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events in facial filler treatments practitioners and internationally strategies for clinics
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Contents • January 2015
06 News
The latest product and industry news
14 News Special Special Feature
Health Education England Stakeholder Summit report Professional Bodies
16 On the Scene
and Associations
Out and about in the industry this month Page 21
19 Aesthetics Conference and Exhibition 2015
A look at the speakers and sessions featured on the ACE 2015
Main Agenda
CLINICAL PRACTICE
IN PRACTICE
21 Special Feature: Professional Bodies and Associations Buying a Laser
We take a look at some of the leading organisations within
Page 59
aesthetics
26 CPD Clinical Article
Dr Julian De Silva discusses the facial danger zones associated
Clinical Contributors
Dr Julian De Silva is a facial cosmetic surgeon,
with fillers and shares advice on how to prevent adverse events specialising in the eyes, nose, face and neck areas.
He has experience in cosmetic/reconstructive
31 Weight and Obesity facial surgery from fellowships in London, LA and
Dr Amanda Wong-Powell discusses the current statistics for obesity New York.
Dr Amanda Wong-Powell is founder and
36 Prescribing in Medical Aesthetics medical director of Dr. W on Harley Street. Having
Brendan Semple outlines the role of prescriptions for aesthetic completed basic surgical training, she is a member
professionals of the Royal College of Surgeons (Edinburgh), as
well as a VASER liposuction surgeon.
38 Incorporating a Dietician Brendan Semple is a community pharmacist
Dr Anita Sturnham explains how to successfully incorporate and director of the TLC Pharmacy Group. He
is a member of the NHS National Appeal Panel
dietary advice into your practice and a board member of the Numark Pharmacy
advisory board.
42 Vitamin C and the Skin
Dr Anita Sturnham is an experienced GP and
Dr Firas Al-Niaimi investigates the properties of this key anti-oxidant specialist dermatologist. She is an ambassador for
Unilever SkinCare and a medical expert for the
45 Glycation consumer store, Superdrug, also regularly advising
Specialist skin nurse Lorna Bowes explores the concept of viewers on skincare via TV.
glycation Dr Firas Al-Niaimi is a consultant dermatologist
and laser surgeon. He trained in Manchester and
48 Mole Removal subsequently did a prestigious advanced surgical
Dr JJ Masani shares his technique for safe and effective mole removal and laser fellowship. He now works at sk:n clinics
in London.
50 Advertorial: SkinCeuticals Lorna Bowes is an aesthetic nurse and trainer.
Discover the new Day/Night Antioxidant kit from SkinCeuticals With extensive experience of delivering aesthetic
procedures, Lorna trains and lectures regularly
51 Abstracts on procedures and business management in
aesthetics. Lorna is director of Aesthetic Source.
A round-up and summary of useful clinical papers
Dr Jamshed (JJ) Masani is a general and
IN PRACTICE aesthetic practitioner, specialising in mole
removal. He trained as a doctor in Southern India,
53 Maximising Your Marketing Budget before moving to the UK and establishing his
London-based clinic, the Mayfair Practice.
Michelle Boxall on the most effective strategies to ensure
best value from your marketing budget NEXT MONTH
• IN FOCUS: Training and Education
56 Building a Better Business • CPD: Consultation and skin analysis
Hugo Kitchen shares his vision for business success in aesthetics • Cultural expectations in aesthetics
• Differing mediums of training
59 Buying a Laser
Don Berryhill outlines the factors to consider when buying a laser
for your clinic Aesthetics Conference
62 In Profile: Dr Tina Alster
Wendy Lewis talks to US-based practitioner Dr Tina Alster
and Exhibition
about her successful career in aesthetics
7-8 March 2015
64 The Last Word: Record Keeping
Dr Askari Townshend recommends the best approach for aestheticsconference.com
handling and avoiding legal complaints
Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical
Subscribe to Aesthetics aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228
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Editor’s letter
“Oh what a night!” The Aesthetics Awards
2014 ceremony was quite an evening. Many
congratulations to all the finalists, commended
and highly commended, not to mention all the
winners. A huge thank you to everyone involved
Amanda Cameron - it was lovely to see all of you who attended
Editor what was a fabulous celebration of our industry.
I felt extremely proud to play a part in the event itself and to have the
opportunity to address the audience and welcome guests. Social
media activity was in abundance, with #aestheticsawards even trending
on Twitter. In the company of such high-calibre professionals and many
marketeers, we were not surprised, but certainly delighted, to see all PR
opportunities being maximised during, and soon after, the event. Inside
the January issue of the journal, we have included a special Aesthetics
Awards supplement so that you can read all about the evening and
the wonderful entertainment, as well as enjoy photographs of the
nights guests and winners. Now that the 2014 awards ceremony is
over, we are already planning an even better event for next year, but
in the meantime, we look forward to the Aesthetics Conference and
Exhibition (ACE) 2015. We have been inundated with registrations for
the free exhibition and clinical and business workshops, and tickets are
selling fast for what will be a very different conference programme this
year. The new format for ACE 2015 will focus on the patient journey,
so rather than simply a series of isolated lectures on the stage, you
will be able to participate in the virtual clinic we are creating, and learn
about areas of practice that you may not have had the chance to
see before. An in-depth preview of the conference agenda can be
found on page 19 of this issue. As we begin anew and look forward
to the unfolding of 2015, we thought it important to speak to some of
our industry associations, professional bodies and organisations that
together form the aesthetic landscape. Our special feature this month
covers the important work that they do, and what their plans are for
the coming year. A traditionally post-festive-season patient concern is
weight, so in this issue we have also included articles on body and fat,
obesity statistics, and incorporating nutritional advice into your clinical
practice. Following the Health Education England (HEE) Stakeholder
Summit, held in early December, you will find a report of the event that
highlights delegate’s thoughts and concerns. The article, to be found
on page 14, will hopefully encourage you all to have your say on HEE’s
recommendations before the consultation period closes on 9 January. I
hope that you all were able to relax and enjoy Christmas, and from all of
us at Aesthetics, we wish you a happy and prosperous 2015.

Editorial advisory board

We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics Journal’s
editorial advisory board to help steer the direction of educational, clinical and business content
Dr Mike Comins is fellow and former president of the Dr Raj Acquilla is a cosmetic dermatologist with over 11 years
British College of Aesthetic Medicine. He is part of the experience in facial aesthetic medicine. UK ambassador, global
cosmetic interventions working group, and is on the faculty for KOL and masterclass trainer in the cosmetic use of botulinum toxin
the European College of Aesthetic Medicine. Dr Comins is also and dermal fillers, in 2012 he was named Speaker of the Year at
an accredited trainer for advanced Vaser liposuction, having the UK Aesthetic Awards. He is actively involved in scientific audit,
performed over 3000 Vaser liposuction treatments. research and development of pioneering products and techniques.

Mr Dalvi Humzah is a consultant plastic, reconstructive and
aesthetic surgeon and medical director at the Plastic and Derma-
tological Surgery. He previously practised as a consultant plastic
surgeon in the NHS for 15 years, and is currently a member of the
British Association of Plastic, Reconstructive and Aesthetic Surgeons
(BAPRAS). Mr Humzah lectures nationally and internationally.
Dr Tapan Patel is the founder and medical director of VIVA
and PHI Clinic. He has over 14 years of clinical experience and
has been performing aesthetic treatments for ten years. Dr
Patel is passionate about standards in aesthetic medicine and
still participates in active learning and gives presentations at
conferences worldwide.

Sharon Bennett is chair of the British Association of
Cosmetic Nurses (BACN) and also the UK lead on the BSI
committee for aesthetic non-surgical medical standard. Sharon
has been developing her practice in aesthetics for 25 years and
has recently taken up a board position with the UK Academy of
Aesthetic Practitioners (UKAAP).
Mr Adrian Richards is a plastic and cosmetic surgeon with
12 years of specialism in plastic surgery at both NHS and private
clinics. He is a member of the British Association of Plastic and
Reconstructive Surgeons (BAPRAS) and the British Association of
Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards
and has written a best-selling textbook.

Dr Christopher Rowland Payne is a consultant
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.
Dr Sarah Tonks is an aesthetic doctor and previous
maxillofacial surgery trainee with dual qualifications in both
medicine and dentistry. Based at Beyond Medispa in Harvey
Nichols, she practises cosmetic injectables and hormonal-
based therapies.

PUBLISHED BY
EDITORIAL
Chris Edmonds • Managing Director
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chris@aestheticsjournal.com
Suzy Allinson • Associate Publisher
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suzy@aestheticsjournal.com
Amanda Cameron • Editor
T: 0207 148 1292 M: 07810 758 401
mandy@aestheticsjournal.com
Betsan Jones • Assistant Editor
T: 0207 148 1292 | M: 07741 312 463
betsan@aestheticsjournal.com
Chloé Gronow • Journalist
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chloe@aestheticsjournal.com
Hazel Murray • Journalist
T: 0207 148 1292
hazel@aestheticsjournal.com
ADVERTISING
Hollie Dunwell • Business Development Manager
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hollie@aestheticsjournal.com
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EVENTS
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 Insider
News @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Talk Aesthetics
#BAPRAS
Nigel Mercer / @NigelMercer
Enormous privilege to take over
@BAPRASvoice Presidency ceremonially from
Graeme Perks at our AGM this evening. He is
one of the nicest men
#PatientCommunication
Pam Underdown / @AestheticGrowth
Patients want to know what COULD go
wrong and what HAS gone wrong in similar
situations, and what steps you’re taking to
minimise that risk
#Keogh
Ashton Collins / @AH_SaveFace
Injectables and treatments using lasers or
intense pulsed light (IPL) are not classified as a
regulated activity by the CQC. #keoghreport
#Revalidation
PIAPA / @PIAPA_UK 
Looking forward to working alongside the NMC
and providing our members with the chance to
contribute to the finalised Revalidation model
#BodySculpting
Dr Ravi Jain / @DrRaviJain
Up early to catch the flight to London for the
British Association of Body Sculpting annual
meeting. #CPD #vaser #liposuction
#MoleScanning
P & D SURGERY / @pdsurgery
Presenting the Mole Scanning Service to staff at
Ramsay Winfield Hospital @ramsayhealthUK
@ramsaycosmetic
To share your thoughts follow us on Twitter
@aestheticsgroup, or email us at
editorial@aestheticsjournal.com
Training
Aesthetic Connections
launches CPD-approved
consultation course
A CPD-approved course, Advanced Consultation Training (ACT), has
received support from key industry opinion leaders for creating a standard
within the practitioner/patient consultation. Aesthetic course provider,
Aesthetic Connections, created ACT with the hope of helping practitioners
better manage patient expectations. Mr Matt James, consultant plastic and
reconstructive surgeon at Guy’s and St Thomas’ Hospital, said, “Advanced
Consultation Training is an excellent method that allows patients access to a
standardised non-biased consultation. Patients are guaranteed high quality
information for their consultation decision-making. The practitioner also has
peace of mind knowing they have delivered all the appropriate information
required to fully advise their patients and have protection against possible
litigation. It also assists in delivering a safe and satisfactory treatment by
realistically managing patient expectations.”
The course hopes to meet demand for a more rigorous consultation framework,
particularly in the post-Keogh and revalidation environment. ACT developers,
micropigmentation specialist, Anouska Cassano and Glenn Callaghan, professor
of psychology and director of clinical training at the department of psychology
at San Jose State University, believe that comprehensive patient evaluation is
key to ensuring successful outcomes from aesthetic treatments. Callaghan said,
“My experience provides a background in clinical psychology and evidence-
based approach to assessment, which is the fundamental principle behind ACT:
helping practitioners develop accountability and thoughtful methods to assess,
treat, and refer clients for the best services in the area of aesthetic procedures.”
Cassano added, “Part of becoming an ACT-certified practitioner is recognising
that not all clients may be right for what we do and the treatments we provide.
Although undergoing the training makes ethical and moral sense, it also makes
good business sense. A more efficient consultation process will result in happier
patients which leads to positive word of mouth recommendations, unarguably
still the best and cheapest form of advertising.” When delegates have completed
their training, their knowledge will be tested to ascertain if they can become
certified ACT practitioners. Once certified, they may then be entitled to
discounted insurance.
The course will be available in the UK in early 2015.

