should be placed
immediately into and below the product.10 For vascular
compromise, serial puncture should be used to inject
hyaluronidase along the course of the vessel. The needle
should be perpendicular to the skin and several injections are
often necessary. During and after the procedure, I recommend
massaging the treated area quite vigorously to optimise the
result and aid mechanical breakdown.
What are the risks of administrating hyaluronidase?
One complication following the administration of hyaluronidase
is allergic reactions,11 and, according to clinical studies, occur at a
frequency of approximately 0.05% to 0.69%.1 There appears to be
conflicting evidence as to whether a patch test of hyaluronidase
should be carried out to rule out evidence of allergic reaction, with
several practitioners suggesting that when it is used for elective
treatments a patch test should be carried to minimise the risk.8
The patch test should be done intradermally (within or between
the skin) and I would advise the practitioner to look for signs of
inflammation, erythma and persistent itching. However, if the
patient is showing signs of a vascular compromise then it could be
justifiable to use the hyaluronidase as soon as possible to lower
the risk of further harm.
Another possible side effect of hyaluronidase is its potential to
degrade the body’s natural hyaluronic acid in preference to the
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
foreign hyaluronic acid filler that has been injected.15 I would
therefore recommend treating the effect rather than absolute
dosage, to go slow and to bring the patient back for additional
treatments. Following the use of hyaluronidase, I would suggest
observing the patient for 30 minutes in a clinical environment and
making sure they have appropriate aftercare information. Results are
often seen almost immediately, although I have found for denser,
more cross-linked products it may take 48 hours for the effects to
be seen. A review appointment at two to three weeks should be
booked and further treatment offered at this point if needed.
Conclusion
Hyaluronidase plays an important role in the management of treating
complications with HA dermal fillers, however, it should not be a
substitute for good technique. Practitioners who deem themselves
qualified to inject and treat patients with HA fillers must also be
capable and confident to treat and manage complications. Having
some knowledge into the use hyaluronidase is not enough to keep
and patients safe, and so it is imperative that a policy is in place that
all injectors can follow, justify and administer hyaluronidase without
delay in an emergency situation. The policy must provide a set of
guiding principles to help with decision-making. This doesn’t have
to be complicated but understood by all injectors and reviewed
regularly. The need for patch testing doesn’t appear mandatory yet
but is often recommended, especially if the situation is not urgent.
Lee Rowe is an independent nurse prescriber and
aesthetic nurse with more than five years of aesthetic
experience. Lee set up Innersense Aesthetics with her
friend and fellow nurse Lorraine O’brien, after leaving
the NHS some years ago, and now works full time in
aesthetics in her clinic in York.
REFERENCES
1. Dr Maurizio Cavallini, Dr Riccardo Gazzola, Dr Marco Metalla, and Dr Luca Vaienti, ‘The Role of
Hyaluronidase in the Treatment of Complications From Hyaluronic Acid Dermal Fillers’, Aesthetic
Surgery Journal 33(8) (2013), 1167–1174
2. Hyaluronidase, (US: Drugs.com, 2015) <http://www.drugs.com/cdi/hyaluronidase.html>
3. Hyaluronidase Enzyme (UK: Clinica London, 2013) <http://www.clinicalondon.co.uk/hyaluronidase-
enzyme/>
4. Medicines and Healthcare Products Regulatory Agency, (UK: Gov.uk, 2015) <https://www.gov.uk/
government/organisations/medicines-and-healthcare-products-regulatory-agency>
5. Off-label or unlicensed use of medicines: prescribers’ responsibilities, (UK: Gov.uk, 2009)
<https://www.gov.uk/drug-safety-update/off-label-or-unlicensed-use-of-medicines-prescribers-
responsibilities>
6. P Lafaille, A Benedotto, ‘Fillers: Contraindications, Side Effects and Precautions’, Journal of Cutan
Aesthetic Surgery 3(1) (2010), 16-19.
7. Necrosis, (US: National Library of Medicine, 2013) <http://www.nlm.nih.gov/medlineplus/ency/
article/002266.htm>
8. Inglefield C, Collins F, Duckett M, Goldie K, Huss G, Paun S, Williams S, Expert consensus of
Botulinum Toxin and Dermal Filler Treatment second edition (UK: Aesthetic Medical Expert Group,
2014)
9. Dr Lisa Danielle Grunebaum, Dr Inja Bogdan Allemann, Dr Steven Dayan, Dr Stephen Mandy and
Dr Lesley Baumann, The Risk of Alar Necrosis Associated with Dermal Filler Injection, (US: Denova
Research, 2009) <http://www.denovaresearch.com/sites/default/files/2009-%20The%20risk%20
of%20alar%20necrosis%20assocaited%20with%20dermal%20filler%20injections.pdf>
10. Berthold Rzany, Petra Becker-Wegerich, Frank Bachmann, Ricardo Erdmann and Uwe Wollina,
‘Hyaluronidase in the correction of hyaluronic acid-based fillers: a review and a recommendation for
use’, Journal of Cosmetic Dermatology, 8 (2009), 317–32
11. David Funt and Tatjana Pavicic, ‘Dermal fillers in aesthetics: an overview of adverse events and
treatment approaches’, Journal of Clinical, Cosmetic and investigational Dermatology, 6 (2013),
295-316
12. Jessica A. Savas, Steven Yang, Katlein Franca, Ivan Camacho, Keyvan Nouri, ‘Inflammatory Nodules
Following Soft Tissue Filler Use: A Review of Causative Agents Pathology and Treatment Options’,
American Journal of Clinical Dermatology, 14(5) (2013), 401-411.
13. Dr Menahem Sasson and Dr Pesach Shvartzman, Hypodermoclysis: An Alternative Infusion
Technique, (US: American Academy of Family Physicians, 2001) <http://www.aafp.org/afp/2001/1101/
p1575.html>
14. Package Leaflet: Information for the User, (UK: MHRA.gov.uk, 2014) <http://www.mhra.gov.uk/home/
groups/spcpil/documents/spcpil/con1424670915822.pdf>
15. Claudio DeLorenzi, ‘Complications of Injectable Fillers, Part I’, Aesthetic Surgery Journal, 33(2013),
561.
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Treating acne
scarring with fillers
Dr Renée Hoenderkamp discusses the treatment
of acne scarring with dermal fillers
Introduction
Acne scarring can be distressing and stigmatising, especially when affecting
the face. Whilst there are a multitude of treatment options available, I do see
patients who have tried everything including combinations of lasers, peels,
retinoids and needling, but are still searching for a solution. I therefore decided
to try and treat some atrophic scars with hyaluronic acid (HA) fillers and
witnessed some excellent results. When treating acne scarring with fillers, I use
one of two techniques depending on the scar type and number. Injecting filler
carefully into the dermis/epidermis underneath atrophic scars lifts them and
improves the overall look of skin blighted by acne scarring. This can be done
by either individually targeting pitted scars with a plumping filler or approaching
an entire area with a lighter filler, used mainly as a skin booster for hydration
and skin conditioning. Having said this, all filler types are being used to treat
acne scarring.1
Anatomy of acne scarring
Acne scars occur when pustules go on to form nodules and cysts. Scarring
is the result of skin damage during the healing of active acne. This process
produces two typical scar types; atrophic and hypertrophic scars, depending
on whether there is a net gain or loss of collagen in the healing process.2 A net
loss forms an atrophic scar (80-90%) and a net gain a hypertrophic or keloid
scar (10-20%).2 Both processes arise from the same pathophysiology, involving
a transition through three stages of damage and healing. The damage caused
initially by inflammation of a blocked sebaceous gland causes blanching and
vasoconstriction. The immune response floods the area with granulocytes,
macrophages, neutrophils, lymphocytes, fibroblasts, and platelets, preparing
for granulation via immune mediator release. As granulation progresses the
final stage is seen: matrix remodelling. The area is then flooded with enzymes,
released from fibroblasts and keratinocytes, which determine the final structure
of the extracellular matrix (ECM). Any imbalance in the enzymatic breakdown
and rebuild of tissue results in scarring.2 When using fillers to treat acne scarring,
only atrophic scars can be treated, because they are the only scars which are
depressed, and these are generally classified into three types; boxcar, ice-pick
and rolling (Figure 1):
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Pros and cons
Procedurally, the biggest consultation discussion
point is permanence. Using semi-permanent fillers
means improvement will gradually wear off and need
repeating. My experience is that scars rarely return
to their previous state due to a degree of subscision
that occurs (and can be actively carried out) during
administration. Filler type will dictate longevity, but I
use HA fillers, so six to 12 months is the norm.3 Results
are instant and improve over the following weeks. I
often address specific scars for patients preparing for
a big event, so timing is key and having the treatment
a few weeks before the event, and not a few days,
is always advisable. The procedure is painful but
bearable. Some practitioners use lidocaine cream,
but I find the associated local oedema is detrimental
to scar visualisation, so I avoid using anaesthesia.
Anecdotally, it appears to be less painful than lip
fillers and these patients have often had many painful
procedures to treat the indication previously, so may
be more tolerant than other filler patients. Injection
site redness and bruising is a possibility, as with all
filler procedures, so careful consenting is key to
managing expectations and guiding patients on how
long potential side effects may last.
Is it effective?
Certainly my experience suggests the use of fillers
is an effective solution for atrophic scar reduction.
Results are seen instantly and improve over weeks
as there is a double effect from the procedure:
physical lifting up and out of the scar, and collagen
development that often follows from fibroblast
stimulation in the dermis by the needle. Not all scars
respond equally, and response is governed by type
and depth of scar and how disrupted the underlying
tissue is; this dictates filler placement and can’t be
predicted. I have found broad rolling scars that are
distensible when the skin is stretched respond best to
fillers, but I have also had success with box car and ice
pick scars that are not too narrow. The improvement,
whilst varied, is always in my experience evident, and,
however slight, is of psychological benefit. These
patients have often struggled for years to improve
their scars, and resulting expectations are lower than
the usual filler patient. They are often so appreciative
of small improvements that it is humbling and a useful
reminder of the stigma suffered.
 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