Tattoo removal
Syneron announce laser
device has been cleared by
FDA for tattoo removal
Syneron Medical has announced that the Food and Drug
Administration (FDA) has cleared their laser device, PicoWay,
to remove all tattoo colours. The PicoWay Picosecond is a dual
wavelength device, using 1064nm and 532 wavelengths. Red, yellow
and orange can be removed with the 532nm wavelength, whilst
black, brown, green, blue and purple are removed using the 1064nm
wavelength. The laser incorporates picosecond (one trillionth of a
second) pulse duration to generate an ultra-short and high peak of
laser energy on the skin. Syneron claims this then creates a strong
photo-mechanical impact that optimises the fracturing of tattoo ink.
In support of the FDA 510 (k) clearance, the Picoway
system was evaluated in a study by practitioners,
including Dr Eric Bernstein, president of Main Line
Center for Laser Surgery. Independent reviews
found that 86% experienced a 50% tattoo clearance
after three treatments. Dr Bernstein said, “As a dual
wavelength Nd:YAG laser, it delivers extremely
high peak-power, picosecond pulses enabling the
treatment of all skin types.”
The company hope the laser will present a new era
in aesthetics and dermatology applications. Amit
Meridor, chief executive officer of Syneron Candela
said, “Tattoo removal represents a significant market opportunity, with
estimates that of the 45 million Americans with at least one tattoo, 20%
want to have their tattoo removed. PicoWay provides a powerful new
option, which clinical trials have shown to offer high rates of tattoo
removal in very few treatments.”

6 Aesthetics | January 2015


@aestheticsgroup Aesthetics Journal Aesthetics
Conference
Award winners to
speak at ACE 2015
Winners from the
Aesthetics Awards
2014 are to present
at the Aesthetics
Conference and
Exhibition (ACE)
in March. Dr Tapan Patel, whose clinic received two
awards, and Mr Dalvi Humzah, recognised at the
ceremony for his training academy Facial Anatomy
Teaching, will lecture delegates on non-surgical
options for facial rejuvenation. Dr Raj Acquilla, who
works with Dr Tapan Patel at his award-winning PHI
clinic, will complete the injectables expert team
to deliver two separate sessions over the ACE
weekend. The sessions, only open to healthcare
professionals, will provide invaluable guidance for
mastering non-surgical treatment of the upper and
lower face and neck using injectables. This will be
the first time the celebrated international speakers
will present together onstage, giving attendees the
opportunity to watch live demonstrations of detailed
techniques for the use of dermal fillers and botulinum
toxin. Delegates can expect to learn how to avoid
high-risk areas, whilst acquiring key skills to increase
patient satisfaction and improve retention rates. Using
the latest conference technology, the trio will teach
attendees how to achieve the best results with dermal
fillers, with the aim of enhancing aesthetic business
and services. Visit www.aestheticsconference.com
to book your place.
Research
Galderma releases
draft results of Angel
study
Galderma has announced that the results from
its recent Angel study look promising. The multi-
centre, prospective, non-interventional observational
study, carried out in France, Germany, Spain and the
UK, assessed patient satisfaction at three weeks and
four months post treatment of glabellar lines with
BoNT-A (s.U). According to Galderma, the results
demonstrated a high level of satisfaction after the
treatment, with 94.7% and 89.6% of subjects being
“satisfied” or “very satisfied” with the aesthetic
outcome at week three and month four, respectively.
Major reasons for satisfaction included the positive
aesthetic outcome, a natural appearance, a rested
look and the comfort of injection. Final publication
date for the study is expected to be late 2014.
Aesthetics | January 2015
Insider
aestheticsjournal.com News
Skincare
New non-prescription products
from Obagi
Healthxchange has introduced two new Obagi skincare products to complement
its existing range. Obagi Retinol 1.0 is a new, stronger retinol product to follow on
from Retinol 0.5 in the Obagi 360 series. The manufacturer recommends that this
high strength, slow release product should be used in conjunction with either the
360 range or the NuDerm Fx range for a more effective non-prescription offering.
The second new offering, Hydrate Luxe, is a rich night hydration cream, designed
for use in conjunction with Hydrate, which launched last year. Hydrate Luxe contains
all the same ingredients as Hydrate – including hydromanil, derived from the Tara
seed – but with added “biomimetic peptides”. These are said to purportedly act
in harmony with the skin to encourage overnight renewal and support metabolic
functions. Obagi claims this delivers a two-in-one moisturising action to create an
instantly moisturised feel, as well as retaining water to provide longer-term hydration.
Anti-ageing
United Cosmeceuticals
launches EVENSWISS
Swiss cosmetics firm United Cosmeceuticals has announced the launch of its
new product line, EVENSWISS. The products included contain the patented active
ingredient Dermatopoietin – a full equivalent of the human epidermal cytokine
interleukin-1 alpha, the natural polypeptide that controls the homeostasis of skin.
United Cosmeceuticals claims that dermatopoietin affects deep skin structures
without penetration. There are ten products in the range which aim to treat ageing
of the face, décolleté, body and hair, with a serum and shampoo designed to
reduce hair shedding and repair hair damage.
Nine of the products are for home use, with one
advanced formula – the Regenerative Plasma –
for professional use. According to the company,
this product helps skin to recover after cosmetic
treatments and supports regeneration.
Accreditation
Save Face announces new
benefits for members and
consumers
Accreditation body Save Face has partnered with workplace service provider PHS
to offer revised benefits to its members. The organisation has also released an app
that allows consumers to research the aesthetic market. According to Save Face,
members can expect reduced costs on services such as waste management, which
includes the disposal and recycling of healthcare, clinical, dental and chemical waste.
Members will also receive a discount on web-based organisation system, iConsult
Aesthetic. The system provides diary management, invoicing, and business report
tools, which aim to collect information that is then used to tailor individual treatments
to each patient’s needs. The Save Face app aims to allow consumers to search for
accredited practitioners, find information on treatments and talk to others considering
aesthetic procedures. Co-director of Save Face Brett Collins said, “We want to
support the industry to help raise standards across the board, so we provide as many
tools as we can to make that happen.”
7
 Insider
News @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Dermal filler Botox

Merz to launch Belotero+ Volume at Research

ACE with Dr Arthur Swift reveals what
Belotero+ Volume is set to have its official launch at the Aesthetics Conference and women want
Exhibition (ACE) 2015. Belotero+ Volume, a volumising HA dermal filler, is the latest
introduction to the Belotero range, which was recently awarded the Aesthetics Award for to know about
Injectable Product of the Year 2014. According to Merz, the new product has the unique
advantage of CPM technology and, together with other products within the range, will Botox
provide a complete solution for treating superficial lines and wrinkles and restoring facial loss.
World-renowned surgeon Dr Arthur Swift will attend the conference to deliver a presentation Research commissioned by Allergan
and demonstrations on the new product, exclusively at the Merz Aesthetics Education & has found that women feel they have
Demonstration Zone. Canadian surgeon Dr Swift completed his board certification in plastic limited information about Botox.
surgery in 1986, and is currently in private practice in Montreal, having trained in both England Allergan joined with SheSpeaks, an
and the United States. Dr Swift is one of the most sought after mentors in aesthetics, and online women’s community, to conduct
is known globally as an expert in both invasive and non-invasive aesthetic treatment. A a survey around what questions women
champion of continuing medical education, Dr Swift has held over 150 master classes for want answered in regards to Botox
aesthetic practitioners in 32 countries, spanning over six continents. Cosmetic. It found that 54% of the 2,200
women surveyed wanted to learn about
Lasers how much Botox actually costs, while
almost half felt that cost was holding
New hair removal laser claims to them back. “Many of my patients believe
that Botox Cosmetic is more expensive
treat the whole back in under four than it is,” said Dr Youn, a board certified
plastic surgeon specialising in cosmetic
minutes surgery. “Patients don’t realise that
the cost of treatment not only includes
Asclepion Lasers has released a new triple wavelength laser, the price of the product but, more
which claims to have the world’s largest spot size. The NeXT PRO importantly, the skill and expertise of
has increased power from 800 Watts to 2400 Watts and two new the healthcare professional who is
handpieces; the XL handpiece and a new 755nm Alexandrite diode, administering the treatment.” Another
which adds an extra wavelength to the existing 810nm and 940nm. major point revealed in the study was
With a spot size of 34mm x 23mm (9.1cm²), Asclepion claim the laser that 40% of women were concerned
is able to treat a full back of hair in under four minutes. As well as about safety and side effects. A smaller
a decreased hair removal time, the laser caters for all skin types, portion (18%) were worried their face
suitable for vascular, acne, and skin rejuvenation treatments. The would not look natural after treatment.
SMOOTHPULSE mode claims to offer a pain-free experience, offering In response to the study, Allergan has
a 12-shot-per-second repetition rate. launched the new Allergan iVisualizer
Nick Fitrzyk from Carleton Medical Ltd, the UK distributor for Asclepion, said, “The new app, which enables consumers to upload
NeXT PRO offers an unrivalled specification compared to other hair removal systems with images of their face in order to see what
810nm, 755nm and 940nm in one upgradeable platform. Asclepion continue to develop the lines and wrinkles would look like post-
highest spec lasers on the market with the lowest running costs, the longest warranties and Botox, as well as providing access to
German-build quality.” further information on the treatment.

Lipolysis

New body contouring device launched

Cryosthetics has launched a new device,
the CryoContura+, which combines
cryolipolysis and laser lipolysis for body
contouring. The aim of the new machine
is to soften the target fat with laser lipolysis
prior to freezing it with cryolipolysis, in order
to achieve better and faster results. The company claims that one
CryoContura+ treatment will remove approximately 25% of fat in the
treatment area. The treatment can be repeated every eight weeks
until the desired result is achieved.
The CryoContura+ machine has two heads, meaning that two
areas can be treated at once, which Cryosthetics claims provides
maximum return on investment.
Cryosthetics managing director Tracey Loughrey said,
“CryoContura+ technology is safe, efficient, non invasive, easily
repeatable and unlike other machines, quick and good value for
money. Following the purchase of a CryoContura+ machine we
provide full training, combining theory and practical sessions. Only
once this is completed will the clinician receive a certificate of
competence and a marketing support package.”

8 Aesthetics | January 2015

 Insider
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com News

Lasers
Vital Statistics
ABC Lasers to distribute Alma
Impact Expert Rhinoplasty was the
most popular cosmetic
ABC Lasers will host an event to celebrate surgery procedure for
the launch of the Alma Impact Expert men in 2013
on 16 January. The Impact Expert laser, BAAPS
introduced by global laser manufacturer
Alma Lasers, aims to help advance active
skincare ingredients into the skin’s layers Between 2010-2015
for enhanced aesthetic results. ABC Lasers
the skincare market is
claim that the device can treat all skin types and improve the appearance
of redness, fine lines and wrinkles, sun damage, dehydrated, oily or 21% expected to have grown
congested skin. At the launch, set to take place at the Mayfair Hotel, growth by more than 21%
London, skin-health expert Mimi Luzon will give a lecture on the Impact MarketLine

Expert and use the device for a live treatment demonstration.