What filler? Technique

Essentially, any proven safe and efficacious dermal filler could potentially The procedure is relatively straightforward, but
be used and selection is governed by the experience and expertise of the it takes longer than other filler procedures. It is
practitioner. There are more than 120 fillers on the market in the UK but HAs are intricate and the local oedema is substantial, so
the most commonly used.4 I prefer them for acne scars and, whilst I turn to both being methodical about how to inject the area is
Galderma and Allergan, I tend mainly to use Emervel Classic for direct lifting crucial.
out of scars, and Restylane Vital/Vital Light for an all over skin improvement
Lifting out individual scars:
approach. This is because Emervel is firm enough to lift out deep scars but
1. Clean the area and photograph well. The
malleable enough to mould if necessary. Restylane Skin Boosters provide an
photographs are an important record and
excellent extra string to the bow when looking at skin in poor condition with
procedure tool. I use an iPad to display them
additional acne scarring, rehydrating rather than volumising to improve overall
and discuss the scars with the patient, identifying
skin texture. As these are resorbable fillers, the effects are not permanent,
areas/scars causing most distress. Only after this
although longevity varies. Whilst there are permanent fillers on the market,
discussion do I start.
it would be inadvisable to use them on acne scarring where the option to
2. Begin at the very furthest edge of the treatment
reverse any unwanted side effects is not available. As well as HA, potential
area and work methodically into the area scar
compatible filler types include poly-l-lactic acids (Sculptra), bovine collagen
by scar.
gel, polymethylmethacrylate (Bellafill) and calcium hydroxylapatite (Radiesse).1
3. Insert the needle, bevel up under the scar and,
Interestingly, Bellafill is the first filler with FDA approval and is licensed for acne
when directly under the pitted/dipped area,
scar treatment in the US.5
begin injecting. You should see immediate lifting
Poly-l-lactic acids (Sculptra): Designed to stimulate collagen synthesis over
out of the area. Withdraw and examine. You
and above that achieved by needle entry, which could give a long-term result
may need to repeat several times until you have
if substantial. Can last several years. Requires a series of injection applications
achieved the desired effect.
over a few months to get results and results are not reversible.1
4. Refer to photography as necessary; some
Bovine collagen gel: An older solution and not so readily used at clinic level
scars will become visible only at certain angles.
any longer. Bovine in origin rules it out on diet and religious grounds for some
If there is a scar on the photograph that you
patients. Results for depressed rolling scars can be good but only last two to
can’t see on the patient, change your angle or
four months. Too soft for any fibrotic scars.6,7
reposition the patient.
Polymethylmethacrylate (Bellafill): The only filler to have a licence for acne
5. Some scars have such tortuous tissue sitting
scar treatment in the US, although only for shallow distensible (rolling) scars.
under them that when the needle is extruded
Not yet readily available in the UK.5
the filler moves to the side. If this happens,
Calcium hydroxylapatite (Radiesse): A cellulose like water-based gel that
withdraw and massage the filler ensuring that
contains calcium hydroxyapatite in microscopic particles designed to create
it is not noticeable. Then, use the needle to
volume. Not as malleable as HAs but can last up to a year.1
subcise the scar tissue by moving the needle
back and forth in different directions. When you
Treatment feel that you have broken down some of the
The ideal patient for demonstrating this technique would have scattered deep scar tissue, attempt to re-site the filler.
scars. Figures 2, 3, 4 and 5 show one of the first patients that I treated for acne 6. Continue across the area, massaging the
scarring using dermal fillers. Here I used Juvéderm Ultra to treat the deepest scars filler under each scar as necessary. Working
seen. The after photos (Figure 3 and 5), taken immediately post procedure, show methodically across the area is crucial because
marked initial improvement which will develop with time. When the needle marks local oedema will grow and individual scars
and oedema subside the results are often remarkable. Although Juvéderm Ultra is will become difficult to isolate. You will reach a
an excellent choice for many filler procedures, I now tend to use Emervel Classic point where local oedema/entry points make
due to it being more malleable and versatile. any further procedure impossible. Recognise
this point and stop. It may mean that when the
Complications oedema has settled there is more that you
Complication risks are as for any fillers and the patient must be consented in can achieve, but results will already be evident
exactly the same way. Risks specific to this treatment appear to be nodules/ and my experience is that a happy patient is
prepared to undertake future treatments.
For using skin boosters, this is my approach:
1. Prepare as above.
2. Use the normal multi-injection point technique
and shallow placement as for standard skin
booster treatment.
3. At individual scars, concentrate several product
placements directly under the scar as you would
when using a standard HA for lifting a scar.
4. Massage the entire area afterwards, checking
the individual scars are not raised.
Fig 2: Left cheek before HA filler Fig 3: Left cheek after HA filler

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

aestheticsjournal.com @aestheticsgroup Aesthetics Journal
lumps/visible filler caused by too superficial a placement. Avoid
this by careful examination and massaging the area post-
treatment. I always give the patient careful instructions for when
their oedema has settled. I tell them not to worry about filler that
they can feel, only that which they can see and don’t like.
I show them how to massage any such areas, but tell them that in
an ideal world I will have done a good enough job that they won’t
need to touch it. I always add to the consent that when treating
very shallow scars a balance has to be found between placing the
filler superficially enough to lift the scar but deep enough not to be
seen. Ultimately, any stubborn superficial filler could be dissolved
with hyaluronidase, but thus far I have not had to do this. You
should always warn the patient that they will probably look worse
on finishing, but explain that this is temporary. The procedure
involves so many needle-points that the combination of this with
oedema and potential bruising can be visually displeasing.
Conclusion
Acne scarring is a debilitating and stigmatising condition, which
drives patients to seek out and spend vast amounts of money in
their quest to improve the situation. By the time they reach the
point of fillers, they have already tried almost all other modes
of treatment and have spent thousands of pounds. This is both
good and bad. It is positive because they will appreciate small
improvements, but could be negative because they can be
vulnerable and sometimes have unrealistic expectations. Fillers
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Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
offer a good solution for many patients but it is important to be
realistic; select your patient carefully and guide them as to the
improvement that may be achieved.
Show them which scars you believe will benefit from treatment
and those which may not, and make sure they are happy with the
proposed improvement before starting by conducting a thorough
consultation. Take good, clear photos and always warn the patient
about how they will look at the end of the treatment. As with all
cosmetic procedures, managing expectation is key to happy
patients.
Dr Renée Hoenderkamp is a GP registrar based in
London, having qualified in April 2010. With a special
interest in aesthetics and women’s health, she founded The
Non Surgical Clinic in 2011, developing a reputation for
natural-looking solutions for facial ageing and deformity.
REFERENCES
1. Treatment Options: Fillers (Canada: A Scar Free Me, 2014) <www.ascarfreeme.com/resources/>
2. Gabriella Fabbrocini, M C Annunziata, V D’Arco, V De Vita, G Lodi, M C Mauriello, F Pastore, G
Monfrecola. ‘Acne Scars: Pathogenesis, Classification and Treatment’, Dermatology and Practice,
October (2010)
3. Michael H Gold, ‘Use of Hyaluronic acid fillers for the treatment of the aging face’, Journal of
Clinical Interventions in Aging, 2(3) (2007), 396-376.
4. Dermal Fillers (UK: Doctors Makeover, 2015) <http://www.cosmeticsurgeryuk.com/dermal-fillers.php>
5. What is Bellafill? (US: Suneva Medical Inc, 2015) <www.bellafill.com/physician/acne-scar>
6.  Varnavides CK, Forster RA, Cunliffe WJ, ‘The role of bovine collagen in the treatment of acne
scars’, British Journal of Dermatology, 116(2) (1987), 199-206.
7. Lisa Sefcik, Collagen Treatment for Acne Scars (US: Live Strong Foundation, 2015) <www.
livestrong.com/article/74155-collagen-treatment-acne-scars/>
www.cosmetic-insurance.com
 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Liposuction
Dr Amanda Wong-Powell discusses
the evolution of liposuction and
presents the case study of a patient
who underwent VASER Liposuction
in her clinic
Background
Liposuction has long been a common procedure in the aesthetic
industry. As early as the 1920s, a French surgeon called Charles
Dujarrier first attempted liposuction by sculpting a ballet dancer’s
calves and knee. Due to an arterial injury, however, the leg was
subsequently amputated, which put a halt on the development of
liposuction for more than 50 years.1,2 It was not until the late 1970s
that Arpad Fischer, Giorgio Fischer, Yves-Gerard Ilouz and Pierre procedures to be performed with a reduced risk of blood loss.5
Fournier developed modern liposuction techniques in France Since then, there has clearly been an increase in the uptake of
and Italy. By the 1980s, the techniques had become popular liposuction procedures, something that has continued into the
in the United States, and, in 1985, Jeffrey Klein revolutionised 21st century. Today, there are many different types of liposuction
liposuction by perfecting the tumescent technique.1,2 Prior to available, including suction-assisted liposuction (SAL), power-
this, all liposuction procedures were performed under general assisted liposuction (PAL), ultrasound-assisted liposuction (UAL),
anaesthetic. This meant that they were associated with significant twin cannula-assisted liposuction (TCAL), external ultrasound-
surgical blood loss and a longer recovery time.3 The tumescent assisted liposuction (EUAL), water-assisted liposuction (WAL),
technique, however, permitted liposuction to be performed and laser-assisted liposuction (LAL).6,7 In my practice, however,
under local anaesthetic, which significantly reduced the level I tend to specialise in Vibration Amplification of Sound Energy
of blood loss, haematoma, recovery time and discomfort post at Resonance (VASER) Liposuction. I find the VASER technology
procedure.3,4 The tumescent, meaning ‘swollen’, technique helps to preserve the connective tissues in the body, which
involves the use of a tumescent solution. The solution comprises ultimately lowers down time for patients as it is a less invasive
a low concentration of lidocaine and adrenaline, which causes the treatment. It also maintains fat cells’ viability for fat grafting
targeted tissue to become swollen and firm, permitting liposuction purposes and, in my opinion, gives very precise body contouring
results to enable better high definition sculpting.

The tumescent technique VASER Liposuction

VASER Liposuction is fast becoming one of the most popular
permitted liposuction variants of liposuction,6 and was invented by Dr William W Cimino
when he first began developing VASER systems in 1998.
to be performed under The procedure involves three major steps: 7,8,9
• Firstly, infiltration with tumescent fluid is carried out by injection
local anaesthetic which into the fatty tissue layer.
• The fat tissues are then emulsified by ultrasound energy
significantly reduced delivered by a small multi-ringed probe. The high frequency
vibrations of the system cause gas bubbles within the tumescent
the level of blood loss, fluid to expand and collapse, thus dislodging the fat cells and
mixing them into the infiltration fluid. This is known as ‘acoustic
haematoma, recovery time streaming’.
• Finally the fluid and emulsified fat is subsequently removed by
and discomfort post the suction cannula.
VASER Liposuction is also gaining popularity with patients
procedure as it is the only recognised technology for mid-definition and
high-definition body sculpting techniques, which aim to deliver
muscular definition and a finer athletic finish to patients.10

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

aestheticsjournal.com @aestheticsgroup Aesthetics Journal
Case study
Patient A is a 28-year-old female postgraduate student who had
gained approximately 10kg within the last couple of years whilst
studying for her master’s degree. She was stress eating, had no
time for exercise and had adopted some unhealthy lifestyle habits.
Prior to seeing me, she had started an exercise regime, started to
eat regularly and had followed a good diet plan – as a result she
had lost approximately 3kg. She found that there were certain areas
where the fat was proving rather more difficult to shift. At that point
she decided to seek help and after some research was interested
in having VASER Liposuction. Her first consultation was a general
chat about the procedure, her suitability, her motivation, and her
expectations from the procedure. A thorough medical history was
also taken and an examination performed. We also discussed
the benefits and risks of the treatment. She was then sent home
to consider her options and decide whether she wanted to have
a further consultation, if she was still keen to go ahead. She was
seen two weeks later; when we went through the consent process,
the risks and the benefits again. We then looked at the areas of
concern and worked out what was possible to achieve with her
procedure. It was decided that she would have liposuction to her
upper and lower abdomen as well as her flanks. We discussed the
pre-operative plan, logistics, the procedure itself and post-operative
advice. We also discussed how she was going to maintain her new
body shape.
She was started on prophylactic oral antibiotics two days prior
to her procedure. In my practice, routine prophylactic antibiotics
(co-amoxiclav) are prescribed to prevent infection. The liposuction
procedure was performed under local anaesthetic. On the
morning of the procedure, she was re-consented routinely for her
procedure. I answered all of her final questions and queries and
then marked her body for the areas where I would perform the
VASER Liposuction. Important structures such as the xiphisternum,
rib cage, other important landmarks and incision areas for portholes
are marked whilst the patient is standing upright. Patient marking
is similar to drawing a topographic map with the contour lines
representing the elevation on the surface and, in this case, the fat
tissues. Frontal, bilateral and back view photographs were taken
to help with photographic documentation and for before and after
comparison. It is also important to point out any asymmetry or
scarring the patient may have prior to surgery, as well as checking
for any hernias. Routine observations are taken prior to starting
and every 15 minutes during the procedure if the patient remains
stable. As we are infiltrating Before
a significant amount of fluid
into the patient, it is important
to ensure that the patient
empties their bladder prior
to starting. Standard sterile
preparation and draping is
used. Local anaesthetic is
then injected into the marked
porthole areas. In this case,
we used five portholes, which
is average for this procedure,
although sometimes we may
use more or less portholes
depending on the size of the
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
patient and the accessibility of the area to be treated. Once the
local anaesthetic started working, a small incision of approximately
0.8mm was made.
Tumescent solution is injected into the fatty tissues to achieve
infiltration. The formula used in the tumescent was; in each litre of
normal saline (0.9%), to add:
- 1mg of Adrenaline
- 12.5ml Sodium Bicarbonate
- 800mg Lidocaine 2% (a total maximum average of 35-45mg/kg
of Lidocaine in the tumescent fluid)
The tumescent fluid acts as a local anaesthetic as well as a buffer
for liposuction. After approximately 20 minutes, the VASER probe
was introduced and the fat emulsification process started. For each
100ml of infiltration, VASER is applied for a maximum of one minute.
The ultrasound energy causes the bubbles of the infiltration fluid to
expand and collapse, thus dislodging the fat cells from the tissue
matrix. The ‘acoustic streaming’ then further separates the fatty
tissue into small packets of fat cells that subsequently mix into the
infiltration fluid ready for suction. The suction was performed using
a specialised VentX cannula, which helps to remove the emulsified
fluids and fat while preserving the tissue matrix. With Patient A,
specific suction techniques were used to give her better definition
of her abdomen and to enhance some musculature and lines. A
total of 2.5 litres was aspirated, of which 1.5 litres was pure fat. A
suitable surgical compression garment was applied immediately
post operation. Patient A was able to get up immediately and
walked to the recovery room. After a short recovery period and
further observations, take-home medications were prepared
comprising further antibiotics and analgesia, and Patient A’s relative
escorted her home.
She had MLD massages on the third day post procedure and
underwent a total of 10 sessions in the following two weeks.
She wore her compression garment consistently for four weeks,
day and night. I saw Patient A for a routine follow-up at two weeks,
six weeks and twelve weeks. Patient A’s recovery was uneventful.
She was very pleased with her results and she continued with
her exercise, healthy diet and lifestyle to maintain her new body
shape. Patient A is a good case example of a very compliant, highly
motivated and suitable patient with good results. As such, this case
particularly highlights the importance of patient selection.
Eight weeks after VASER Liposuction
aestheticsjournal.com @aestheticsgroup Aesthetics Journal
Patient selection, safety and post-operative care
Patient selection is key in most procedures in aesthetic practice.
In procedures such as liposuction this holds particularly true
in order to ensure good and sustainable results. Patients with
unrealistic expectations, who are extremely overweight, have
poor skin laxity, poor compliance, or multiple medical problems
would not be suitable candidates. If patients have unrealistic
expectations, it is likely that they will not be entirely satisfied with
the results of the procedure, while overweight patients who are
not compliant with the aftercare may need other interventions
such as bariatric surgery to achieve long-term successful
results. In addition, patients suffering from skin laxity may need
an abdominoplasty following liposuction treatment to remove
any excess skin. As for any surgical procedure, taking a good
medical history and performing a thorough examination is of vital
importance. Explaining the procedure in basic layman terms to
the patient, and discussing the associated benefits and risks, are
equally important. Risks discussed should include asymmetry,
bleeding, bruising, haematoma, swelling, pain, chronic pain,
infection, neurovascular damage, lipodystrophy, unevenness,
change in skin and skin sensation, skin burn, skin laxity,
Lidocaine toxicity, seroma and scarring. Other rare risks include
perforation, surgical shock, organ damage and death.11,12,13,14,15
Managing the patient’s expectations is paramount. It is important
to ensure that the patient is aware of the entire process of the
liposuction procedure from pre-operative preparation through
to peri-operative and post-operative management. It is crucial
that patients are made aware that results are often only visible
six weeks post procedure, and best results around 12 weeks
post procedure, to ensure they are not initially disappointed
with the outcome. Patients also need to understand the risk
of bruising, swelling, pain and ‘leakage’ post procedure. They
need to be compliant with the post-operative care requirement
of wearing a surgical compression garment for approximately
two to four weeks, as well as having manual lymphatic drainage
(MLD) massage for the first couple of weeks.12 The surgical
compression garment helps the skin contract smoothly to the
body’s new contours. The MLD massage is aimed at decreasing
Patients with unrealistic
expectations, who are
extremely overweight,
have poor skin laxity, poor
compliance, or multiple
medical problems would
not be suitable candidates
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
swelling and lymph drainage. It is a very efficacious massage
that helps to improve the lymphatic system as well as stimulating
and increasing the rate of removal of waste products, toxins and
excess fluid from the body’s tissues.11,12
A short period of rest (typically 12 hours) is recommended directly
after the procedure, followed by two to three weeks of general
recovery when strenuous activities should be avoided. Simple
analgesia post procedure will help keep patients comfortable and
relieve their initial pain in the first few days. Patients should be able
to return to sedentary work in about a week and more strenuous
work within two to three weeks. Light exercises are encouraged two
weeks after the procedure and more strenuous ones around four to
six weeks after the procedure are often recommended. It is essential
that patients are able to commit themselves to a healthy lifestyle,
comprising a balanced diet and a post-operative exercise regime to
achieve the best possible result and maintain their new body shape.
Conclusion
VASER Liposuction is now often coupled with fat grafting.16 In
my opinion, this technique will be the new frontier of aesthetic
medicine and surgery, along with the practise of harvesting
stem cells and the use of platelet rich plasma (PRP). These can
be mixed with the harvested fat to enhance the viability and
longevity of the fat graft, as well as to improve skin rejuvenation.
The harvested autologous fat can be re-injected into the breasts,
buttocks, face, décolletage, hands and wherever necessary for
volumising and revivifying purposes.17 Liposuction is the second
most popular aesthetic procedure performed in the world today.6
Given careful patient selection and appropriate procedure
design, diligent pre- and post-operative care, along with effective
operative techniques, I have found VASER Liposuction to offer
highly satisfactory outcomes to a range of patients.
Dr Amanda Wong-Powell is the founder and medical
director of Dr. W on Harley Street. She has completed
her basic surgical training, and is a member of the
Royal College of Surgeons (Edinburgh). She is a VASER
liposuction surgeon, and also has an interest in weight
loss management. She is also medical director of Meducatus, the
medical training platform for doctors and surgeons.
REFERENCES
1. Flynn TC, ‘History of Liposuction’, Dermatologic Surgery, 26(6) (2000), pp.515-520.
2. Coleman III, William. P. ‘The History of Liposculpture’, Journal of Dermatologic Surgery &
Oncology, 16 (12) (1990), p.1086.
3. KleinLipo, Dr Jeffrey Klein M.D (US: KleinLipo, 2013) <http://kleinlipo.com/staff/dr-jeffrey-klein/>
4. Klein JA, ‘Post-tumescent liposuction care: Open drainage and bimodal compression’, Derma-
tol Clin, 17 (1999) pp.881–90.
5. Rudolph H, De Jong M, ‘Tumescent Anesthesia: lidocaine Dosing Dichotomy’, International
Journal of Cosmetic Surgery and Aesthetic Dermatology’, 4 (1) (2004), p.1. <http://online.liebert-
pub.com/doi/abs/10.1089/153082002320007412>
6. Liposuction 2nd most popular aesthetic surgery procedure in the world (ISAPS, 2013) <http://
www.isaps.org/Media/Default/Current News/ISAPS 2013 Statistic Release FINAL (2).pdf>
7. Shiffman MA, Di Giuseppe A, ‘Liposuction Principles and Practice’, Springer (2006).
8. Shiffman MA, Di Giuseppe A, ‘Body Contouring’, Springer (2010).
9. VASERlipo Science (VASER from Solta Medical, a division of Valeant Pharmaceuticals North
America, LLC) <http://www.vaser.com/vaserphysician/vaser-science/vaserlipo-science>
10. Hoyos EH, Prendegast PM, ‘High Definition Body Sculpting’, Springer (2014).
11. Housman TS, Lawrence N, Mellen BG, George MN, Filippo JS, Cerveny KA, et al, ‘The safety of
liposuction: Results of a national survey’, Dermatol Surg, 28 (2002), pp.971-8.
12. Coleman WP, 3rd, Glogau RG, Klein JA, Moy RL, Narins RS, Chuang TY, et al., ‘Guidelines of
care for liposuction’, J Am Acad Dermatol, 45 (2001), pp.438-47.
13. Lawrence N, Coleman WP, ‘Liposuction’, J Am Acad Dermatol, 47 (2002) pp.105-8.
14. Coleman WP, ‘Powered liposuction’, Dermatol Surg, 26 (2000) pp.315-8.
15. Venkataram J, ‘Tumescent Liposuction: A Review’, J Cutan Aesthet Surg, 1(2) (2008) pp.49-57.
16. Schafer ME, et al., ‘Acute Adipocyte Viability After Third-Generation Ultrasound-Assisted Lipo-
suction’, Aesthetic Surgery Journal, 33(5) (2013) pp.698-704.
17. Fisher C, et al., ‘Comparison of Harvest and Processing Techniques for Fat Grafting and Adipose
Stem Cell Isolation’, Plastic Reconstructive Surgery, 132(2) (2013) pp.351-61.
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aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

in the superficial dermis.2 It is also claimed that the injection of

mesotherapy products promote skin rejuvenation by increasing both
hydration and fibroblast activation, and re-establishing skin tone
and elasticity.3 At present, mesotherapy is used to treat a variety of
conditions such as acne, rosacea, cellulite, localised adipocytes,
stretch marks and hair loss, as well as for skin rejuvenation. In this
article I will highlight the case study of a patient with dry skin below the
eyes and the mid cheek area.

Treatment Protocol
The mesotherapy for hydration protocol consists of four sessions.
These four sessions are carried out weekly or fortnightly depending
on the availability of the patient. To ensure efficacy and even delivery

Mesotherapy
of product to the skin, the treatment is performed with an automated
mesogun, ensuring that each individual injection perforates the skin at
the same depth and with the same amount of product.

for Facial Skin Session 1

Each session utilises the same protocol of products – in my practice
I use a cocktail of products to improve different aspects of the skin.

Hydration
Aesthetic nurse Juan Lopez highlights
the benefits of using mesotherapy for
facial skin rejuvenation
Too often we focus our efforts on treating what patients request,
without recommending or suggesting other treatments that would
improve their general appearance. In this manner, I believe that we are
not working hard enough to care for our canvas. For us, as aesthetic
practitioners, the canvas is our patients’ skin, and therefore treatment
of this organ should always be our first recommendation. Good skin
health makes our patients look better, and will also help to improve
the results of any other treatments implemented in the future, such as
dermal fillers and botulinum toxin. If the skin looks better, the results
of other treatments will be greater. This is comparable to an artist’s
masterpiece – undoubtedly, any distinguished artist would ensure that
their canvas was of the best quality, to assist them in creating equally
high-quality work. Likewise is true of caring for our patients’ skin.
For the purpose of improving the skin, I believe in following in the
footsteps of the French doctor Michel Pistor. In 1976, Dr Pistor first
described a technique involving injections of medications directly into
the skin, also known as mesotherapy.1 The aim of mesotherapy in skin
rejuvenation is to maintain and restore a healthy and youthful texture.
The desired final effect is to firm, brighten and moisturise the skin by
injecting suitable products that are biocompatible and absorbable
For skin hydration I use the following products and ingredients shown
in Table 1. This protocol can be individually tailored depending on
the requirement of the patient and their age. Generally, the mesolift
cocktail can be changed for other cocktails, such as an anti-ageing
cocktail or a firming cocktail. For example, if you have an older patient
you can change the mesolift cocktail for the regeneration cocktail,
which is better suited for older skin. The type of cocktail that I deploy
for this effect contains centella asiatica as the main ingredient,
believed to heal the skin, acting alongside dermal regenerative
actives dexpanthenol, elastin and organic silicium, working to improve
collagen fibres. If you have a younger patient, you can change to the
radiance cocktail to help achieve glowing skin, which is what younger
patients generally request. This protocol has been adapted from Dr
Britta Knoll.4
Pre-treatment Considerations
Before considering any form of treatment it is crucial to take a
thorough medical history, thereby ensuring mesotherapy is not
contraindicated for any patient. This should be followed by a full
explanation of what the patient can expect, the length of time that
the treatment will take and the maintenance required to maintain the
effects on the patient’s skin. The patient will need to be aware of the
latter’s implications, commitment and potential cost in the long term.
Following consent, and as part of the protocol, it is necessary to take
photographs of the patient and the skin condition at the first visit as a
baseline, before commencement of treatment. This is also crucial in
each session before the treatment in order to be able to monitor and
document the progress of the results.2

Table 1: Mesotherapy Protocol for Skin Hydration

Product Composition Percentage of total mixture
Hyaluronic acid medium molecular weight Non-cross-linked hyaluronic acid MW 2% 30%
Nutritive complex for poly revitalising Hyaluronic acid, 10 vitamins, 25 30%
amino-acids, 2 co-enzymes, 4
nucleic acids, 2 reducing agents
Mesolift cocktail Hyaluronic acid, sodium DNA, 32%
multivitamins BCAE, organic
silicium, DMAE
Procaine Procaine 2% 20mg/ml 8%