Research Even on cloudy

days, up to 80% of
Study reveals large majority the sun’s harmful
UV rays can
dislike having their picture penetrate skin
taken American Academy
of Dermatology

A recent study has revealed that 76% of people felt that dissatisfaction with
their appearance had prevented them from having their picture taken. The
study by Sinclair IS Pharma, commissioned by Silhouette Soft, was conducted
in order to find out what participants feel ages a person most. Of those
surveyed, 69% felt that facial sagging and wrinkles aged a person more than Each year, more than 3.5 million
anything else, but despite this, 80% would not consider invasive surgery due cases of basal and squamous cell skin
to cost and safety concerns. Almost half stated that signs of ageing affected cancers are diagnosed in the US
their confidence. The research also addressed social media issues, where it Medical News Today
was revealed that 32% of women did not post images on social media due to
dissatisfaction with their appearance. It was found that the majority of people
who were unhappy with their looks were aged between 30 and 39, at a rate If one parent has psoriasis, their child
of 66% in this age group. Over 25% of all surveyed admitted that they judged
is around 10% more likely to also
people based on the way they were ageing, with most people wanting to
look young while appearing to age naturally. suffer from the skin condition
National Psoriasis Foundation

Psoriasis

LEO Pharma announces 6 million

results for topical psoriasis Americans suffer from the signs and
symptoms of rosacea
treatment National Rosacea Foundation

Danish pharmaceuticals firm LEO Pharma has released the preliminary

findings from its study into the efficacy of its Daivobet gel for the topical In the past 12 months
treatment of psoriasis. The company stated that use of the product resulted WhatClinic.com have
in significant improvement in disease severity and patient preference.
seen a 37% increase in
1,795 European patients who had mild to severe psoriasis took part in the
study. In all cases the psoriasis had not responded sufficiently to previous
the volume of enquiries
topical treatment. After eight weeks of treatment with the calcipotriol/ for medical aesthetic
treatments in the UK
betamethason dipropionate, 36.5% of patients were described as “clear” or
“nearly clear” of psoriasis symptoms. Preliminary results were published in
37% WhatClinic.com
the Journal of the European Academy of Dermatology and Venereology.

Aesthetics | January 2015 9

 Insider
News
Events diary
29th January - 1st February 2015
International Master Course on
Ageing Skin – IMCAS Annual
Meeting 2015, Paris
www.imcas.com/en/imcas2015/
congress
7th - 8th March 2015
The Aesthetics Conference and
Exhibition 2015, London
www.aestheticsconference.com
26th - 28th March 2015
13th Anti-Aging Medicine World
Congress, Monte Carlo
www.euromedicom.com/amwc-2015/
index.html
7th - 9th July 2015
British Association of
Dermatologists Annual Meeting
2015, Manchester
www.bad.org.uk
Skin analysis
Skin analysis
system launched
by Observ UK
Observ UK has launched a new skin
diagnostic machine, the Observ 520
Skin Analysis System. The Observ 520
system uses six different skin analysis
modes – Daylight, True UV, Woods Light,
Cross Polarised, Parallel Polarised and
Complexion Analysis – to diagnose skin
conditions and assess the severity of
various age-related skin concerns, such as
wrinkles, hyperpigmentation, porphyrins,
enlarged pores, sun damage and excess
keratinsation.
The machine then produces a detailed
analysis report, which the practitioner
can then use to create a personalised
facial rejuvenation programme, as well as
providing the option of sending a copy of
the report directly to the patient.
The Observ 520 app is also available for
use in conjunction with the skin analysis
system, allowing practitioners to monitor
their patients’ progress using an iPad.
10
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Research
Long-term Botox patients
perceive themselves as younger
than their age
According to a study presented at the 2014 American Society for Dermatologic Study
Annual Meeting, patients receiving continuous Botox treatment over the course of
several years perceived themselves to look younger than their actual age.
Alistair Carruthers, Fellow of the Royal College of Physicians of Canada (FRCPC) presented
the results of the study, which assessed 194 patients, aged 18 and above, with at least
five years history of continuous treatment. Carruthers and his team reviewed patient
records of Botox treatments from 1999 to 2012, evaluating facial areas treated, dosage per
area, number of treatments performed, any accompanying aesthetic treatments and any
adverse events associated with the Botox treatment. The mean age at first injection was
46.3 years, and data was collected from 5,112 treatment sessions with an average of two or
more treatments annually, over a mean of 9.1 years. The researchers found that the longer
patients were injected, the younger they perceived themselves to be. They also found
that although dosing for glabellar lines and crows’ feet remained stable over the period
covered, dosing for forehead lines had decreased since 1999.
ACE
Med-fx to be registration and
consumables partner at ACE 2015
Med-fx has been announced as the registration and consumables partner of the
Aesthetics Conference and Exhibition (ACE) 2015. The logistics company holds 25,000
medical products at its base in Essex, from dermal fillers to laser and surgery consumables,
and supplies more than 7,000 practices in the UK. “Med-fx is a highly sophisticated
logistics company, offering what you want, when you want it, allowing for maximum
stock turn. Whilst price is something we instinctively think of, it is not necessarily the most
important component in operating an efficient and profitable clinic. Stock turnover and
zero wastage means far more than a few pounds off, to the successful day-to-day running
of your business,” said David Gower. He added, “Med-Fx are delighted to once again
work with ACE as the registration and consumables partner. We are ideally placed to
support the huge clinical agenda for 2015, which features live technique demonstrations
and masterclasses from the UK’s top practitioners.” In addition, Med-fx’s sister company,
Medical Aesthetics Group will sponsor an ACE Masterclass on PDO threads, presented by
Dr Elisabeth Dancey and Dr Sarah Tonks.
Skincare
Handheld device launched for
skin treatments
Schick Medical has released a handheld device used to treat various skin conditions.
The device, Sqoom clinical, is used in conjunction with a range of gels which Schick claim
aid skin issues such as psoriasis, rosacea, neurodermatitis and acne.
Sqoom clinical is said to work by using a magnetic field and ultrasound combination
alongside restorative gels that are gently massaged into the skin via one million vibrations
per second. The company claim that through the vibrations, gel penetrates the upper skin
layers and through to the dermis.
With three different programme levels, the device has been developed to treat various
skin types, such as gentle treatment of sensitive skin. Schick also claim the device can
treat the pain of fractures to the tibia, distal radius and long tubular bones.
Aesthetics | January 2015