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

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aestheticsjournal.com @aestheticsgroup Aesthetics Journal
My protocol for
mesotherapy for hydration
is to repeat this treatment
every two to three
months, depending on the
condition of the skin
The Mesogun
As previously mentioned, it is important to distribute the same amount
of product at the same depth in each injection. For that reason, we set
up the mesogun to inject at 1mm depth and at a rate of 300 injections
per minute. In my experience, patients find the treatment with the
mesogun more confortable than manual injections. A study by Duncan
and Chubaty5 describes how some practitioners reported that use
of a mesogun improved the patient’s experience and lowered the
perceived pain sensation.
Case Study
Patient One is a 37-year-old female, who had visited my clinic
previously to have treatment with botulinum toxin type A for facial
dynamic lines, hyaluronic acid (HA) fillers for volume replacement
and a hydrating HA product for hydration of the skin. Previous skin
hydration with the HA product had had a positive effect but the patient
found that by the end of the day the skin was suffering and very
dry. On previous occasions we had discussed the use of a course
of mesotherapy treatment for skin hydration in the area of concern.
Following consultation, the patient agreed to undergo four sessions of
mesotherapy for the whole face, as is the protocol used in my clinic.
First Treatment
Once Patient One’s skin was cleansed with chlorhexidine solution
and the mesogun preloaded, 5ml of the protocol mixture was injected
for a full facial treatment. It is always necessary to make sure that the
patient is getting the product at the right skin depth. However, excess
product will remain on the skin, which will be absorbed if enough time
is allowed before cleaning the skin. According to Patient One, the
treatment was not painful with the exception of the top lip area where
the treatment was slightly uncomfortable.
The Injection Technique
The technique used during this facial treatment was ‘Nappage’. El-
Domyati et al6 describe this technique as quick and linear injections
at superficial or mid dermis (1-4mm). 6 The volume injected should be
0.1ml for each single droplet, at a distance of a few millimetres apart.
Post Treatment
The treatment was finalised with the application of a recovery cream
and a broad-spectrum sunscreen (SPF 50). No bruising was observed
immediately post-procedure or in the days following the session. Once
the treatment was finished, Patient One was advised not to wash her
face for a few hours.
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
Further Treatments
As per protocol, the treatment continued for a total of four sessions. All
sessions followed the same preparation, technique, dosage and post
treatment care as the first treatment. The sessions were booked every
two weeks, and photographs were taken before each session.
Feedback and Outcome
Patient One reported after the first session that her skin had improved,
exceeding her expectations, and she claimed she felt her skin was
more hydrated. The greatest changes observed by both Patient
One and myself were after the third and fourth sessions. Patient One
described her skin as looking fresh and rested.
The last review session was four weeks following the final treatment.
At this session Patient One reported that previously her skin used to
feel fresh in the mornings, but due to the stress and nature of her job,
her skin would start to feel dehydrated again by mid-afternoon; with
the mesotherapy she was noticing a fresher look lasting all the way
to the evening. For her this was a very positive outcome and one that
she wanted to maintain.
Treatment Maintenance
Patient One was keen to maintain the results. My protocol for
mesotherapy for hydration is to repeat this treatment every two to
three months, depending on the condition of the skin. The skin is
reviewed after two months, after which a treatment is scheduled
accordingly, but generally is booked for the following month or earlier
if required.
Conclusion
In my experience, the use of mesotherapy for skin rejuvenation and
hydration is a highly effective treatment. This kind of approach will
benefit the long-term health and look of the patient’s skin. Other
advantages cited by Tosti and De Padova7 include minimal pain and
very reduced incidence of complications, and the treatment can be
performed on every skin type with less downtime compared with other
aesthetic treatments (e.g. microneedling). Both the patient and I agreed
the results on her skin had been favourable, consequently improving
the patient-practitioner relationship/trust. With this in mind, aesthetic
practitioners can confidently offer this treatment in clinic to maintain
patient satisfaction.
Juan Lopez is an aesthetic nurse and independent
prescriber with more than five years of experience. His
special interests are skin health and mesotherapy. He is
the owner of DermaTops.com and is preparing the launch
of his new clinic, Skin Medico, in London. Juan is also a
training consultant for Vida Aesthetics Ltd.
REFERENCES
1. Pistor, M., ‘What is mesotherapy?’, Le Chirurgien-dentiste de France, 46 288 (1976), p. 59.
2. Savoia, A., Landi, S., & Baldi, A., ‘A new minimally invasive mesotherapy technique for facial
rejuvenation’,Dermatology and therapy, 3(1) (2013), 83-93.
3. Lacarrubba, F., Tedeschi, A., Nardone, B., & Micali, G., ‘Mesotherapy for skin rejuvenation:
assessment of the subepidermal low-echogenic band by ultrasound evaluation with cross-
sectional B-mode scanning’, Dermatologic Therapy, 21(s3) (2008), S1-S5.
4. Knoll, B. & Sattler, G., Illustrated Atlas of Esthetic Mesotherapy. (London: Quintessence
Publishing Company, 2012)
5. Duncan, D. I., & Chubaty, R., ‘Clinical safety data and standards of practice for injection lipolysis:
a retrospective study’, Aesthetic Surgery Journal, 26(5) (2006), 575-585.
6. El-Domyati, M., El-Ammawi, T. S., Moawad, O., El-Fakahany, H., Medhat, W., Mahoney,
M. G., & Uitto, J., ‘Efficacy of mesotherapy in facial rejuvenation: a histological and
immunohistochemical evaluation’, International journal of dermatology, 51(8) (2012), 913-919.
7. Tosti, A. & Pia De Padova, M., Atlas of Mesotherapy in Skin Rejuvenation, (London: Informa
Healthcare, 2007)
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aestheticsjournal.com @aestheticsgroup
Spotlight On: Kybella
Following Kybella’s recent FDA approval for treating
submental fat, Aesthetics investigates the drug’s
efficacy and how it should be used in practice
Double chins have long been associated
with a displeasing aesthetic appearance,
with many consumers resorting to surgery
to remove unwanted submental fat.
Now, however, a non-surgical alternative is
expected to cause a stir in the US aesthetic
market.1 In 2014, the American Society for
Dermatologic Surgery (ASDS) reported
that 68% of consumers are bothered by
submental fullness.2 This notably high statistic
is unsurprising says Dr Heidi Waldorf, director
of laser and cosmetic dermatology at Mount
Sinai Medical Center in New York and a lead
clinical investigator in the Kybella study.
“Many of my patients, both women and men,
are looking for non-surgical options to help
treat their double chin,” she explains, adding,
“the statistic is almost as much as those
who say they are bothered by the lines and
wrinkles around their eyes [71%2].”
Yet there seems to have been a distinct
lack of non-surgical options for treating
this ‘problem’ area – until now. Kybella,
manufactured by US-based company
Kythera Biopharmaceuticals, is expected
to become available to US-based
practitioners who have completed training
in its administration this summer. As of yet,
however, no filings have been submitted for
the product to launch in Europe.
Despite this, the Food and Drug
Administration (FDA) approval of the drug
has generated global news headlines.
The Telegraph reported that Kythera’s
shares jumped by almost 8% following the
announcement,3 whilst business analysts
have suggested that Kybella could bring in
more than $300 million a year.1
Of course this is not only significant news for
investors in Kythera, it represents to many
a new treatment option for those who are
unhappy with the amount of fat below their
chin. Submental fullness can affect both men
and women – of any age or weight – and
is often resistant to diet and exercise.4 “The
FDA approval of Kybella fills an unmet need
for physicians and patients,” explains Dr
Waldorf. “Before this, there was an empty
spot in our therapeutic toolbox.”
Also know as ATX-101, Kybella is identical to
the deoxycholic acid that is produced in the
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics Journal Aesthetics
body, which works to help the body absorb
fat.5 The FDA explains that Kybella is a
cytolytic drug, which aims to destroy fat cells
when injected into submental fat. Kythera
claims that once destroyed, those cells
cannot store or accumulate fat.4
Kybella is administered by injection into the
fat under the chin, which can be tailored
to individual patient requirements. Patients
can receive up to 50 injections in a single
treatment, with up to six single treatments
administered no less than one month apart.
Dr Waldorf says, “Personally, I’m excited
about the opportunity to offer my patients
a clinically-proven, non-surgical option that
I can customise to the patient and their
treatment goals.”
Research into the efficacy of Kybella
was supported by a global development
programme, which included more than
20 clinical trials and 2,600 participants
worldwide. More than 1,600 participants
were treated with the drug, of which 68.2%
responded to Kybella in the final phase III
trials, compared to just 20.5% who were
treated with the placebo drug.6
Significantly, patients noted not only an
improvement in the amount of fat under
their chin, but also an improvement in the
emotional impact of receiving treatment. For
Dr Waldorf, this was very satisfying to hear;
“As a cosmetic dermatologist, I want my
patients to feel better about themselves both
physically and emotionally,” she explains.
The FDA enrolled 1,022 adult participants
with moderate or severe submental fat
in its two clinical trials into the safety and
efficacy of Kybella. Participants underwent
treatment with either Kybella or a placebo
for up to six treatments and results
indicated that a reduction in the fat was
observed more frequently in those who
were treated with Kybella.5 Each treatment
takes approximately 15 to 20 minutes and,
according to Kythera, patients experience
visible results after two to four treatments.4
Up to six treatments may be administered
and once aesthetic response is achieved,
re-treatment is not expected.4
The drug does, however, come with
reported side effects. In the clinical trials, 72%
of subjects treated with Kybella experienced
injection site hematoma/bruising, and
cases of marginal mandibular nerve injury
were reported.4 These manifested as an
asymmetric smile or facial muscle weakness
and resolved spontaneously from 1-298
days, with a median of 44 days.4 In addition,
dysphagia (difficulty swallowing) occurred
in patients during the trials, with subjects
experiencing pain, swelling, and induration
of the submental area. Again, cases of
dysphagia resolved spontaneously, ranging
from 1-81 days, with a median of three days.4
Kythera advises practitioners to avoid
injecting into or in close proximity to the
marginal mandibular branch of the facial
nerve, avoid using Kybella in patients with
a current or prior history of dysphagia, and
take caution when treating patients with
bleeding abnormalities, or those who are
currently being treated with antiplatelet or
anticoagulant therapy.4 The company also
notes that in order to avoid potential tissue
damage, Kybella should not be injected
into or in close proximity (1-1.5cm) to salivary
glands, lymph nodes or muscles.4 It is
further advised that the drug should not be
injected outside the submental area or in the
presence of infection at the injection site.7
Upon reflection of the research discussed,
it seems likely that Kybella will have a
substantial impact on the way in which
aesthetic practitioners approach submental
fat treatment in the future. And whilst there
may be no plans to launch the drug in the
UK in the near future, UK-based practitioners
can take this as an opportunity to follow
Kybella’s overseas’ development and
learn more from our US-based colleagues
administering the treatment.
REFERENCES
1. Damian Grade, Kythera FDA approval for its double-chin-
shrinking shot, (US: Fierce Biotech, 2015) <http://www.
fiercebiotech.com/story/kythera-bags-fda-approval-its-double-
chin-shrinking-shot/2015-04-29>
2. American Society for Dermatologic Surgery, 2014 ASDS
Consumer Survey on Cosmetic Dermatologic Procedures, (US:
ASDS, 2014) <https://www.asds.net/uploadedImages/2014%20
Infographic%20FINAL.jpg>
3. Gregory Walton, New cure for double chin approved, (UK:
The Telegraph, 2015) <http://www.telegraph.co.uk/news/health/
news/11572510/New-cure-for-double-chin-approved.html>
4. Kythera Biopharmaceuticals, Kythera Biopharmaceuticals
Announces FDA Approval of Kybella (also known as ATX-101)–
First and Only Submental Contouring Injectable Drug,
(California: MyKybella.com, 2015) <https://mykybella.com/wp-
content/uploads/2015/04/KYTHERA-FDA-Approval-Press-
Release-4.29.15-FINAL_.pdf>
5. Food and Drug Administration, FDA approves treatment for fat
below the chin, (US: FDA, 2015) <http://www.fda.gov/
NewsEvents/Newsroom/PressAnnouncements/ucm444978.htm>
6. Kythera Biopharmaceuticals, Fact Sheet Kybella (deoxycholic
acid) injection (US: Kythera, 2015)
<http://media.globenewswire.com/cache/23392/file/33701.pdf>
7. Kythera Biopharmaceuticals, Full Prescribing Information, (US:
Kythera, 2015) <https://mykybella.com/wp-content/
uploads/2015/04/KYBELLA-Combined-FINAL-Labeling.pdf>
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aestheticsjournal.com @aestheticsgroup Aesthetics Journal
A summary of the latest
clinical studies
Title: Outcomes of polydioxanone knotless thread lifting
for facial rejuvenation
Authors: DH Suh, HW Jang, SJ Lee, WS Lee, HJ Ryu
Published: Dermatologic Surgery, June 2015
Keywords: Thread lifting, non-invasive, facial rejuvenation
Abstract: Thread lifting is a minimally invasive technique
for facial rejuvenation. Various devices for thread lifting using
polydioxanone (PDO) are popular in aesthetic clinics in Korea,
but there have been a few studies regarding its use. The objective
was to describe PDO thread and techniques adopted to counteract
the descent and laxity of the face. A retrospective chart review
was conducted over a 24-month period. A total of 31 thread
lifting procedures were performed. On each side, 5 bidirectional
cog threads were used in the procedure for the flabby skin of
the nasolabial folds. And, the procedure was performed on the
marionette line using 2 twin threads. In most patients (87%), the
results obtained were considered satisfactory. Consensus ratings by
2 physicians found that objective outcomes were divided among
“excellent,” “good,” “fair,” and “poor.” Texture wise, the outcome
ratings were 13 as excellent and 9 as good. Lifting wise, ratings were
11 as excellent and 6 as good. The incidence of complications was
low and not serious. In conlusion, facial rejuvenation using PDO
thread is a safe and effective procedure associated with only minor
complications when performed on patients with modest face
sagging, fine wrinkles, and marked facial pores.
Title: A novel non-invasive radiofrequency dermal heating device
for skin tightening of the face and neck
Authors: AA Nelson, D Beynet, GP Lask
Published: Journal of Cosmetic and Laser Therapy, May 2015
Keywords: Non-invasive, radiofrequency, rejuvenation, skin
tightening
Abstract: Loose, lax skin is a common cosmetic complaint.
Previous non-invasive skin tightening devices had modest efficacy
and were associated with pain or downtime. New technologies may
allow for effective skin tightening with a series of no downtime,
radiofrequency treatments. The objective was to evaluate the
efficacy and safety of a novel bipolar radiofrequency device for skin
tightening. 15 consecutive female patients were enrolled in the case
series; 14 completed the study and were included in the analysis.
The device under investigation is a novel, bipolar radiofrequency
device allowing for achievement and maintenance of optimal dermal
temperatures to stimulate collagen remodeling and skin tightening.
Patients underwent a series of 4-6 weekly treatments. Three blinded,
experienced cosmetic physicians evaluated paired blinded pre-
treatment and post-treatment photographs and determined the
associated improvement, if any. All patients (14/14) were determined
to have a clinical improvement, as the pre-treatment and post-
treatment photos were correctly identified by the evaluators. 21%
(3/14) patients were observed to have significant improvement, 50%
(7/14) observed to have moderate improvement, and 29% (4/14)
had mild improvement. No pain, side effects or adverse events were
observed. This novel bipolar radiofrequency device represents a safe,
effective treatment option for non-invasive skin tightening.
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
Title: A comprehensive health impact assessment and determinants
of quality of life, health and psychological status in acne patients
Authors: C Pagliarello, C Di Pietro, S Tabolli
Published: Giornale Italiano di Dermatologia e Venereologia,
June 2015
Keywords: Acne, health, psychological impact, effects
Abstract: Acne adversely affects all aspects of quality of life (QoL).
Although many papers assessed acne-specific QoL impairment, there
are few data on its impact on general health and psychological status.
Apart from acne severity, little is known about determinants of a
worse QoL. The aims of this paper were to measure acne impact on
QoL, health and psychological status and to analyse the relationship
between socio-demographic variables, disease severity and mental
status on QoL of acne sufferers. Acne cases were selected from a survey
conducted in 2010. The Short-Form 12-Item Health Survey and the
Skindex-29 were used to assess health status and QoL. The 12-Items
General Health Questionnaire was used to identify individuals at risk
for non-psychotic psychiatric disorders (GHQ-positive). Physician
(PhGA) and patient global assessments were obtained. We investigated
the variables involved in the QoL through a logistic regression analysis.
One hundred ninety-five cases were analysed. Twenty-six percent were
GHQ-positive; acne’s impact on health status was worse compared to
other chronic diseases. A GHQ-positive status (Skindex-29 overall:
OR 2.6; 95% CI 1.20-5.60, P<0.05, functioning: OR 2.5; 95% CI
1.17-5.44, P<0.05, symptoms: OR 3.0; 95% CI 1.36-6.53, P<0.01;
emotions: OR 2.55; 95% CI 1.19-5.46, P<0.05) and having a severe/
very severe PhGA (Skindex-29 overall: OR 3.4; 95% CI 1.20-10.38,
P<0.05) were associated with a poor QoL. Age of onset >25 was linked
to being GHQ-positive (OR 2.92; 95% CI 1.2-7.1, P<0.05) controlling
for gender, marital status and educational level. Acne is not a minor
disease in comparison with other chronic conditions. Age of onset is
capable to influence GHQ status which in turn affects QoL.
Title: Effective protection of biological membranes against photo-
oxidative damage: Polymeric antioxidant forming a protecting shield
over the membrane
Authors: O Mertins, PD Mathews, AB Gomide, MS Baptista, R Itri
Published: Biochimica et Biophysica Acta (BBA), June 2015
Keywords: Gallic acid, photodamage, biological membranes,
oxidative stress
Abstract: We have prepared a chitosan polymer modified with
gallic acid in order to develop an efficient protection strategy for
biological membranes against photodamage. Lipid bilayers were
challenged with photoinduced damage by photosensitisation with
methylene blue, which usually causes formation of hydroperoxides,
increasing area per lipid, and afterwards allowing leakage of internal
materials. The damage was delayed by a solution of gallic acid in
a concentration dependent manner, but further suppressed by
the polymer at very low concentrations. The membrane of giant
unilamellar vesicles was covered with this modified macromolecule
leading to a powerful shield against singlet oxygen and thus
effectively protecting the lipid membrane from oxidative stress. The
results have proven the discovery of a promising strategy for photo
protection of biological membranes.
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aestheticsjournal.com @aestheticsgroup Aesthetics Journal
The internet has completely disrupted the
‘rules’ of traditional marketing. Whilst emphasis
was previously, for the most part, placed on the
interaction between the business and the consumer,
the dialogue between consumers themselves is
gaining increasing importance, with online review
sites at the forefront of this ‘consumer to consumer’
(C2C) marketing revolution. With more online review
sites popping up every day, understanding how they
work – and how to maximise them for your business
– is essential. Clinics can either spend time reacting
to the fall out or, at best, spend time turning this
disruption to their advantage. What they cannot do
is simply ignore them. Access to this new world of
C2C marketing is never far away. With the touch of
a screen on a smartphone, consumers can access a
number of platforms where they can gripe, moan and
criticise via words, photos and even high definition
video. Let’s take a look at some of the review
platforms available in the UK.
In recent years, Google has added Google Reviews
to its portfolio.1 With both Google Maps and the
colossal brand power behind this product, it’s not
to be ignored. Now your clinic is just as likely to be
listed on here as in the phone book. Once you have
verified your business on Google+, you can then
respond to these reviews. Google has also made it
particularly easy for people to leave Google reviews
via their smart phones.
WhatClinic.com Reviews launched in 2008. The site
lists more than 100,000 clinics, including medical
aesthetic, plastic surgery and private hospitals in
more than 120 countries.2 It has also recently added
photos and videos to its review content. It provides
clinics with tools and apps to get the most out of
patient reviews.
Facebook Pages3 also provides a review feature
for businesses, as launched in 2013.4 This is proving
more and more popular, with the number of small
businesses using Facebook Pages rising by 10
million in just one year.5 It is enabled for pages
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
Why you shouldn’t
ignore online clinic
reviews
Emily Ross, director of communications at
WhatClinic.com, helps you to make the most
of online reviews in order to acquire and
retain new patients
that are categorised as ‘Local Businesses’, allowing people to post reviews and
ratings onto your page. Although you don’t get to decide which reviews are
published, you can, however, complain to Facebook if a review doesn’t meet its
community guidelines.6 These guidelines stipulate that content may be removed
if of a threatening or violent nature, or if activity constitutes bullying or harassment.
Users can choose to switch off reviews if it’s more than they can handle. The best
approach to Facebook online reviews, indeed to all online reviews, is to handle
them appropriately. Here I’ll share some simple guidelines for effective review
management.
Seven steps for handling a bad review
No matter what business you’re in, if you deal with members of the public you’ll
probably agree that most people are quite reasonable. But there are some
exceptions, and, unfortunately, it’s the exceptions that tend to make the most noise.
While online review sites can be a great space for people to share and read positive
opinions, it’s also the perfect forum for a small number of people to cause business
owners a real headache. So, how should you deal with negative comments?
1. Actually read the review
Try and be impartial. Remember that every review is written by a real person, who
came to you seeking help. Criticism is always hard to take, but is there anything
you can learn from this review? Is there a grain of truth or more in what was said?
Irrespective of the medium in which the complaint is made, it is incredibly bad
practice to disregard feedback from a paying customer.
2. Respond – the sooner, the better
We’re all human, and we can sometimes let our natural defensiveness play out. If
you feel very strongly about a review, think before you respond. Wait until the next
morning, and try and reply in a professional manner, and as calmly as possible.
Or, if you can’t trust yourself to be calm, get someone else to sense-check
your response before you post it online. A moment of anger may damage your
reputation, and can leave a lifetime of regret.
3. Never, ever include private patient data in your response
An obvious one, you’d think, but most clinics are caught out by what is actually
classified as ‘private’. Any information relating to an individual’s visit, including
the date, time, gender, and treatment choice might be considered confidential
information. Essentially, anything that is specific to that patient. ‘When you visited
our clinic last Tuesday’ is an excellent example. This very general sentence is
personal, because it refers to the individual. Speak only on general policy and
practice in your public answers.
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aestheticsjournal.com @aestheticsgroup Aesthetics Journal
4. Handle it offline
This is the first recommended action for managing any disgruntled
patient review. There are times when email conversation can
make a bad situation worse. Email has a dehumanising effect, and,
because of this, it’s easier to be irate in email dialogue. By picking
up the phone and making the effort to speak to the customer, and
with the effort of simply listening to them, many frustrations and
miscommunications can easily blow away.
5. Take time to listen
As we all know, in any complaints process, having someone listen
to us and empathise is the first step to resolving any dispute. In your
online comments show that you are really listening and empathising
with the patient who has taken the time to provide feedback, before
inviting the person to contact you directly.
6. Don’t ‘fob them off’
Referring the user to information on your website or brochure page
is a good idea only if the specific issue is clearly and succinctly dealt
with in your website or brochure. But, let’s face it, very few websites
are as well laid out as they should be, and it may be harder than
you’d imagine to find the one little nugget of information that is
relevant or important. Making the user feel as though it’s their fault
that they haven’t been able to find the relevant information might
only fuel their irritation.
7. Don’t be surprised if…
People publicly post your private responses to them. That’s okay
– they have the right to broadcast your responses. Unfortunately,
you don’t have the same privilege. Don’t be surprised if irate
customers say things that aren’t true, frame responses negatively,
or are downright offensive. Also, don’t be surprised if someone
who is very angry doesn’t bother responding to your carefully
crafted comments, or polite invitations to discuss the issue. In these
cases, let your last words be the ones to remember. Remain calm,
be pleasant, utterly professional and always well-mannered. This is
what will last in the mind of the reader – no matter what the initial
complaint.
Dealing with malicious reviews and trolling
Negative comments and complaints are one thing, but there’s a fine
line that can be crossed. Have you heard of internet trolls? This is
the term I would use for a person who starts online arguments or
upsets people by posting inflammatory or off-topic messages in an
online community, in order to provoke an emotional reaction from
fellow contributors and readers. The very best advice is: do not feed
the trolls. Some people are so provocative, and so clearly driven by
malice, that their own comments are enough to ensure that no-one
takes them seriously. By engaging in an online back-and-forth you
are simply playing into their hands, and potentially causing more
trouble than it’s worth. It’s also incredibly difficult to engage with
people who are purely out to stir and cause argument without losing
your cool, which sends out the wrong message on a public space,
and can damage your brand. Check to see if their content warrants
a complaint to the host of the review site (if their comments are
clearly untrue, for example) and in the meantime, leave well alone.
Most review sites provide you with means to flag malicious content,
such as the report button on Facebook,6 and many companies will
have their own guidelines that must be adhered to. WhatClinic.com
is based in Ireland where defamation law is extremely stringent,
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
as outlined in the Defamation Act 2009 (which came into effect
in 2010).7 No matter where the location of the clinic that is being
reviewed is, as the publisher, WhatClinic.com must adhere to Irish
law. This means all of these reviews are verified, both by phone and
by email, to confirm they come from real patients.
Then, a moderator actually reads the review to ensure that it’s
not offensive, malicious or defamatory. It means a considerable
number of reviews don’t make the grade and cannot be published,
but we work hard to engage with patients to help them get their
point across in a frank and honest manner, which meets our review
guidelines.
Negative reviews only have power if they stand alone
When you think about it, one or two poor reviews beside a hundred
great ones are actually not that bad. In fact, they can be quite
reassuring to the consumer, because it shows that these are indeed
genuine reviews from real patients. Realistically, if no one provided
any constructive criticism, would you really trust the forum?
Many would argue not. How you handle a bad review is often of
more interest to other readers than the actual complaint.
Every poor review is an opportunity for you to show off your
customer care, your patience and your empathy, and you shouldn’t
lose sight of that. On our site, we have found that clinic listings with
lots of reviews are more popular than those without. There are lots
of ways you can encourage patients to leave reviews:
1. Put a link to a review site in the bottom of your emails or on your
website
2. Email customers and ask them politely if they would like to review
your clinic
3. Add suggestions to receipts and in promotional material that you
welcome patient reviews
It’s also a great idea to maximise the value of online reviews
and market them to your benefit. Why not share your favourite
reviews on your social media platforms, or to add them to your
website, brochures and point of sale? As a means to really get to
understand your patients as consumers, reviews can give you a
window into how real patients view your business. That information
can often be worth its weight in gold. Whilst online reviews have
led to an increased power of C2C marketing,8 remember that it’s a
conversation that you too can very easily, and effectively, engage in.
Emily Ross is the marketing and communications
director of WhatClinic.com – a search engine that
lists more than 100,000 private clinics worldwide. She
is a regular speaker and lecturer on social media and
digital marketing.
REFERENCES
1. Get Reviews on Google (US: Google, 2015) <https://support.google.com/business/
answer/3474122?hl=en-GB>
2. About (Ireland: WhatClinic.com, 2015) <http://about.whatclinic.com>
3. Josha Sophy, Facebook enables starred reviews for some businesses (US: Small Business
Trends, 2013) <http://smallbiztrends.com/2013/11/facebook-starred-reviews.html>
4. Anthony Ha, Facebook Says There Are Now 40m Active Small Business Page (US: Tech Crunch,
2015) <http://techcrunch.com/2015/04/29/facebook-40-million/#.eqpw5y:74fl>
5. What Happens After You Click “Report” (US: Facebook, 2015) <www.facebook.com/notes/
facebook-safety/what-happens-after-you-click-report/432670926753695>
6. Defamation Act 2009 (Ireland: Houses of Oireachtas, 2009) <www.irishstatutebook.ie/pdf/2009/
en.act.2009.0031.pdf>
7.  Myles Anderson, Local Consumer Survey 2014 (US: BrightLocal, 2014) <www.brightlocal.
com/2014/07/01/local-consumer-review-survey-2014/>