@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Sunscreen
AADA welcomes passing of
Sunscreen Innovation Act
The American Academy of Dermatology Association (AADA) has released a
statement applauding US Congress for passing the Sunscreen Innovation Act.
The new act will give the Food and Drug Administration (FDA) the authority to
prioritise the review and approval of more effective sunscreen ingredients, many of
which have long been available outside of the US.
The FDA has not approved a new sunscreen ingredient since the 1990s, and
the AADA believe that consumers will now be able to reap the benefits with less
exposure to harmful UV rays.
In the statement, AADA President Brett M Coldiron said, “The American Academy of
Dermatology Association praises Congress for its widespread, bipartisan support of
skin health with its passage of the Sunscreen Innovation Act. The move by Congress
signals the urgent public health need to make more effective products available to
consumers, as skin cancer rates continue to rise at an alarming pace.” He added,
“The AADA looks forward to working closely with the FDA to implement the new law,
and will be providing comments on its implementation.”
Dermatology
Survey shows US public
misunderstands the work of
dermatologists
The results of a study published in the November issue of the Journal of
the American Academy of Dermatology show that the US public has a low
understanding of what dermatologists do, believing they spend far more time
on cosmetic procedures than is actually the case.
800 adults were surveyed by telephone for the study, which was carried out
by researchers at the University of Colorado. 92% of respondents believed that
primary care physicians (GPs) put in longer hours than dermatologists, with 54%
thinking the former have a more difficult job and 63% believing that primary care
physicians have a more critical profession. 46% thought that dermatologists spent
the majority of their time treating skin cancer, and 27% cosmetic treatments.
“The study shows that the public may not be fully aware of all the various areas
of expertise and services that dermatologists provide, especially in the realm of
medical dermatology,” said study co-author April Armstrong, of the University of
Colorado. “Changing the public’s perception to reflect the reality of our range of
expertise is an important and worthwhile long-term goal for our field.”
Equipment
Laser Physics introduce loyalty
scheme
Aesthetics equipment supplier Laser Physics has introduced a rewards
scheme for customers to earn three points on every pound spent on
products. Each point is then worth one penny on future Laser Physics
purchases. The launch of the loyalty scheme coincides with the introduction
of several new products to the Laser Physics medical and cosmetic range,
including white skin marker pens, disposable towels, non-woven swabs, cotton
buds and facial tissues. Practitioners can sign up by completing the form on the
Laser Physics website.
Aesthetics | January 2015
Insider
News
60
Stuart Rose, Managing Director
at Merz Pharmaceuticals
Tell us about the new
Merz Vision.
Over the last 12 months Merz
has undergone a full strategic
review, and aesthetic medicine is
now at the very heart of our global business. Our
Vision is to become the most trusted, admired and
innovative aesthetics and neurotoxins company in
the world.
What tangible steps are you taking on that
journey?
Our biggest impact in the short term will be in our
product offerings. In the first half of 2015 Merz will
integrate the recently acquired Ultherapy platform
(ultrasound energy device) to our business. Like
the rest of our portfolio, Ulthera is FDA approved
(four indications), and is unique in the energy
device market in the precision it can deliver for
skin lifting. The Belotero+ range will have one
of the most exciting advances to that range,
with the launch of our volumising HA (Belotero+
Volume). Soon after this we will launch Radiesse+
(containing lidocaine). These new product
launches, coupled with the recent crow’s feet
licence for Bocouture, will give us one of the most
impactful FDA-approved portfolios for aesthetic
practitioners worldwide.
You have some tough competition. How
achievable is your Vision?
Aesthetic practitioners do benefit from some
excellent competitors in the market. What makes
Merz unique is our ability to focus on the long
game and make investment decisions that may
have longer-term payback than most public
company shareholders would accept. Merz
remains fully family owned which means that we
are not subject to stock market or institutional
shareholder pressures. All of our management
time is dedicated to business growth. Our focus is
always on what is right for customers, patients and
employees. We want to build a business that has
genuinely robust, sustainable value in it and, as
we grow, invest our improving returns in product
innovation, not shareholder dividends. The Merz
family are very clear – we are not for sale. We want
to invest and grow our business to deliver our
Vision. And we will.
This column is written and supported by
11
 Insider
News
News in Brief
Juvea Aesthetics launches
training academy
Juvea Aesthetics clinic, run by plastic
surgeon Dr Faizeen Zavahir, will
launch a new training course, Medical
Aesthetic Training Academy (MATA),
in March 2015. The Royal College
of Surgeons has granted MATA
permission to use cadavers for practical
training. The training courses will cover
all abilities, from basic to MSc level.
Karen Betts hosts Britain’s first
certified permanent cosmetics
exam
All 29 participants passed the UK’s
first certified permanent makeup
cosmetics exam. Permanent makeup
artist Karen Betts hosted the exam
at her Yorkshire Training Academy in
October where 29 candidates sat the
exam. The international exam was
launched by the Society of Permanent
Cosmetic Professionals (SPCP) in
2004, following concerns that there
was no official credentialing system in
place for the profession.
MedivaPharma appointed
distributor for Merz Aesthetics
Pharmaceutical supplier
MedivaPharma has been appointed
distributor for Merz Aesthetics.
The company, which has more than
ten years’ experience working in
medical aesthetics in Europe, will also
work with the Private Independent
Practices Association (PIAPA) to
provide support and mentoring
services to aesthetic medical
professionals.
British doctor appointed
lecturer at Norwegian
university
Glasgow-based aesthetic practitioner
Dr Kieren Bong has secured a
position as clinical lecturer at
Buskerud University College,
Norway’s leading centre for cosmetic
dermatology. Dr Bong will lecture at
the university, as well as sit on the
examination board for the Masters
degree, and head the dermal fillers’
faculty of Senzie Academy. Dr Bong
currently runs the Essence Medical
Cosmetic Clinic in Glasgow.
12
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Psoriasis
Global survey highlights psoriasis
sufferers’ wish to better
understand disease
and treatments
An online survey has found that patients feel they need better education on treatments
available to aid psoriasis. The International Federation of Psoriasis Associations (IFPA)
brought attention to the results on World Psoriasis Day. They found that the top tool voted
for was ‘Educating the patients about treatment options’. The survey was launched in June
2014 and features 17 suggested tools within advocacy, awareness and education. It is
open to psoriasis patients and practitioners treating the disease, as well as family member
and friends, until May 2015. Lars Ettarp, president of IFPA, said, “Today, patients wish to
be well-informed about treatment options, especially when they have a chronic condition
such as psoriasis, so that they can make important decisions regarding their disease
management and care together with their doctors.” The results further highlighted that
professionals and patients felt there was a lack of awareness about a number of serious
conditions associated with psoriasis, such as psoriatic arthritis and metabolic syndrome,
and a need for more information.
Rosacea
Survey reveals other skin
conditions often present
in rosacea patients
A survey conducted by the National Rosacea Society has revealed that rosacea patients
frequently suffer from other skin conditions, although they don’t tend to aggravate the
symptoms of rosacea.
Of the 1,141 respondents, 55% reported to have suffered from another skin complaint at
some point in their lives. Of those, 32% cited atopic dermatitis (eczema), 31% seborrheic
dermatitis, 29% acne and 28% said they had been diagnosed with skin cancer. Psoriasis
and actinic keratosis affected 16% and 14% respectively.
Of those who display symptoms of another condition, 42% said that their rosacea flares up
when the other disorder is present, however only 23% reported an aggravation in rosacea
symptoms during treatment for another condition.
Milestone
Lifestyle Aesthetics celebrates 10-
year anniversary
Lifestyle Aesthetics, the UK distributor for TeoSyal dermal fillers and cosmeceuticals,
LA Science hair products and Jessners Peels, are celebrating their tenth anniversary
working within the aesthetics industry.
Founded in 2004 by Sandra Fishlock and Sue Wales, both health industry professionals,
the company was launched with the intention of providing safe and effective anti-ageing
solutions for customers with busy lifestyles. The pair said, “The pursuit of this fundamental
goal has been, and continues to be, the main focus of Lifestyle Aesthetics’ drive, as we
strive to earn the trust of our partners and customers. Ten years on and Lifestyle Aesthetics
has had more success than forecasted, winning many awards for our innovative, high
quality product portfolio. Sourcing products that truly make a difference in people’s lives,
Lifestyle Aesthetics continues to impress, influence and innovate the world of beauty.”
Aesthetics | January 2015
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 Insider
News Special @aestheticsgroup
Health Education England (HEE) held a
consultation meeting for its report on
‘Non-surgical Cosmetic Interventions and
Hair Restoration Surgery’, on 9 December.
HEE Stakeholder Summit
The Stakeholder Summit, which took place at the Kia Oval,
London, brought together again representatives from
professional associations, royal colleges, regulatory bodies,
education providers and insurers.
Lead members of the Expert Reference Group (ERG) presented
HEE’s Qualification Requirements and latest developments, before
answering delegate questions.
Most recommendations were well-received by stakeholders,
particularly the Recognition of Prior Learning (RPL) and
Accreditation of Prior Learning (APL). It was debated, however,
how all of the recommendations would be regulated in practice.
Dental surgeon and aesthetic practitioner Dr Souphiyeh
Samizadeh asked, “What measures are going to be put in place
to make sure non-health professionals are not providing level
seven [advanced] treatments, especially prior the implementation
of these recommendations?” Many agreed with this question,
further supporting her query on public protection. Professor David
Sines, chair of the ERG, acknowledged, although possibly difficult
to regulate, this issue would be addressed post-consultation.
Noel Griffin, team leader of the Department of Health (DoH) Public
Health Policy and Strategy Unit, replied, “It’s good that work
has already started and all we can try to do is ensure that work
continues.” Dr Samizadeh argued this was insufficient. She said,
“I am very glad that work towards regulating this industry has
started, however it is not enough to leave patients and the public
unprotected for another few years until training requirements and
accreditation become mandatory.”
Many stakeholders felt implementation of the recommendations
would take too long. Whilst HEE’s final report will be sent to
the DoH in April, a delay in publication is likely due to May’s
General Election. Carol Jollie, HEE performance and delivery
manager, explained, “The date of publication depends on whether
there is a change in government and what their priorities are.
She continued, “It would be beneficial if education providers
supporting the proposals start adapting their courses, or create
new ones that meet the requirements. Membership associations
could also recommend that their members work towards HEE’s
recommendations.”
Mike Mulcahy, dentist and ERG member representing the
Faculty of General Dental Practice UK (FGDP), noted that he was
impressed with the the suggestion made by another ERG member
that prescribers of Prescription Only Medicines should be within
the building when they are used, and be available after the event
to deal with any postoperative side effects. Other stakeholders,
however, questioned the location of the supervising prescriber.
Elizabeth Allen, trustee and principal tutor at the British Association
of Skin Camouflage, felt that supervisors should be present in the
same room, not just building.
HEE recommend that practitioners should perform 150 procedures
over the preceding three-year period to be classed as a
supervisor for training or providing oversight of more complex
14 Aesthetics | January 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
cosmetic procedures. Where clinical oversight was recommended,
the regulated health professional would remain accountable for
complications. Stakeholders doubted whether this number was
sufficient to be regarded as an ‘expert’. Mrs Sarah Pape, consultant
plastic surgeon and ERG modality lead representing the British
Association of Plastic Reconstructive and Aesthetic Surgeons
(BAPRAS), said the ERG had difficulty choosing the number,
explaining, “There’s some evidence to suggest that if you have
acquired 50 repetitions of any practical skill you’ve climbed the
steepest part of the learning curve.” She highlighted that despite
performing numerous procedures, not all practitioners are flexible
enough to adapt to unexpected situations.
Providing supervisors can adapt their skills, consultant plastic
surgeon Mr Dalvi Humzah agrees with the recommendation. He
said, “The number may sound low but it does have some evidence
base. Also, not everyone will want the responsibility of being
accountable for other practitioners, and would not want to have to
put themselves forward to be critical of practise when required.”
Andrew Rankin, nurse and ERG modality lead representing the
British Association of Cosmetic Nurses, presented the possibility of
creating an industry standards body, the Joint Council of Cosmetic
Medicine, which would encompass the current associations and
statutory regulators, and aim to improve cross-communication.
This suggestion received mixed reactions, with some
stakeholders, such as independent nurse prescriber Emma
Davies, supporting the idea: “We must rally support for a Joint
Council”, whereas others like aesthetic practitioner, Dr Askari
Townshend highlighted potential pitfalls: “The proposal was well
intentioned but not something that I think is necessary or one that
will contribute more than its cost in money and bureaucracy.”
Moving forward, Mr Humzah said, “I think we’re starting to see
a basic framework but it needs to have some proper teeth to
enforce it.” He added, “We need to look very carefully at who’s
providing training and who’s labelling themselves as an expert.”
Although question time was limited, Carol Jollie emphasised
that the consultation period, ending January 9, provides the
opportunity for stakeholders to highlight concerns and share
ideas. “It’s absolutely key that we get a good response from
across the industry,” she said. “We want to fill our final report
to the DoH with endorsements from practitioners, membership
associations, insurance companies and training providers to
ensure the recommendations have the support of everyone
involved.”
To conclude, Emma Davies said, “HEE has to be commended for
achieving so much, working with so many stakeholders, to deliver
on its remit in such a timeframe. I think the one positive that has
come out of this is that we’ve all gained professional experience
working together.”
Email cosmetics@nwl.hee.nhs.uk to get a copy of HEE’s report and
submit your views on the consultation.
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 Insider
On the Scene @aestheticsgroup
Ellansé Training Day,
London
Sinclair IS Pharma ran an Ellansé training day with board-
certified plastic surgeon Dr Pierre Nicolau, who travelled from
Europe to share his expert knowledge on the Ellansé products
and techniques.
The international pharmaceutical company held the event at Harley
Street on November 21, offering practitioners the opportunity
to utilise Dr Nicolau’s understanding and techniques. Aesthetic
trainers and doctors, including Dr Askari Townshend, Dr Linda
Eve, and Facial Anatomy Teaching founder Mr Dalvi Humzah,
were amongst those who attended the event. Katrina Ellison,
Sinclair Pharma brand manager, said, “It was very inspiring to bring
together some of Sinclair Pharma’s finest doctors and trainers to
meet with Dr Pierre Nicolau and gain further understanding of the
Ellansé brand.”
Guests first attended a theory session with Dr Nicolau to learn the
science behind the Ellansé product, and were later treated to a
practical session. Lunch was followed by an afternoon consisting of
practical demonstrations. Dr Eve said, “I was very impressed with
the training from distinguished French plastic surgeon Mr Pierre
Nicolau. He shared his extensive knowledge about Ellansé and
discussed the differences between fillers that are bio-stimulators
and those which are simple volumisers, whilst showing us the
comparative benefits of each group. Ellansé is an effective
treatment for both deep supra-periosteal and also sub-dermal
injections, and provides long lasting results for 1-2 years.”
Wigmore Medical Group Open Day, London
The Wigmore Medical Open Day, held
on November 29 at the Royal Society
of Medicine (RSM) in London, aimed to
strengthen and develop industry knowledge
regarding skincare, body contouring, and
injectables.
The open day, which included training and information on ZO Systems,
consisted of three seminars by a group of aesthetic practitioners that
included Dr Aamer Khan, Dr Rachael Eckel and Dr Sam van Eden.
“It was uplifting as a presenter to see the ZO Systems Day so well
received. The ardour of the delegates was unwavering, yet especially
palpable upon discourse of the new ZO products,” said Dr Rachael
Eckel, cosmetic dermatologist and Z0 trainer.
The injectables agenda was run by Dr Aamer Khan, alongside other
16 Aesthetics | January 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
Allergan #THISISME
Campaign, London and
Manchester
Allergan recently hosted two
consumer events in London and
Manchester in order to mark
the launch of its new campaign,
#THISISME. The events were
organised with the aim of educating
women on the various filler treatments
available, as well as encouraging
them to embrace the signs of ageing.
Allergan ran the events in conjunction
with Hello! Magazine, and speakers
included beauty journalist Alice Hart-
Davis, psychologist Honey Langcaster-James and, finally, aesthetics
practitioners Dr Tracy Mountford and Dr Jonquille Chantrey. The rise
of celebrity influence was discussed, along with the social trends
that affect perceptions of ageing and can impact on women’s self
esteem. Guests were also educated on dermal fillers, with speakers
highlighting that those seeking treatment should not be concerned
with media expectations of how older women should look.
They noted that people should age in the way they want to.
Attendees were invited to participate in mini consultations
with Allergan’s aesthetic practitioners, Alison Telfer, Dr Sherina
Balarathnam, Annie Grant and Rachel Goodard, as well as
meet ambassadors of the campaign – who gave their first-hand
experience of using fillers. Guests were also able to enjoy high-tech
facial analyses, which used VISIA and VECTRA technology.
“The talks were very informative, but to me the ambassadors were
the most inspiring part. Pictures on a screen can clearly be airbrushed
but real life models clearly can’t. Having the practitioners, with whom
we could discuss options available, and the ambassadors where we
could see the finished result, in the same room was very effective,”
said Julie Pitcher, 54, a consumer who attended one of the events.
Allergan also commissioned celebrity make-up artist Louise Constad
to provide make-up tips for ageing skin. Guests were then treated to
complImentary eyebrow shaping treatments from HD Brows.
international speakers such as Dr Kieren Bong, who demonstrated a
comprehensive range of fillers and advised delegates on what to use,
where to use it and why. The event was free of charge to all Wigmore
Medical account holders, and attendees were able to watch live
demonstrations and learn about product updates throughout the day.
Live demonstrations also allowed delegates from the audience to
participate in an engaging debate on how best patients should be
assessed and marked-up in preparation of treatment. With three
separate agendas, Wigmore Medical aimed to provide something for
everyone. The day mainly consisted of clinical sessions and ended
with the Ivasix agenda, which detailed the benefits of using InMode
applications. Dr Stephen Mullholland closed the event with a lecture on
‘How to run a successful aesthetic clinic’ and all delegates received a
free copy of his book of the same title.
 Insider
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com On the Scene