Enhancing the
patient journey
Clinic operations director Deborah Vine
outlines how her team works to provide
the best experience for patients on their
treatment journey
The regulation of cosmetic surgery and
associated treatments has been under the
spotlight for a good few years. Press coverage
has sparked conversation at all levels, especially
online via social media and forums, and, in turn, this
has heightened awareness surrounding aesthetic
treatments. The demand for clearer information is
now huge, and this demand has been answered
by an increase in information on television, online
and through media coverage. Perhaps due to
this scrutiny, patients are now more informed,
and ask more questions. However, despite this
growing confidence, we must not lose sight of
their primary reason for visiting us – often this is
because something about their body is causing
them concern, embarrassment, frustration, or worse.
Making that first enquiry will have taken courage
and will not have been taken lightly. Throughout this
entire experience, each patient may feel completely
outside of the realms of comfort, and we must
consider this at every point of their journey and craft
our responses to their queries carefully.
The Journey
There are numerous feelings and considerations
which affect the decision process in our potential
patient’s mind. Our role is to carefully de-construct
this, identifying and stripping back any potential
barriers, whilst always ensuring that the patient’s
best interests remain at the centre of everything we
do. Our objective is to make each experience along
the way as simple as possible, allowing the patient
to focus on getting all of the information that he or
she needs in order to help them make an informed
decision about treatment with a clear mind. The
patient journey begins with the patient identifying
their concern and taking the decision to act. This
must be where our journey also begins. As a team,
we must make things as easy as possible for them
and should consider some key questions. Where
might they hear about us? How might they find us?
How are we represented and, more importantly,
how much can they learn about us? Are we
encouraging them enough to take a further step?
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Going Digital
Today, clinics must ensure that they convey a clear, consistent and informative
message across all mediums. Attention to detail in all areas has become vital
as businesses have several ‘windows to the world’, and each should reflect the
consistent service level that the patient can expect throughout their experience.
Digitally, video and blogging have become very useful ways to prepare the patient
for what they can expect. One very popular project we commissioned at Karidis
Cosmetic Surgery London was a video of our customer journey. We wanted people
to feel comfortable with where they would be coming to take away any uncertainty.
During the video, they pass through the doors of our clinic, where our reception desk
is situated, then see other patients sitting in our waiting area, followed by clips of a
consultation. Later in the video, the viewer will see what the hospital room would
look like on the morning of a surgical procedure, with a patient in a gown and robe
discussing their procedure pre-operatively. We believe all of this will help to break
down barriers and make the patient feel at home, and the beauty is that they can
experience this in their own home where they are already at ease. Although the video
is an effective visual aid, some patients would rather read hard facts. In this case, we
found that some information was easier to document in a written format, so to reflect
this, we created a surgical and non-surgical patient journey guide which is featured on
our website. It gives a step-by-step guide of how to get to us, where to park, and what
to consider, in order to resolve any uncertainty.
Interaction
Each time there is interaction with a patient, be it digitally, via email, telephone, letter or
personally, it triggers a touch point. Each one should be considered carefully, ensuring
that clarity, simplicity, information and business identity have been considered and
well represented at all times. In giving patients consistency we nurture their trust,
and the patient will feel reassured that they are in safe hands if our message and
service remains the same throughout their experience. Any doubt can lead to a lack
of confidence and make things difficult. Of course, some patients would prefer to
approach the clinic by more traditional methods such as calling or dropping by. My
entire team mystery shop other clinics at least once annually with the objective of
putting themselves into the patient’s shoes. They look at presentation, information and
cleanliness. However, what is more important is that they truly feel what our patients
feel. There are some great clinics out there and it is so good to hear when my team
return full of inspiration. The exercise is about more than information gathering as it
forces the team to examine how they talk to people and react to situations; they also
feel the nervous anxiety when they are waiting to explain to someone what they least
like about themselves, and how the attitude of those they come into contact with can
influence this experience. The ambience in waiting areas varies hugely, and trying to
reflect your brand image and showcase your offering whilst creating a comfortable
and inviting area can be challenging. Patients can also be waiting a considerable
amount of time, so essentials like cleanliness and comfort are basic but vital things to
get right in order to avoid a bumpy first meeting. Interaction and information are also
aestheticsjournal.com @aestheticsgroup Aesthetics Journal
key considerations here. We feel it is important that the reception team
do not use the reception desk as a barrier. When a patient arrives the
receptionist should come around from behind the desk to welcome
them, and, if needed, put the patient at ease. They also must ensure
they keep patients abreast of any changes, as time is precious to us all.
Little touches are always the icing on the cake; they do not have to cost
much but do make a huge difference. Detailed follow-up calls, skincare
tips, a personal visit from our own surgeon, Mr Karidis, following their
surgery – these things all add to the experience. Within our clinic, Mr
Karidis sends each of his surgical patients flowers, which are waiting
for them in their room when they return from theatre. This is just a small
gesture, but one that is always well received.
Striving For Improvement
Receiving feedback, whether positive or otherwise, is always a
blessing. Through our patient satisfaction surveys, we are able to
nip dissatisfaction in the bud and formulate plans to make future
experiences even better. Making time to listen to our patients is crucial
to giving our clinic heart. Although feedback may occasionally not
be as positive as you had hoped, it is also a starting point to help you
overcome future situations and build upon solid foundations. Any
patient dissatisfaction is discussed at our weekly meetings and, as a
team, we work out how to resolve them with the best possible outcome
for all. One question I have asked my team is to imagine they were
considering surgery; what are the questions that they would want to ask,
but feel too embarrassed (or too foolish) to ask? Their questions were
sometimes personal and sometimes so obvious that we have never
addressed them in our patient journey information. Results from these
sessions have formed the basis of how we plan to move forward. It is a
very good exercise and has really got the team to think like our patients.
Clinical Consultation
Once a patient gets to the stage of consultation and treatment,
Mr Karidis, supported by our clinical and admin teams, works hard
to ensure that each detail is addressed and that outcomes are
discussed to make sure there are no surprises. Only once the
patient has been fully consulted do they meet with an administrator
to discuss logistics and pricing. This is a major part of the customer
journey and a huge step for each patient, which is why it is absolutely
vital that each patient meets Mr Karidis so he can assess and advise
them as individuals, based on his knowledge and experience.
Patients invest a lot in this process, not just financially but also with
trust, with the added potential of exposing a plethora of feelings
including guilt, fear and anxiety. A patient meeting their surgeon
and the supporting team with whom they are investing is integral to
the journey within our clinic. Results of our mystery shop also allow
us to gauge follow up after a consultation. However, there is no
industry formula here – we all want patients to feel cared for, but not
harassed. In our experience, many clinics do not appear to follow
up at all. From their mystery shops, members of my team reported
that they liked a clinic who sent a well constructed personal email
which thanked them for coming and sign-posted that a call would be
made in a week’s time to discuss matters further, but that also gave
an option to decline this call. This ensures there are no surprises
and that patients have the choice to opt out easily. Following their
procedures, our clinic has many patients who want to share their
positive results with others. What is fantastic for us is that these
people become ambassadors for our clinic and at prearranged times
will talk to prospective patients, with a view to providing reassurance
and answering any questions they might have.
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
Moving On
Keeping in touch with our patients is key to the success of our
business. The team are instrumental in how often people are
contacted and, again, this can be through various methods including
social media, online forums, newsletters and emails to keep people
informed. One of our main ways to engage with patients is through our
events and gatherings. We host information evenings for our patients
and potential patients with speakers well-established in the aesthetic
field to discuss topics and treatments, and to answer any questions.
Mr Karidis is always on hand at these events to offer new, insightful
information, but, most importantly, will utilise the opportunity to interact
with each attendee. We believe this is vital to help people see that he
respects and understands how important these social events are, as
well as the private consultation. We strive to ensure that our events
offer an ‘open door’ policy; where nothing is hidden from attendees
who wish to learn more. Participation and excellent communication
make the journey through our clinic smoother for the patient. Keeping
patients informed and making them feel comfortable and reassured
at every point, increasing their confidence in the practice and allowing
them to break down their barriers and communicate effectively is key.
Surveying our patients about what they like and getting them involved
in our future choices and the way we do things has formed a huge part
of our plans for 2015, and will be evident in the direction our business
takes in the coming years. Our goal is to continue to make it easy for
people to glean all the information that they need for making informed
decisions, with a very good idea of the agreed potential outcome. With
increasing demands and ever changing expectations there will always
be room for improvement, however by actively engaging our team
and keeping things simple, approachable and accessible, the patient
journey becomes a harmonious experience for all.
In Practice
“Surgery is a big step for most people, and making
this decision is associated with a host of different
emotions, such as fear and anxiety. We always try to
reassure patients as best we can, keeping open channels of
communication even after the consultation, so in the event of
any uncertainty they can quickly get their questions answered.
We hope that this all leads to a very reassured atmosphere for
the patient, which makes them feel safe in our hands. When
armed with proper information, patients can make a properly
informed decision about whether or not surgery is for them. From
the moment a patient begins to contemplate possible surgery,
that’s when the journey begins. We as a practice and collective
team have the ability to favourably influence this patient journey
at various points in order to make it as seamless, painless and
comfortable as possible. If we can end that journey with a happy
and satisfied patient, then we can consider that we have done our
job well. Many return for other treatments, and this is a testament
to our skills in being able to offer a great patient journey, which in
turn gives our team great job satisfaction.”
Mr Alex Karidis, founder of Karidis Cosmetic Surgery London
Deborah Vine is director of operations at Karidis.
She has a wealth of experience creating comfortable
environments for people to recognise and achieve
their personal goals. With a career spanning across a
plethora of industries and high profile brands, Deborah
has worked to develop a deep understanding of the emotional
decision-making process.
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aestheticsjournal.com @aestheticsgroup Aesthetics Journal
Social
Media
Etiquette
Paul Jackson aims to eliminate the
possibility of committing a social
media faux pas with his guide to
communicating concisely and
effectively online
Social media is forming an increasingly important part of aesthetics
clinics’ marketing and customer relations. It is a valuable way to
convey your personality, to converse and increase awareness of your
services with potential and existing patients, as well as to encourage
feedback and word of mouth recommendations.
With so many businesses seeing the potential of social media, there
is a great deal of competition in terms of clinics vying for patients’
attention. Social media users are therefore becoming more and more
picky about who they follow and who they engage with online. So
whilst social media presents huge opportunities to build and interact
with your audience, it can also be a swift way of alienating them if
you’re not doing it effectively. In everyday face-to-face interactions
if somebody is self-centred, waffling, moaning, talking too much,
or talking about things you’re not interested in, you’re unlikely to
give them too much of your time, and it’s exactly the same scenario
online. Establishing good social media etiquette is crucial, and falling
short in this respect can cause you to lose followers faster than you
are gaining them. This article aims to ensure that you are not only
meeting expectations, but standing out as a glowing example of how
to behave and succeed on social media.
It’s Not About You
A common misconception regarding social media is that it is a
platform for voicing your thoughts, detailing the events of your day-
to-day life, and promoting your products and services. This is what
a large proportion of businesses on social media are doing, but this
completely disregards its ‘social’ element.
Instead, think of social media as a platform for engaging with your
audience, learning about them, and offering them genuinely valuable
content and insights. It’s all about your target audience and what they
want to read about or view. A good rule to follow is the 80:20 rule – for
every two posts that are directly about you or your businesses, eight
should not be and should instead be conversing directly with people,
providing useful resources, or commenting on relevant topics.
Pace Yourself
We all want our posts and content to be seen by our audience, and
the more we post, the more visible we’ll be. However, over-posting
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
on social media is one of main reasons that social media users stop
following or engaging with people or businesses.1
A clever trick to use here is to determine the days of the week and the
times of the day that your social media posts are generally seen the
most and receive the best response. Facebook, Twitter and Pinterest
all make this data available to you for free via their analytics sections,
and free online tools such as Hootsuite and Pagemodo can be used to
help you schedule your posting on other social media sites. Use your
analytics data to schedule your posts for these times, keeping in mind
that quality always beats quantity on social media.
Through analysing this data you will also learn about your audience
and you’ll start to see trends developing. For example, from my
experience of the aesthetics industry, it is common to see social
media engagement peaking at lunchtime, during end of school
time whilst people are waiting to pick up their children, and in the
early evening when people might be making their train journeys
home, as well as later in the evening (perhaps when people are
browsing online in bed).
It’s Not What You Said…
As well as considering what to say and when to say it, tone of voice
is critical to your social media success. One of the limitations of
communicating online is that it can be difficult to understand the
intended tone of a post, and tone can often be misinterpreted.
Take time to determine exactly how you want to be perceived. As
an aesthetic clinic or practitioner you are likely to want to come
across as friendly and approachable, understanding and caring, and
knowledgeable and trustworthy. This can go a long way to securing
your first bookings from potential customers, or further bookings
from existing customers. Think about whether your post could be
misinterpreted, especially if you are making a light-hearted comment,
and take steps to make the intent clear.
Knowing Where to Draw the Line
There have been a number of well-publicised news stories of incidents
where people have said things they shouldn’t have on social media,
such as celebrities commenting on stories that were under super-
injunctions.2 In the aesthetics industry, two potential minefields are
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aestheticsjournal.com @aestheticsgroup Aesthetics Journal
patient confidentiality and giving medical advice online.