The Aesthetics Awards, London

presented to Dr Roy Saleh, who received a standing ovation from many
of his fellow practitioners in honour of his hard work and dedication
to medical aesthetics. Dr Saleh said, “Wining this award means that
there is a belief, an acceptance and a feeling that you’ve reached
a certain level in your career, but it’s important for me to say that my
career isn’t over. The evening has been lovely – it’s been a delight.
Receiving this honour is the best part of it as it’s such an achievement
for me. I don’t think that many people have won this award, and that
makes me even more proud of the fact that I have.” In addition to
The Aesthetics Awards, held in London at the Park Plaza celebrating aesthetic achievements, a generous £1,663.13 was raised
Westminster Bridge Hotel, was a night of celebrations for the top for the Awards’ chosen charity, Changing Faces. See this month’s
practitioners, clinics, products, distributors and manufacturers special Aesthetics Awards supplement for a full list of winners
within the aesthetic specialty in 2014. The event, on December 6, and to see a gallery of images from the evening or visit www.
began with a pre-dinner drinks reception before guests were moved aestheticsawards.com.
into the grand ballroom for a sit-down dinner, where Aesthetics
journal editor Amanda Cameron gave a welcoming speech to
officially open the ceremony. After dinner, guests were treated
to a performance by comedian Dominic Holland, which was soon
followed by the award presentations. Winners were recognised in 21
categories, with 145 entrants being successful in reaching the final
stages. The awards included Training Initiative of the Year, won by Mr
Dalvi Humzah for his training course Facial Anatomy Teaching, and
The Save Face Aesthetics Award for Aesthetic Medical Practitioner of
the Year, which was awarded to practitioner Dr Linda Eve. Finally, the
prestigious Aesthetics Source Award for Lifetime Achievement was

Botulinum toxin and its applications -

a day course
Thursday 29 January 2015
Royal Society of Medicine, London
RSM member rates: £599
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Dermal fillers course
Friday 30 January 2015
Royal Society of Medicine, London
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Aesthetics | January 2015 17

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@aestheticsgroup Aesthetics Journal
Amanda Cameron, Aesthetics journal editor and
Aesthetics Conference and Exhibition
programme organiser, highlights why ACE is set
to revolutionise the conference line-up of 2015
The unique ACE 2015
learning experience
The main agenda at the Aesthetics
Conference and Exhibition 2015 is a
programme with a difference. At Aesthetics,
we know from our experience and
knowledge of the specialism that there is
a need for in-depth, CPD accredited and
practical hands-on training in every aspect
of the profession. At ACE 2015, we will give
you this kind of training. ACE will recreate
clinic environments and give you options for
solutions to patient issues, including how to
consult, carry out differential diagnosis and
post-treatment follow up. Those attending
will be able to customise their own learning
agendas by choosing to attend one or more
of the four main sessions, rather than only
being able to select either a one or two-day
conference pass, as is traditional at past
UK aesthetic conferences. The ACE main
agenda will begin on Saturday March 7 and
will look at the treatment of fat on the body
and face – with regards to both removing and
replacing. With the demand for non-invasive
procedures to improve the body increasing
year-on-year, it is vital for practitioners to
stay up-to-date with the latest developments
in this field. This key session will be led by
consultant plastic surgeon Mr Taimur Shoaib
and Dr Mike Comins, who will together chair
a panel of specialists in weight management
and body sculpting. Mr Shoaib says, “The
session will be a unique opportunity for
clinicians of all training backgrounds to
discuss fat reduction and enlargement. I’m
excited by the conference session because
of its uniqueness and the innovative way the
session will be delivered.”
The session will run for three hours and will
feature audience participation and debate
on the merits of non-surgical fat reduction
with surgery. Different types of surgical
fat reduction methods will be discussed
including laser, ultrasound and radiofrequency
assisted liposuction. Dr T Vetpillai will present
an alternative view of fat management
with her unique approach to coaching and
weight loss. During this session attendees
will be invited to discover a range of different
energy-based fat reduction methods that
Aesthetics aestheticsjournal.com
HEADLINE SPONSOR
could be used in their clinic. Interaction
will be at the forefront of all sessions, with
delegates able to discuss treatment planning
with the expert panel and debate on key
issues including: which is better – vaser or
laser? Who should be performing liposuction?
Where is fat grafting appropriate and where
should you use fillers? Saturday afternoon at
ACE is host to ‘Face Off’, the first instalment
in the highly anticipated two-part advanced
anatomy and injection session, led by award-
winning surgeons and physicians Mr Dalvi
Humzah, Dr Tapan Patel and Dr Raj Acquilla.
Both ‘Face Off’ and the continuing Sunday
morning zonal treatment session will combine
unique dynamic anatomical explorations
with demonstrations on how to analyse the
face to get the best results. This is a never-
seen-before opportunity to experience these
three world-class injectors demonstrating
and presenting together onstage in practical
and interactive sessions, open only to
healthcare professionals. The top injectors
will explore non-invasive treatments for
upper and lower-face beautification, and
attendees will be able to watch live technique
demonstrations detailing the use of dermal
fillers and botulinum toxin in the peri-orbital,
peri-oral and neck regions. Delegates will
also learn how to avoid high-risk areas in the
upper and lower face, and how to deal with
potential complications. The engaging format
will allow attendees to question the experts
and achieve tangible learning objectives
through use of the latest conference
technology. Of the session, Mr Humzah
says, “I am looking forward to working with
some of the leading experts in aesthetics
and leading an interactive session with the
presenters and delegates who attend ACE
2015. These sessions will be extremely
informative, inspirational and enjoyable for
all.” The final session of the weekend will
be run by dermatology leaders Dr Stefanie
Williams and Dr Christopher Rowland Payne,
and is an unmissable opportunity for all
those treating patients for skin issues and
conditions, or for those looking to expand
their treatment menu in this area. Follow the
Aesthetics | January 2015
ACE 2015
Programme Overview
patient journey from live consultation, through
to detailed discussion on the treatment of
common dermatological conditions, looking
at aesthetic treatments and combination
treatment options, concluding with post-
procedure maintenance. Delegates will learn
how to manage common conditions such
as acne, rosacea, seborrheic dermatitis and
eczema, and will be invited to question the
panel on the best cosmeceutical ingredients
for anti-ageing and prevention. As part of
the session, Dr Daron Seukeran will also
provide key guidance on how to treat skin
conditions using lasers. “Laser technology is
advancing rapidly and continues to increase
our range of treatment which can be safe
and effective when used appropriately,” says
Dr Seukeran. “I will describe the main use of
lasers in treatment of the skin and aesthetics,
and explore why different lasers are required
to provide the full range of treatment.” The
dermatology team will be joined by aesthetic
nurses and skin experts Lorna Bowes and
Anna Baker who will demonstrate expert
techniques and treatments for anti-ageing,
and other key issues such as the diagnosis
of suspicious lesions. Anna Baker says,
“Patients will frequently present in aesthetic
practice with a variety of skin lesions, some
of which may be non-melanoma skin cancer,
which is increasing in prevalence. Topical
photodynamic therapy is an effective
treatment modality for specific superficial
lesions; an interactive overview of the
treatment pathway as well as the licensed
indications for treatment will be discussed
to provide an insightful perspective on this
efficacious treatment.” Dr Acquilla concludes,
“ACE 2015 is shaping up to to be the most
exciting live injection symposium I’ve been
involved within the UK. We will be delivering
the latest anatomical knowledge and injection
techniques in facial aesthetic medicine using
cutting edge multimedia technology, giving
the audience a unique interactive educational
experience they won’t forget.”
The flexibility of the premium conference
programme allows delegates to focus
on their individual learning needs. Those
choosing to attend more than one session
are entitled to a discount which increases
with the number of sessions booked.
Spaces are limited so visit the website
to secure your place today. ACE will also
once again feature Expert Clinic live
demonstrations, supplier Masterclasses
and Business Track workshops as part
of the free Exhibition registration. Go to
www.aestheticsconference.com to see the
full programme and to register.
19
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@aestheticsgroup Aesthetics Journal
BCAM (British College of Aesthetic
Medicine)
What is BCAM? Founded in 2001, BCAM is
a professional body that aims to encourage
regulation within the industry and make
aesthetic medicine safer for the public. It is a
doctor-only organisation encompassing any
medical specialty.
What does it do? BCAM has increasing
input into standard setting across a range of
institutions, such as Health Education England
(HEE) and the General Medical Council
(GMC), various diplomas and the Department
of Health. This allows the organisation to
influence the aesthetic agenda and provide
education to the public and the medical
profession.
Member benefits: Any aesthetic doctor
can apply for associate membership and
after two years, following Board approval, full
membership. It offers peer support through a
website forum, advice on matters concerning
practice, and appraisal with a Responsible
Officer, leading to revalidation. It also hosts an
annual conference and is involved in standard
setting, on which members have a chance to
present their views.
The future: Dr Paul Charlson, president of
BCAM, says, “In the future we aim to become
more involved in diploma development.
We aim to create a new website with social
media linkage to allow members to be easily
identified by the public, and increase our
media presence and membership in order to
be seen as the ‘go to’ organisation for high
quality advice and practitioners.”
BCAM has a
network of over
300 doctors.
www.bcam.ac.uk
Special Feature
Aesthetics aestheticsjournal.com Aesthetic Organisations
The benefits
of belonging
This month’s special feature takes a closer look
at the professional bodies and organisations
that together make up the UK aesthetic
landscape, and asks, what do they have to offer
practitioners in 2015?
BAAPS (British Association of Aesthetic Plastic Surgeons)
What is BAAPS? BAAPS is a professional body specifically for surgeons
practicing aesthetic surgery. It is a registered charity dedicated to advancing
education and the practice of aesthetic plastic surgery for public benefit.
What does it do? BAAPS offers training and support to members. All members
need to be on the specialist register, sponsored by two other full members, and be
able to demonstrate competence in aesthetic surgery. They must submit an annual
audit of their figures and abide by a code of practice, reinforcing the BAAPS brand
to the public. BAAPS has recently launched regional training meetings and hopes to
assist the industry by promoting training, research, ethics, public education and safety.
BAAPS has an average annual meeting
attendance of 200 surgeons.
baaps.org.uk
Member benefits: Practitioners can attend a free annual meeting, receive
a free subscription to the Aesthetic Surgery Journal, contribute to an annual
national surgical audit, and support research into aesthetic surgery. BAAPS
claims that patients can look for membership to the association as reassurance
that their surgeon will act in an ethical and safe manner according to a specific
code of practice.
The future: Paul Harris, BAAPS council member, says, “As a result [of the Keogh
report], we should be able to establish a clear set of standards in training, audit
and patient communication that will significantly reduce the chances of rogue
practitioners causing damage to or profiteering from patients.”
BACN (British Association of Cosmetic Nurses)
What is BACN? The BACN is a professional membership organisation for fully
qualified nurses or trainees, in cosmetic nursing. It aims to ensure cosmetic nurses
are recognised and can access current legislation, education and peer support to
ensure consumers receive safe, professional treatment.
What does it do? The BACN agreed a three-year strategic plan in 2014 meeting
their member needs. It also saw publication of the RCN/BACN Accredited
Competency Framework for Aesthetic Nurses. It aims to be an integral part of
shaping the standards of non-surgical practice in both Europe and the UK, actively
encouraging member participation.
Member benefits: In 2015, BACN hopes to offer a strong, revitalised regional
network for nurses to meet, exchange best practise, attend workshops and obtain
CPD points. Members can expect news, events and resources on practise, research,
products and suppliers. They may also receive discounted insurance, events, and
magazine subscriptions.
Aesthetics | January 2015 21
 Special Feature
Aesthetic Organisations @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