In the informal and conversational setting of social media it can
be easy to feel like you are in ‘off the record’ discussions, but
professionalism and ethics should always be at the forefront of your
mind. Whether it’s a quick mention of a celebrity patient who has
just been in for an appointment, or making treatment or procedure
recommendations without a face-to-face consultation, give these
topics a wide berth and err on the side of caution when in doubt.
Social media is also a place to show sensitivity and awareness.
Many people who are considering an aesthetic treatment, and even
those who have them regularly, are shy, embarrassed or wary about
publicising that fact. Following and initiating contact with your patient
and customers online can bring the relationship to the attention
of others when they would prefer it was kept private. Instead,
encourage them as much as possible to follow and contact you via
messaging on your website, in emails, in your clinic and in person.
Professional vs Personal
Another area where social media’s blurred lines can limit your
success is when it comes to deciding whether you are posting
personal or professional content, and this is a particularly tricky
issue in aesthetics. Many clinics and practices are built on the skills,
reputation and brand of an individual, whilst some practitioners are
connected with multiple clinics or practices. When people decide to
follow a clinic or a professional they don’t expect to see posts that
are far removed from the aesthetics industry. On sites such as Twitter,
it is better to have a professional or clinic profile and a separate
personal profile in order to separate the two and ensure the right
types of content are being posted on each.
Speak Their Language
Your target audience is likely to have a range of knowledge levels,
from those who are new to aesthetic treatments through to those who
have experience of a range of procedures. In technical and medical
industries it is easy to fall into the trap of using acronyms, niche
phrases and little-known brand names in your social media content.
If a user does not understand your posts, they are unlikely to engage
with you or share the post. It also gives the impression that your
business is not in sync with customer needs. Keep in mind that your
target audience is not likely to consist of other aesthetic professionals,
so post content that will appeal to your potential and existing
customers, rather than other people in the industry.
#Overuse #of #Hashtags
There are numerous bad habits that you’ll come across online,
and overuse of hashtags is a common sight along with people
creating their own hashtags unnecessarily. Hashtags are designed
for categorising social media posts. If somebody is interested in
a certain topic, a certain news story, or a certain person, hashtags
allow them to see all the posts that related to what they are
interested in. My recommendation would be to have no more
than two hashtags in a post. When deciding on a hashtag to use,
consider what it is that people will be searching for when they
might like to see your post. When a post has too many hashtags
it suggests that there is no real value in the post itself and it can
cause them to be overlooked and ignored.
Be Wary of Shortcuts
There is an array of free and premium social media tools available
online to help you to manage your social media presence
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics
and schedule posts in advance, such as the ones mentioned
previously. These tools typically offer you the option to type out
a post and then send it out across all your different social media
profiles in one go.
Despite being an effective time-saver in many cases, bear in
mind that different types of posts and different wording are more
effective on different social media sites. For example, short and
snappy posts typically perform well on Twitter, whilst image posts
tend to perform strongest on Google+, and more insightful and
professional content is usually better on LinkedIn. A less formal
approach normally has greater appeal on Facebook.3
Social media management tools are a valuable asset and allow
you to save time and improve the quality of your activity – the key
is to remember to keep tailoring and personalising what you are
doing. It’s better to focus on hitting the mark on one social media
channel than missing it on several channels.
Avoid the Hard Sell
At the end of the day, businesses and professionals are using
social media to build or retain their patient base, or to achieve
other goals that will contribute to that, such as building their
reputation, status and visibility. Social media really is a marathon
and not a sprint so it is important to avoid jumping to the end goal,
whether that is convincing a new patient to book a consultation or
generating repeat business from an existing customer. In a face-
to-face meeting, it would be too abrupt to meet somebody for the
first time and to start pushing your products and services to them,
and the same applies on social media. Play the long game, build a
relationship, get to know your audience, let them get to know you
and trust you, and naturally they will make their decisions about
you and your services. Sure, you can help them along the way, but
continually painting the best picture of yourself and your business
is the key, rather than promoting a sales pitch.
The Key Takeaways
Meeting and exceeding expectations for social media etiquette
essentially boils down to a very simple set of considerations.
• It’s not about you or what you are interested in talking about,
it’s about your audience and what they are interested in you
talking about.
• Before posting anything on social media sites, ask yourself: should I
be posting this, who would want to see this post, what value does it
offer them, and what response do I want?
• Social media is just like an offline conversation or friendship.
Nobody wants to stay and talk to the person who talks too much
and only about themselves, so be the listener, the helper, the expert
– the person everyone wants to talk to.
Paul Jackson is senior marketing consultant at
Reload Digital and specialises in social media and
online marketing for the aesthetics, beauty, cosmetics
and fashion industries. As a chartered marketer and
Google certified partner, Paul can be seen speaking at
marketing events across the country.
REFERENCES
1. Carr, D, Why do people unfollow you on Twitter (www.marketingtechblog.com, 2012)
<www.marketingtechblog.com/twitter-unfollow/>
2. BBC News, Alan Davies pays Lord McAlpine damages over tweet (UK, www.bbc.co.uk,
2013) <http://www.bbc.co.uk/news/uk-24654289>
3. Betancourt, L, How to optimise content for social media (engage.scribblelive.com, 2014)
<http://engage.scribblelive.com/Article/704594-How-to-Optimize-Content-for-Social-Media)>
 @aestheticsgroup
“You are never too good or too
old to learn something new”
Beverly Hills dermatologist Dr Zein Obagi has been an
outspoken figure in the skincare world for more than
three decades. Wendy Lewis talks to him about his
considerable achievements in skin health
Researcher, lecturer, author and board-certified dermatologist, Dr
Zein Obagi is considered by many to be a pioneer in advanced
skincare, and one who has broken new ground at every stage of
his career. His innovations in pigmentation disorders and chemical
peels in particular are widely respected throughout the specialty.
Dr Obagi’s interest in skin health began early on. He took a circuitous
route into dermatology, having started out as a pathologist dealing
with diseased tissues. “I found my true calling when I embraced
dermatology as my specialty,” he says.
“A baby’s skin always fascinated me. Microscopically, each cell
is fulfilling its precise function, which corresponds to its flawless
appearance. As a physician, I wanted to offer this possibility to all
patients. The fundamental principle driving my approach is that
skin must be holistically restored at the cellular level. If the focus
is limited to treating only the disease or its symptoms, the results
will be limited and short-lived,” he says. In 1983, Dr Obagi was
instrumental in pioneering the concept of skin health for the mass
market, and developed a line of medical skincare products – the
original Obagi Nu-Derm System – that aimed to transform ageing
skin. Of that time, he says, “My intention was to challenge the norms
of traditional skincare.” His goal was to take the confusion out of
skincare for patients by maintaining the stature of physicians, nurses
and aestheticians as the true skin care experts. “Who better to know
how to maintain healthy skin and treat disease?” he asserts. Today
many of his ideas about skin health have become mainstream. Dr
Obagi founded the Obagi Skin Health Institute in Beverly Hills in 1985
as a comprehensive dermatology practice exclusively dedicated
to advanced skin treatments, where he still sees patients from all
over the world. The Institute has since expanded to three additional
locations; Laguna Niguel, San Gabriel and Pasadena, California.
The trio of Obagi Skin Health Institutes in Southern California are
stunningly modern facilities. These state-of-the-art clinics offer a full
programme of cosmetic and medical treatments, as well as luxurious
spa therapies. After his original company, WorldWide Products,
was sold in 2007, he started a new chapter with ZO Skin Health. In
keeping with his original vision, ZO markets products exclusively to
medical professionals in more than 100 countries. In fact, the company
is not afraid to target any business or individual that violates their strict
anti-diversion policy. A high functioning integrated team has been
crucial to the success of ZO Skin Health, and under the direction of
CEO Jim Headley, the ZO Skin Health brand has flourished Dr Obagi
serves as the ZO Skin Health, Inc. medical director, where he drives
the development of new products, protocols and treatments.
“I make sure that each new formulation delivers the level of results
our physician partners have come to expect and that their patients
want,” he says. 2014 was a significant year for Dr Obagi, with the
launch of the second edition of his original best selling textbook,
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
The Art of Skin Health Restoration and Rejuvenation: The Science
of Clinical Practice. To carry on his legacy, he has handpicked a
special group of physicians from the US and all over the world to
join the ZO Faculty. This elite group of skincare experts, including
plastic surgeons, dermatologists and cosmetic doctors, lecture and
conduct research on skin health, based on Dr Obagi’s experience
and teachings. In May 2015, the first of many planned ZO Skin
Centres opened in the Fashion Island shopping centre in Newport
Beach, California. The model, which is the culmination of his vision,
incorporates all of Dr Obagi’s current thinking about skin health and
features an integrated offering of facials, peels, and advanced anti-
ageing treatments with his signature products. Despite all of his major
achievements, for Dr Obagi family will always come first, having raised
nine children with his partner Samar. Now in his seventh decade, Dr
Obagi has the energy and sharp intellect of a man half his age, and
shows no signs of slowing down.
What is your core philosophy for educating healthcare
professionals?
I want to get the message across that skin health restoration
can’t be accomplished by products alone; the physician needs to
know how to use them in the most effective way, through step-
by-step treatment protocols.
What is the biggest mistake patients make with their skin?
They get bad advice, use the wrong products, and over
moisturise their skin which makes the skin weaker instead of
strengthening the skin. The skin cells get lazy and it actually
makes them look older. When they come to us, we take them off
moisturisers and put them on a regimen of products to restore
skin health.
Who is the driving force behind your great success?
Without a doubt, my wonderful wife Samar is my biggest fan. She
is a very talented businesswoman and has helped me exceed
my potential. She runs the business side of Obagi Skin Health
Institutes, and oversees public relations and marketing, among
other ventures. I don’t know how she does it all.
What is the best advice you can offer practitioners today?
To not just accept the status quo. Challenge yourself, do your
own research, experimentation, and clinical studies. You are
never too good or too old to learn something new.
Wendy Lewis president of Wendy Lewis & Co, a global
aesthetic consultancy business. Lewis is an international
figure in the field of medical aesthetics, and is a frequent
presenter at international conferences. In 2008, she
founded Beautyinthebag.com and serves as editor in chief.
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The Last Word
Dr Sam Robson argues for greater
clarity in the use of professional titles
What’s in a name? Does it matter what we call ourselves when it comes to our
patients? I think it does. Aesthetic medicine can provide an important medical service
to patients, having a positive impact on their self-esteem and quality of life. Our job title
will convey a certain sense of experience, expertise and ability to both prospective
and current patients. The field is already considered to be a slightly grey area ethically.
As it comprises completely private medicine, it could be considered by some to be
exploiting patients’ desperation for remedies to treat their aesthetic concerns, or even
perhaps of selling ‘snake oil’ – a term used to describe fraudulent health products
or, more likely in our case, unproven medicine. To improve this negative association,
practitioners should strive to put patient care above financial gain.
To this end, it is imperative that practitioners portray their capabilities and qualifications
honestly to the public and their patients. In 2015, the Care Quality Commission
(CQC) published an update to its Regulation of Candour which stated that, ‘Providers
[of healthcare] must promote a culture that encourages candour, openness and
honesty at all levels. This should be an integral part of a culture of safety that supports
organisational and personal learning.’ Surely we should be advocating this culture in
our medical aesthetic clinics and complying with the CQC’s notion of openness and
honesty? Across the board, however, individuals claim to be “advanced” practitioners
and yet where is the evidence from their practice? To my mind, at every step of our
interaction with patients we must be open and credible in how we present ourselves.
Simply put, we should first declare whether we are surgeons, doctors, dentists or
nurses and stand behind the recommendations that only practitioners with the
appropriate qualifications be permitted to perform aesthetic treatments. We should
then be clear on our individual claims within each of these four practitioner categories.
I have some concerns, however, about how individual practitioners prefer to portray
themselves:
Surely it is a fundamental
expectation to be honest
from the outset about who we
actually are and our true level of
qualifications and expertise
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
Surgeons
Under this title practitioners should obviously be
surgically trained and have completed specialist
training, and therefore be on the GMC specialist
register. Each individual is in no doubt as to whether
or not they fulfil this criterion. Within the individual
professions, we understand the significance of being
on the GMC register as a doctor, and take this to be
a mark of excellence, having achieved a certificate
of completion. If we are not surgically trained or
have not completed our training, however, should
we be calling ourselves a plastic surgeon, aesthetic
surgeon or an ENT surgeon? To me, the answer is
a clear no – and I believe that only those who have
received their FRCS (Plast) status should be referred
to as plastic surgeons. The lay public may presume
that we have a level of expertise and seniority that
we have not actually earned. Is it really appropriate
to allow a perception that we are more qualified than
we are? Should we be undertaking facial cosmetic
surgery procedures if our expertise is in orthopaedics
– unless, of course, we have formal qualifications,
experience and certification in these areas?
Doctors
Are we General Practitioners (GPs) or General
Practitioners with Special Interest (GPwSI)? Should
we use the term dermatologist if we do not have a
certificate of completion of training in dermatology?
Although cosmetic dermatology is recognised as
a sub specialty within dermatology,1 as far as I am
aware there is no real qualification of ‘cosmetic
dermatologist’ and yet so many doctors with
no formal qualification in dermatology claim this
title. Would it not be more transparent to declare
ourselves as GPs with an interest and some expertise
in cosmetic dermatology? (Although bear in mind the
scope of this is yet to be defined.)1
Dentists
Unless a dentist has a medical qualification too, should
they be calling themselves a ‘doctor’? It would appear
that many dentists still call themselves ‘doctor’, despite
patients being confused by this and even expressing
in blogs a desire to have some clarity.2,3 In 2010, the
General Dental Council (GDC) published a report on
patient and public attitudes to standards for dental
professionals.4 It stated that, “The current GDC proposal
is that the use of the term ‘doctor’ (or the abbreviation
Dr) by dentists should be limited to practitioners
who have a PhD or who are medically qualified and
registered doctors. The document continued, “It is
against the law, for a dentist or DCP to use any title or
description ‘reasonably calculated’ to suggest that (s)he
has a professional status or qualification other than one
which is indicated against his/her name in the register;
however, cases alleging misuse of titles, descriptions
or qualifications by dentists or DCPs can be dealt
with through GDC fitness to practise investigatory/
disciplinary processes.” The document further stated
aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