The future: “There are some exciting new benefits for BACN members for 2015 BAPRAS (British Association of
including strategic sponsored Super meetings, in addition to regional meetings, and Plastic Reconstructive and Aesthetic
a new BACN App for easier website access to news, classifieds, guidelines and Surgeons)
protocols,” says Sharon Bennett, chairperson of BACN. “We are also hoping to agree
an associate membership for other professionals, giving access to meetings and What is BAPRAS? BAPRAS is a registered
education to GMC, GDC and overseas nurses, though retaining NMC registrants at charity and the only statutory association for plastic,
board level. The BACN is working on the NMC pilot for revalidation, along with other reconstructive and aesthetic surgeons and trainees
healthcare organisations, to enable a smooth transition when the service is initiated in the UK.
in September 2015.” What does it do? The goal of the association
is to drive professional standards, education and
Since 2010 the BACN innovation across plastic surgery. BAPRAS works
have grown to over with its members to create best practice in the UK
and internationally, and aims to deliver improved
600+ members. outcomes for patients. It also aims to differentiate
www.cosmeticnurses.org itself by developing policy in a patient-focused
manner from the perspective of plastic surgeons as
UKAAPS (UK Association of Aesthetic Plastic Surgeons) a community,.
Member benefits: BAPRAS offers a range
What is UKAAPS? UKAAPS was formed as a professional body by a group of of membership options to suit all levels of
like-minded plastic surgeons, with membership only available to those who are fully surgical expertise. The association facilitates
accredited and practice non-surgical aesthetics and aesthetic/cosmetic surgery. the development of plastic surgery both by
What does it do? It provides support for aesthetic plastic surgeons and aims subspecialty and as a whole. Members are
to show the public that there is training available for aesthetic plastic surgeons. expected to contribute to the speciality and take
The training provided by UKAAPS is in the form of the MCh Plastic and Aesthetic part in an on-going exchange of information,
Surgery Practice course, which allows practitioners to develop their knowledge knowledge and expertise. They receive reduced
and expertise as aesthetic plastic surgeons, and also works to assure the public of rates of registration for BAPRAS meetings and
full specialist training. courses, as well as support from colleagues and
Member benefits: UKAAPS offers members training and event days, which vary special interest groups in dealing with challenging
from live surgery events to industry meetings. They have regular council meetings clinical cases and ethical issues.
to discuss developments and showcase live surgeries in the UK and abroad. The Future: “BAPRAS is collaborating with major
Plastic surgeons on the MCh degree course must complete 14 competencies independent providers and other mainstream
and are provided with VLE learning platforms, live surgery demonstrations and surgical associations to represent surgery as a
supervised practical surgery. All whole and to develop novel methods for the
UKAAPS members are members of Over 185 surgeons training of surgeons in procedures no longer
BAPRAS. available on the NHS,” says Mark Henley, chairman
The future: Professor James internationally of the BAPRAS Independent Practice Committee.
Frame, president of UKAAPS, says, logged in to “This includes the use of surgical simulation and
“UKAAPS has already set its house ‘Hands On’ training in the independent sector.”
in order before the Keogh report
watch UKAAP’s
and the GMC recommendations. It July Surgery BAPRAS has 800+
provides the world-first university
Masterclass online. members to date
validated training course in aesthetic www.bapras.org.uk
www.ukaaps.org
surgery for plastic surgeons.”

BCDG (British Cosmetic Dermatology Group) The BCDG has

What is the BCDG? A section of the British Association of Dermatologists (BAD), the 56 full members,
BCDG is a national body for dermatology trainees, consultant dermatologists who are GMC
specialist registered and physicians with approved post-graduate dermatology training.
all on the GMC
What does it do? The BCDG provides academic and clinical knowledge in cosmetic Specialist Register.
dermatology. It shares advice on cosmetic training, as well as advising post-graduate www.bcdg.info
medical education students and the Government. The BCDG aims to facilitate communication between the BAD in a professional, evidence-
based and unbiased manner for the benefit of the public and media.
Member benefits: Members will receive educational training to further their understanding and expertise in cosmetic dermatology and
cosmetic procedures. The BCDG communicates with consultant and trainee dermatologists, providing them with information on ethical and
clinical standards of practice within the cosmetic area. The BCDG also provides educational programmes, which are all CME/CPD approved.
These include an annual clinical and scientific meeting, focused practical workshops and teaching sessions at the annual BAD meeting.
The future: “The BCDG is committed to continued education. This year, members can look forward to workshops on neurotoxins and fillers
in April, discussions on dyspigmentation at the BAD meeting in July, and the annual BCDG Clinical Meeting in November”, says Nick Lowe,
BCDG president.

22 Aesthetics | January 2015

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 Special Feature
Aesthetic Organisations @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

IHAS (Independent Healthcare PIAPA (Private Independent

Advisory Services) Practices Association)
What is IHAS? IHAS is a division of the What is PIAPA? PIAPA was founded by a group
Association of Independent Healthcare of aesthetic nurses in 2004 with the aim of offering
Organisations (AIHO), the trade association for support to independent practitioners.
independent hospitals. What does it do? PIAPA aims to promote safety,
What does it do? Within the last decade IHAS integrity and clinical excellence within the industry.
has had a significant role in the operational policy IHAS links with Board members regularly meet with Health
and regulation in the independent healthcare Education England and the Nursing and Midwifery
sector. AIHO/IHAS works in tandem with ISCAS,
AIHO, representing Council to discuss the implementation of new
the Independent Sector Complaints Adjudication over 200 hospitals regulations and practise guidelines.
Service, which provides an independent Member benefits: Members can expect to
nationally.
review stage for third stage complaints from receive training opportunities, access to business
aiho.org.uk
independent hospitals and clinics. Private patients coaching, certificate of membership, NMC and
treated in the UK do not have access to the Public Services Ombudsman for revalidation information, discretionary discounts
resolving complaints. and portfolio and APEL advice.
Member benefits: IHAS offers networking opportunities through its medical The future: Co-founder of PIAPA Yvonne Senior,
revalidation workstream for all the Responsible Officers in the sector, who meet said “PIAPA was created to support, reassure and
on a regular basis with the GMC. It also assists with the development of the improve practitioners, and as we face a pivotal
National Workforce minimum dataset, so workforce data can be captured from the time of change in medical aesthetics, we plan to
independent sector in conjunction with the NHS. do exactly the same in the future.”
The future: “IHAS has maintained its relationships with the system regulators in
all four countries and with the professional regulators,” says director Sally Taber. PIAPA has
“IHAS was asked by the previous government to set up a self- regulation scheme for more than 200
cosmetic injectables. Treatments You Can Trust (TYCT) has been established since
2010 to ensure the quality assurance of those who undertake cosmetic injectables.” members.
www.piapa.co.uk

SOMUK (Society of Mesotherapy UK) Save Face

What is SOMUK? SOMUK is the only society specialising in
Mesotherapy in the UK, with membership available to all interested
medical professionals.
What does it do? SOMUK aims to establish and maintain
standards of clinical excellence in the science of mesotherapy. It
also acts as a resource for safe ethical practice and strives for the
development of evidence-based medicine in support of the use of
mesotherapy. It further aims to elevate mesotherapy as a recognised
established therapy in aesthetics and pain management, and aims
to work closely with authorities and insurance companies in order to
ensure the safe practice of mesotherapy.
Member benefits: Members are updated with information on
mesotherapy, are able to attend congresses at a reduced fee, and
potentially receive free of charge training courses. Members are
actively encouraged to engage in networking both nationally and
internationally to share experiences, ideas and innovation in order to
improve and maintain standards of safe ethical practice.
The future: “Within one year we are proud to have become official
partners of well-known national and international congresses, which
is a great benefit for members and the development of mesotherapy
in the UK,” said Dr Philippe Hamida-Pisal, president of SOMUK. “One
of our main goals for the future is to set up a post-graduate university
diploma in Pain Management using mesotherapy.”
What is Save Face? Save Face is the largest voluntary register
of accredited practitioners in the UK. The organisation provides
consumers with information on non-surgical treatments so that they
can be fully informed when deciding on aesthetic procedures. Save
Face is not a substitute for membership with a professional body.
What does it do? Save Face aims to educate and protect the
consumer. Its support packages aim to add value to practitioners,
whilst the organisation hopes to establish an objective set of
standards, which both practitioners and clinics can be measured
against in order to achieve accreditation.
Member benefits: Practitioners must pay to register with Save
Face and will receive an independent inspection and verification of
their standards in practise, and a means to gather and present their
evidence when required for appraisal, revalidation, insurance, and
job applications. Save Face offers a verification process, providing
policies and forms of support to ensure safe running of clinics.
Members can also receive discounted services.
The future: “We need to build consumer confidence in the safety of
these treatments when delivered by safe hands in a safe environment
using safe products,” said Emma Davies, clinical director of Save Face.
“The consumer needs a credible register that provides more than just
a register, whilst professionals need to recognise the place for – and
value of – this model of self-regulation, and support it.”

SOMUK has a current Since August Save Face has

membership of 47 accredited 110 practitioners
interested parties. across 200 UK locations.
www.somuk.co.uk www.saveface.co.uk

24 Aesthetics | January 2015

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Facial Danger Zones point @aestheticsgroup
Facial Danger Zones:
avoiding serious complications
in non-surgical filler injections
Dr Julian De Silva discusses facial danger zones
and how to treat and prevent serious adverse events
Abstract
Over the past decade non-surgical filler injections have become
an increasingly popular treatment for soft tissue augmentation
and facial rejuvenation. For the most part, these filler injections are
considered relatively safe. Yet from my knowledge of case reports
and conference discussions, there seems to be an increasing number
of serious adverse events occurring, including loss of visual function,
blindness, skin necrosis and facial scarring associated with the use of
filler injections. In this article, I discuss the underlying facial anatomy
and mechanism of these serious adverse events, the concept of
facial danger zones, and present a discussion of both treatment and
prevention of these serious adverse events.
Introduction
Soft tissue fillers are an increasingly popular treatment for soft tissue
augmentation and facial rejuvenation. The American Society for
Aesthetic Plastic Surgery reported approximately 13% growth in
non-surgical treatments between 2012 and 2013; with non-surgical
treatments making up over 80% of all treatments performed.1 The
consequences of serious adverse events can be devastating.
They can include visual blindness,2,3,4,5,6,7,8,9,10,11 skin necrosis11,12,13 and
permanent facial scarring.11,12,13 In this article I examine the concept
of facial danger zones specific to facial anatomy. I discuss the facial
anatomy that underlies the danger zones, and the treatment and
avoidance of these complications with modified techniques.
The most serious complications with non-surgical and surgical filler
treatments include:
• Unilateral or bilateral visual impairment or blindness
• Skin necrosis
• Cerebrovascular event
Soft tissue filler products that have been associated with
these serious adverse events include; hyaluronic acid, calcium
hydroxylapatite, poly-L-lactic acid and polymethyl methacrylate,
silicone and fat transfer.7
Facial Anatomy
Key to our understanding of how these serious adverse events occur
is knowledge of the facial vascular anatomy. Anatomy of the face can
be broadly defined into these five layers:
1. Skin (Epidermis and Dermis)
2. Subcutaneous fat in compartments (Figure 1)
3. Underlying facial muscles and SMAS (Superficial muscular
aponeurotic system) (Figure 2)
4. Profuse anastomosis of facial vessels (Figure 3)
5. Skull
The arteries that branch from internal and external carotid arteries
provide the vascular supply to the skin and subcutaneous tissue
26 Aesthetics | January 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
of the face. The eye is vascularised by the ophthalmic artery via a
branch from the internal carotid artery – called the central retinal
artery (Figure 4). The central retinal artery is essential for normal
visual function and any damage or blockage of this artery has the
potential to reduce visual function within minutes. The ophthalmic
artery continues in the orbit to the supraorbital and supratrochlear
arteries. The supratrochlear artery lies in the areas of the
corrugators and inferior anastomoses with the dorsal nasal artery.
The supraorbital nerve exits the orbit in the superior orbital notch
and anastomoses temporally with the superficial temporal artery.
The external carotid artery lies in the lateral aspect of the neck.
At the antero-inferior tragus it divides into the superficial temporal
artery and the middle temporal artery. Although the larger vessels
are anatomically described, there is a rich vascular anastomosis
that increases the risk of an intra-arterial injection of filler with non-
surgical treatments (Figure 3).
A further consideration is that patients who have undergone
previous non-surgical or surgical treatments may have an
underlying change in their anatomy and be at higher risk of a
serious adverse event. This is evident for the nose where previous
rhinoplasty may have injured vascular anastomosis, making non-
surgical filler injections post-rhinoplasty a higher risk procedure.15
Mechanism of Serious Adverse Events
Loss of visual function occurs as a consequence of occlusion
of the central retinal artery. The central retinal artery provides
the principle blood supply to the key part of the eye (retina) that
provides vision. If these cells are deprived of oxygen, even for
a short period, they become permanently damaged leading to
a irreversible loss of visual function. For this to occur there is
a mechanical blockage of arterial blood flow along the central
retinal artery. In this case, filler injected into the soft tissues
around the periorbital areas is inadvertently injected intra-
arterially (Figure 5) into one or more of the five facial danger
zones. With sufficient pressure and volume, there is a retrograde
flow of the filler along the artery via vascular anastomosis to the
central retinal artery. Some of the filler product flows antero-
grade into the central retinal artery, resulting in occlusion of the
central retinal artery and compromised visual function. The extent
of the visual function deterioration will be dependent on the
volume of filler that has flowed along the artery and the resulting
homogeneity of the central retinal artery blockage.
If sufficient volume and pressure of the filler is injected, the
entire ophthalmic artery may become occluded. Occlusion of
the ophthalmic artery will result in ischaemia to the anatomical
structures of the orbit including ocular rectus muscles for eye
movement. This is characterised by visual loss coupled with pain

@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Although serious adverse
events from the use of
non-surgical treatments are
rare, the consequences can
be devastating
and loss of normal ocular movements.3
Necrosis of the skin occurs as a consequence of compromised
arterial blood supply to the skin. The injection of filler into an end-
artery may result in antero-grade flow and occlusion of the blood
vessel. In addition, injection of a sufficient volume of filler near an
end-artery may result in compression of the vessel; this may be
more likely with a filler that expands after use such as a hydrophilic
hyaluronic acid. Compromised arterial supply to the skin results in
rapid hypoxia, characterised by blanching of the skin and ischaemic
pain.12,16
A very rare complication is a cerebrovascular accident (CVA or
stroke) as a consequence of non-surgical hyaluronic acid fillers.18
This occurs as a consequence of the rich vascular anastomosis
between the vascular supply of the face and orbit, retrograde flow
of the advertent injection of hyaluronic acid material to be forced
into the ophthalmic artery and internal carotid artery. Subsequent
anterograde flow of the material in the internal carotid artery is then
able to result in blockage of the end arteries to the brain resulting
in a CVA.
Facial Danger Zones
On evaluation of both the medical literature for complications related
to filler injections and our knowledge of the facial anatomy, we can
derive specific areas of the face that are at a higher risk of these
potentially devastating adverse events (Figure 6 & 7).
Facial danger zones and associated facial arteries:
1. Glabellar area: Supraorbital & Supratrochlear arteries
2. Nasal augmentation: Angular artery
3. Nasolabial groove: Facial artery
4. Tear trough (Nasojugal groove): Infraorbital artery
5. Temporal volume loss: Superficial temporal artery
Treatment of Complications
The treatment of visual loss as a consequence of intra-arterial
filler injection and central retinal artery occlusion is challenging.
The use of a hyaluronic acid filler warrants the injection of
hyaluronidase with the intention of dissolving the filler. Urgent
blue light referral to an ophthalmic emergency unit is warranted
as failure to take action could result in permanent visual loss.
Treatment includes the use of medications to reduce intra-
ocular pressure, carbogen treatment to cause vasodilation and
hyperbaric oxygen. Cadaver studies have suggested treatment
with urgent retro-orbital injection of hyaluronidase into the
retro-bulbar orbital space may be effective in the treatment of
blindness.19
The treatment of impending skin necrosis is characterised by an
attempt to reverse the end-arterial occlusion and to reduce the
resulting inflammatory process that results in soft tissue damage.
Treatment with an emergency kit should include hyaluronidase
Aesthetics | January 2015
CPD
Facial Danger Zones
(only applicable for hyaluronic acid fillers), a nitrate patch or paste,
anti-inflammatory medication (oral or intravenous prednisolone:
reduce inflammatory damage to the ischaemic soft tissues),
vasodilators and hyperbaric oxygen (increase blood supply to
the soft tissues reducing ischaemic tissue damage).16 There is
currently limited scientific evidence that supports the use of the
different treatment modalities, and the treatment methodology
listed is mostly derived from relatively low level scientific evidence
including anecdotal evidence and case reports.
Based on the limited information we do have, here are
suggestions for an emergency filler kit for treatment of vascular
necrosis:
• Hyaluronidase: If hyaluronic acid injected 6-8x 0.05cc of
hyalurondiase (150units/ 0.1cc) into the skin (although up to
1,000 units has been advocated) or alternatively into Retro
Bulbar Orbital Space (400-800 units injected with 25-gauge
needle or cannula into infero-temporal orbital quadrant )19
• Warm compression and massage
• Nitrate patch or Nitroglycerine paste (for 12 hours)
• Aspirin (Acetylsalicylic acid) 300mg
• Intravenous hydrocortisone 100mg
• Oral dexamethasone 60mg for five days
• Sildenafil (Vascular dilation)
• Hyperbaric oxygen
• Antibiotics (prevent secondary bacterial infection)
• Antivirals (around mouth to prevent secondary viral infection)
Discussion and Prevention of Complications
Although serious adverse events from the use of non-surgical
treatments are rare, the consequences can be devastating. They
can include blindness, skin necrosis and facial scarring. The
treatment of these serious adverse events is both challenging
and limited, and prevention of these complications is preferred.
There are a number of measures that can be taken to mitigate the
risk of a serious complication after non-surgical filler injections.
In the first instance this is an understanding of the underlying
anatomy and the concept of facial danger zones. On injection
of the filler, aspiration of the filler before injection may result in a
flash back of blood if the needle is injected into a facial artery –
although this method may not be conclusive if there is no flash
back, as there may be a collapse of the artery on the pressure
of aspiration. A flash back of blood would enable the injector
to re-position the needle to an alternative location. From my
experience, I have noted that the use of cannulas with blunt-
Key points: prevention of complications
• Knowledge of vascular facial anatomy
• Concept of facial danger zones associated with higher risk
of treatment
• Hyaluronic acid product has the advantage of hyaluronidase
antidote
• Aspiration needle technique before injection
• Cannula technique over needle technique
• Low pressure injection
• Low volume fractionated technique of injection
• Recognise immediate blanching of skin
• Use of local anaesthesia with adrenaline to cause local
vasoconstriction of facial blood vessels
• Emergency filler kit
27
 CPD
Facial Danger Zones @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

ended tips is less likely to result in traumatic injury to an arterial Conclusion

wall and can result in the injection of the filler intra-arterially. In my The use of non-surgical filler injections for soft tissue augmentation
opinion, a low-pressure injection makes an intra-arterial injection and facial rejuvenation continues to grow and is generally regarded
less likely, and a low volume of filler injection makes the bolus as safe and effective. The adverse events such as the loss of visual
less likely to result in central retinal artery occlusion. An injection function, blindness and skin necrosis, which have been reported,
that results in immediate blanching of skin should be treated as highlight the importance of adequate knowledge in the management
vascular compromise and requires urgent treatment (vascular and prevention of further serious complications. Knowledge of
occlusion results in skin hypoxia, the reduced oxygen carriage in the underlying anatomy, mechanism, preparation for emergency
the skin results in a change in skin colour). The pre-filler use of treatment and steps taken towards prevention are important to
local anaesthesia with adrenaline results in local vasoconstriction ensure that the risk of these events is minimised and appropriate.
(reduced diameter of the arteries), reducing the risk of intra-
arterial injection. Some injectors prefer filler treatments without Dr Julian De Silva is a facial cosmetic surgeon,
specialising in the eyes, nose, face and neck areas. He
the use of adrenaline in the local anaesthesia as this may mask has experience in cosmetic/reconstructive facial surgery
the discolouration
//Figures//   caused by intra-arterial injection,17 making the from fellowships in London, LA and New York.
Figure  1:  Subcutaneous  fat  compartments  of  the  face  (Rohrich,  2007) 12
ishcaemia caused by intra-arterial more difficult to see.
Figure  2:  Muscles  of  facial  expression

 
 
Figure  5:  Intra-­‐arterial  injection  of  filler  results  in  retro-­‐grade  flow  of  the  filler  into  
Figure 1: Subcutaneous fat compartments   Figure
the   2: Muscles
ophthalmic   artery  and  ofthe  
facial
central  expression
retinal  artery.  Occlusion  of  the  central   Figure  
Figure 3:4:  Profuse
Anastomosis  oanastomosis
f  facial  vessels  around  
of the  facial
eyes   blood vessels
 
of the face (Rohrich, 2007)12 retinal  
Figure   3:  aPrtery  
rofuse  raesults   in  painless  
nastomosis   loss  
of  facial   of  vvessels  
blood   ision.  courtesy  of  Prof.  Von  Hagens   courtesy of Prof. Von Hagens 2014.
2014.    

     
Figure  
Figure 5:  Intra-­‐arterial  
4: Anastomosis injection  
ofof  facial
filler  results  
vessels in  raround
etro-­‐grade  
the flow  
eyes of  the  filler  into   Figure  
Figure 6:  5:
The   concept  of  facial  injection
Intra-arterial danger  zones.  
of Ifiller
njections  
results of  filler  
ininto  
retro-these  areas     Figure 6: The concept of facial danger zones.
the  ophthalmic  artery  and  the  central  retinal  artery.  Occlusion  of  the  central   have  
grade an  flow
increased   risk  ofiller
of the f  intra-­‐arterial  
into theinjection  
ophthalmic and  can  artery
result  in  
and serious  
theadverse   Injections of filler into these areas have an increased
retinal  artery  results  in  painless  loss  of  vision.   events.  
central retinal artery. Occlusion of the central retinal artery risk of intra-arterial injection and can result in serious
results in painless loss of vision.
 
adverse events.

REFERENCES autologous fat injection into nasolabial groove’, Br J Ophthalmol, 80 (1996) p.1026-1027.
10. Egido JA et al., ‘Middle cerebral artery embolism and unilateral visual loss after autologous fat
1. ‘Cosmetic Surgery National Data Bank Statistics’, (American Society for Aesthetic Plastic injection into the glabellar area’, Stroke, 24 (1993) p.615-616.
Surgery: US, 2103) http://www.surgery.org/sites/default/files/Stats2013_4.pdf Last accessed: 17 11. Ozturk CN, Li Y, Tung R, Parker L, Piliang MP, Zins JE, ‘Complications following injection of soft-
December 2014 tissue fillers’, Aesthet Surg J, 1 (2013) p.862-77.
2. Carle MV, Roe R, Novack R, Boyer DS. ‘Cosmetic facial fillers and severe vision loss’, JAMA 12. Funt D, Pavicic T, ‘Dermal fillers in aesthetics: an overview of adverse events and treatment
Ophthalmol, 5 (2014) p.637-9. approaches’, Clin Cosm Inv Derm 129(2013) p.295-316.
3. Chen Y, Wang W, Li J, Yu Y, Li L, Lu N, ‘Fundus artery occlusion caused by cosmetic facial 13. Dayan SH, Arkins JP, Mathison CC, ‘Management of impending necrosis associated with soft
injections’, Chin Med J (Engl), 127 (2014) p.1434-7. tissue filler injections’, J Drugs Dermatol JDD, 10 (2011) p.1007-12.
4. Yanyun C, Wenying W, Jipeng L, Yajie Y, Lin L and Ning L, ‘Fundus artery occlusion caused by 14. Rohrich RJ, Pessa JE, ‘The Fat Compartments of the Face: Anatomy and Clinical Implications
cosmetic facial injections’, Chinese Medical Journal, 127 (2014) p.1434-1437. for Cosmetic Surgery’, Plast Reconstr Surg, 119 (2007) p.2219-2227.
5. Kim YJ, Choi KS, ‘Bilateral Blindness after Filler Injection’, Plast Reconstr Surg, 131(2013) p. 298- 15. Kurkjian TJ, Agnad J, Rohrich RJ, ‘Soft-Tissue Fillers in Rhinoplasty’, Plast. Reconstr. Surg, 133
299. (2014).
6. Kim SN, Byun DS, Park JH, Han SW, Baik JS, Kim JY, Park JH, ‘Panophthalmoplegia   and vision 16. Tsai M, Hsia T, Han Y, Wu H, Lin Y, ‘Successful Hyperbaric Oxygen Therapy In Complications Of
Figure  loss after
6:  The   cosmetic
concept   nasal
of  facial   dorsum
danger   zones.  Iinjection’,
njections  of  Jfiller  
Clininto   21 (2014) p.678-80.
these  areas  
Neurosci, Fillers Rhinoplasty Cases Report’, The Internet Journal of Alternative Medicine, 9 (2014).
have  
7. aLazzeri
n  increased   risk  of  intra-­‐arterial  
D, Agostini T, Figus M, injection  
Nardi aM, nd  Pantaloni
can  result  iM, n  serious  
Lazzeri adverse  
S, ‘Blindness following cosmetic 17. Emer J, & Waldorf H, ‘Injectable neurotoxins and fillers: There is no free lunch’, Clinics in
events.  injections into the face’, Plast Reconstr Surg, 129(2012) p.995-1012. Dermatology, 29 p.678-690.
 