that, ‘Dentists and practices should not advertise themselves as
specialists where no such specialist list exists.’5 Despite these points,
it seems many dentists continue to use the term ‘doctor’, which, in my
opinion, has the potential to confuse and mislead patients.
Nurses
There seems to be many varieties of nurses practising aesthetics;
my understanding is that there are aesthetic nurses, independent
nurse prescribers, nurse practitioners, advanced nurse practitioners
(ANPs) and aesthetic nurse specialists. There are nurses who
call themselves ‘medical directors’, which, to me, suggests they
are portraying themselves as doctors. Apart from independent
nurse prescribers and ANPs, none of these titles require different
or additional qualifications to one another and are merely self-
appointed titles. Nurse prescribers are an exception as they do
require a prescribing qualification, however, this does not indicate
that a nurse is aesthetically trained – just that he or she has
completed a prescribing course.6 In 2007, the Nursing and Midwifery
Council (NMC) explained that the plethora of titles used by nurses
is of concern, as they do not help the public understand the level of
care that they can expect. In addition, the Royal College of Nurses
stated in 2012 that, “Both the RCN and NMC oppose nurses and/or
employers using the title of ANP where a nurse has not completed
the appropriate education and preparation.”7 Surely, we should be
using one title for all aesthetic nurses or setting levels of qualification
where their title will change upon completion? It is confusing
enough for those of us within the profession to decipher any level
of expertise, qualification or experience – without bamboozling the
layman with a cacophony of terms designed to impress as well. Is it
not a fundamental expectation to be honest from the outset about
who we actually are and our true level of qualifications and expertise,
before we subject a potentially vulnerable patient to aesthetic
treatment? We should be aiming to reassure the public that not only
are we transparent about our ability and level of expertise; we are
also aware of our limitations and will ultimately put the care of our
patients first. I believe that the job titles that we claim for ourselves
are the first step in establishing ourselves as a credible and
trustworthy body of professionals.
Dr Sam Robson trained as a GP before beginning her
career in aesthetics in 2004. She is the medical director of
Temple Medical in Aberdeen, an appraiser for the British
College of Aesthetic Medicine and a voluntary medical
advisor for the Royal National Lifeboat Institution.
REFERENCES
1. Care Quality Commission, Regulation 20: Duty of Candour, (UK: Care Quality Commission, 2015)
<http://www.cqc.org.uk/sites/default/files/20150327_duty_of_candour_guidance_final.pdf>
2. Yusef I et al, A career in dermatology (UK: British Medical Journal, 2010) <http://careers.bmj.com/
careers/advice/view-article.html?id=20001048>
3. Hareyan A, Dentists are not doctors: It’s official now (UK, EmaxHealth, 2008) <http://www.
emaxhealth.com/1/79/25802/dentists-are-not-doctors-it-039-s-official-now.html>
4. Jackson L, Surgeon, Doctor, Dentist – are they really who they say they are? (UK, Consulting
Room, 2012) <http://www.consultingroom.com/blog/309/surgeon,-doctor,-dentist---are-they-
really-who-they-say-they-are?>
5. http://www.gdc-uk.org/Newsandpublications/research/Documents/GDC%20Public%20
Attitudes%20to%20Standards%20for%20Dental%20Professionals.pdf
6. Information available via the British Association of Cosmetic Nurse
7. Advanced nurse practitioners (UK: Royal College of Nursing, 2012) <https://www.rcn.org.uk/__data/
assets/pdf_file/0003/146478/003207.pdf>

Annual British College

of Aesthetic
Medicine Conference
Registration for the annual
BCAM conference is now open!

This year’s event will be held at the Church House Conference Centre
on Saturday 26th September 2015
BCAM is the responsible body for aesthetic medicine and manages appraisals for aesthetic doctors. BCAM is
essential for you as an aesthetic doctor and so the annual conference on 26th September is not to be missed –
be there to ensure you don’t get left behind!
This year’s rich lineup includes speakers from the cutting edge of aesthetic medicine including Mr Rajiv Grover,
Dr Nick Lowe, Mr Paul Banwell, and Dr Ravi Jain.
Our conferences are always educational, informative and inspiring; an event where you can acquire new knowledge
and expand your development whilst networking with colleagues.
Register via the events page on our brand new website www.bcam.ac.uk/membership/events
NETWORKING SESSIONS WITH YOUR COLLEAGUES
FUN CHAMPAGNE RECEPTION BOOK YOUR PLACE TODAY

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015

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