8. Woo SJ, Park SW, Park KH, Huh W, Jung C, Kwon OK, ‘Iatrogenic retinal artery occlusion 18. He MS, Sheu MM, Huang ZL, Tsai CH, Tsai RK, ‘Sudden bilateral vision loss and brain infarction
caused by cosmetic facial filler injections’, American Journal of Ophthalmology, 154(2012) following cosmetic hyaluronic acid injection’, JAMA Ophthalmol, 131 (2013) p.1234-5.
p.653-662. 19. Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers A, ‘Blindness caused by cosmetic
9. Lee DH, Yang HN, Kim JC, Shyn KH, ‘Sudden unilateral visual loss and brain infarction after filler injection: a review of cause and therapy’, Plast Reconstr Surg, 134 (2014) p.1197-201.

28 Aesthetics | January 2015

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 Spotlight On
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Obesity Statistics

Figure 2: Obesity prevalence rates quoted by QOF, by

Region in England – 2012/13

Region Obesity Prevalence (%)

North of England 12

Midlands and East of England 11.2

London 9.2

South of England 9.7

problems. Adults with a BMI of more than 35 have a very high risk
Obesity rate with any waist circumference (Figure 1).4
The Quality and Outcomes Framework (QOF) prevalence data
tables for 2012/13 show a breakdown of obesity at a regional level
Pandemics: in England (Figure 2). It shows that there is a clear north-south
divide, with Northern England having higher obesity prevalence
rates than Southern England.4

The Fat Figures In 2012, in Scotland 27.1% of adults were classified as obese,
and 64.3% of adults were classified as being overweight or
obese . In Wales, 23.0% of adults were classified as obese, and
Dr Amanda Wong Powell presents 58.5% of adults were classified as being overweight or obese.
the statistics around obesity in the This compares with 24.7% of adults being obese in England and
UK and internationally 61.9% of adults being overweight or obese.4 These results put the
Scottish on top of the overweight and obese list followed by the
Obesity and being overweight are the number five cause of English and then the Welsh.
death globally, causing 2.8 million adult deaths annually.1,2 One In 2013, more than half (52.6%) of the adult population in the
in four adults are now classed as obese, and worldwide obesity European Union reported that they were overweight or obese.
has nearly doubled since 1980.1,2 The World Health Organisation This compares to just two years ago when 50.3% of the European
(WHO) classifies a person as overweight if they have a body mass adult population in The Organisation for Economic Co-operation
index (BMI: kg/m2) of more than 25, and a person as obese if their and Development (OECD) reported that they were overweight
BMI is more than 30. The obese group is further classified into or obese. The least obese countries were India (2.1%), Indonesia
Class I: moderately obese with a BMI of 30-35, Class II: severely (2.4%) and China (2.9%). The most obese countries were the US
obese with a BMI of 35-40 and Class III: very severely obese with (36.5%), Mexico (32.4%) and New Zealand (28.4%).7
a BMI of more than 40. An endocrinology study8 suggested that India has the lowest
Although BMI is a very acceptable method of measuring obesity, it obesity rates due to its traditional strengths in maternal nutrition,
does not differentiate between mass due to fat or muscle. Hence, walking, yoga, meditation and traditional folk dance. Perhaps the
waist circumference is also another method used to measure lifestyle difference, diet, pattern of snacking, eating frequency,
obesity. A waistline of more than 102cm in men and 88cm in portion sizes, and high proportion of food prepared outside the
women is considered to be overweight. The National Institute home is a more likely cause of the increased obesity rates in
for Clinical Excellence (NICE) guidance on overweight and western countries.9
obesity statistics highlights the impact of increased BMI and waist The obesity pandemics lead to increased risk factors for other
circumference on risk factors for developing long-term health medical conditions, including cardiovascular (heart disease
and stroke predominantly),
Figure 1: NICE Risk Categories diabetes, and musculoskeletal
disorders (osteoarthritis
Waist Circumference
particularly). Childhood obesity is
BMI Low High Very High associated with a higher chance
(<94cm in men) (94-102cm in men) (>102cm in men)
(<80cm in women) (80-88cm in women) (>88cm in women)
of adult obesity, disability, and
premature death. But in addition
Normal: 18.5-25 No increased risk No increased risk Increased risk to increased future risks, obese
children experience breathing
Overweight: 25-30 No increased risk Increased risk High risk
difficulties, greater risk of fractures,
Obesity I: 30-35 Increased risk High risk Very high risk hypertension, early markers of
cardiovascular disease, insulin
Obesity II: 35-40 Very high risk Very high risk Very high risk resistance, and psychological
effects.5,12 The rising numbers of
Obesity III: 40 + Very high risk Very high risk Very high risk
overweight patients will place

Aesthetics | January 2015 31

 Spotlight On
Obesity Statistics @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Figure 3: Obesity Risks 6 will be even better. As healthcare professionals,

supporting our patients in their weight loss
Classification BMI (kg/m2) Risk of co-morbidities programme can play a significant role. The National
Obesity Forum has a very useful Obesity Care
Underweight < 18.5 Low* Pathway Toolkit on weight management service.10
Identifying patients who are ready to change, and
Healthy weight 18.5– 24.9 Average
are prepared to commit to the change, will determine
Overweight (or pre-obese) 25–29.9 Increased the success of the programme.
The food industry can help promote healthy lifestyles
Obesity, class I 30–34.9 Moderate by reducing fats, sugars and salt content, as well as
ensuring healthy and nutritious foods are available
Obesity, class II 35–39.9 Severe
and affordable to all consumers. One problem,
Obesity, class III ≥ 40- Very severe which has always been difficult to address, is that it
is generally cheaper for a family to eat unhealthily.
*Other health risks may be associated with low body mass index (BMI).
Despite changes made to food labelling to inform
consumers, it is still hard for a non-expert, even an
increasing demands on health services as a consequence. educated one, to make sense of the figures on packaging in
These cut-offs are based on epidemiological evidence of the link order to make appropriate purchasing decisions.
between mortality and BMI in adults. Monitoring of health, exercise and fitness are growing industries,
The causes of obesity lie with mismanaged and disproportionate but it is probably the case that the people regularly running,
calories intake – people are eating more than they need and working out and monitoring themselves with active wristbands
not shifting those excess calories. It is our lifestyle; particularly and mobile apps, are not the people with the obesity problem.
the higher consumption of processed food, high calories, It is estimated that by 2025, 47% of men and 36% of women
high fat, non-active jobs, and a ‘couch potato’ attitude. The (aged between 21 and 60) will be obese. By 2050, it is estimated
supermarket ‘Buy One Get One Free’ deals do not help either. that 60% of males and 50% of females could potentially be
We as consumers need to be more savvy and as individuals more obese.11 There is no quick fix to this epidemic. This is a global
conscious of our body. It is not difficult to understand that if you issue, which needs to be tackled by everyone on every level.
eat too much and do not exercise enough, the excess energy will Having insight into the issue is a start.
then be saved as fat, but it is our mentality and habit that results in
weight gain. Obesity is preventable and it is our duty as aesthetic Dr. Amanda Wong-Powell is the founder and Medical
practitioners and medical professionals to educate our patients Director of Dr. W on Harley Street. She has completed
her basic surgical training, and is a Member of the Royal
as to not only what we can do for them, but also what they can do College of Surgeons (Edinburgh). She was a registrar in
for themselves.2 Trauma and Orthopaedics before deciding to venture
Choosing to have a healthy diet that incorporates fruit and into aesthetic medicine, which she has been practising for the last 6
vegetables, as well as cutting out food high in fats and sugars, years. Dr Wong-Powell is a VASER liposuction surgeon, and also has
an interest in weight loss management. She is also Medical Director of
can help immensely. Exercising at least twice weekly for at least Meducatus, the medical training platform for doctors and surgeons.
half an hour will help, although half an hour a day every day
REFERENCES:
1. Obesity Facts and Figures, (Europe: European Association for the Study of Obesity, 2013) <

As healthcare
http://easo.org/obesity-facts-figures> [accessed 24 November 2014].
2. Obesity and Overweight Fact sheet No311,(World Health Organisation, 2014) http://www.who.
int/mediacentre/factsheets/fs311/en/ [accessed 24 November 2014].
3. BMI Classification (World Health Organisation, 2014) http://apps.who.int/bmi/index.
jsp?introPage=intro_3.html [accessed 24 November 2014].

professionals, 4. Paul Eastwood ‘Statistics on Obesity, Physical Activity and Diet: England 2014’, Health & Social
Care Information Centre (2014) http://www.hscic.gov.uk/catalogue/PUB13648/Obes-phys-acti-
diet-eng-2014-rep.pdf [accessed 24 November 2014].
5. David CW Lau et al, ‘2006 Canadian clinical practice guidelines on the management and

supporting prevention of obesity in adults and children’ Canadian Medical Association Journal (CMAJ),
176 (2007) http://www.cmaj.ca/content/suppl/2007/09/04/176.8.S1.DC1/obesity-lau-onlineNEW.
pdf [accessed 24 November 2014].
6. ‘Obesity: preventing and managing the global epidemic. Report of a WHO Consultation’,

our patients in World Health Organisation (WHO) Technical Report Series 894 (2000) http://www.
who.int/nutrition/publications/obesity/WHO_TRS_894/en/ [accessed 24 November 2014].
7. ‘Health at a Glance 2013, OECD Indicators’, Organisation for Economic Co-operation and
Development (2013) http://dx.doi.org/10.1787/health_glance-2013-en [accessed 24 November

their weight loss 2014].

8. Unnikrishnan AG et al, ‘Preventing obesity in India: Weighing the options’, Indian J Endocrinol
Metab, 16 (2012) p.4-6 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263196/ [accessed 24
November 2014].

programme 9. BA Swinburn et al, ‘Diet, nutrition and the prevention of excess weight gain and obesity’, Public
Health Nutrition, 7(1A), p.123-146. http://www.who.int/nutrition/publications/public_health_nut3.
pdf [accessed 24 November 2014].
10. David Haslam et al,‘Obesity Care Pathway Toolkit’ National Obesity Forum (2006) http://www.

can play a
nationalobesityforum.org.uk/images/stories/care-pathway-toolkit/Toolkit_supporting_
obesity_care_pathway_annexes_1_to_9__Feb_07_2006.pdf [accessed 24 November 2014].
11. ‘Healthy lives, healthy people: A call to action on obesity in England’ Department of Health,
(2011) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213720/

significant role.
dh_130487.pdf [accessed 24 November 2014].
12. ‘Complications of Childhood Obesity’, Childhood Obesity Foundation, http://www.
childhoodobesityfoundation.ca/complicationsOfChildhoodObesity [accessed 24 November 2014].

32 Aesthetics | January 2015

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Aesthetics | January 2015 35

 Clinical Practice
Prescribing
Prescribing
in medical
aesthetics
Pharmacist Brendan Semple discusses the
role of prescriptions in medical aesthetics
Often, the first thing many practitioners
wonder when they complete their
aesthetic training is how to access the
drugs and devices that they are going to
require in order to start their aesthetic
practice. It can sometimes be their first
venture outside of the NHS, and having
to manage the legal, ethical and VAT
implications can be quite daunting. This
article seeks to clarify some of these
matters and help you navigate the current
legislation.
All practitioners are able to purchase
certain commonly-used products over the
counter in a pharmacy. Needles, syringes,
swabs, gloves, cannulas and, most
surprisingly, dermal fillers are classified as
medical devices and there are no legal
barriers to their supply. In our pharmacy we
always check a practitioner’s professional
qualification and ensure that they have
completed a course in the use of fillers
before making a sale, but there is no
legislation in place that prevents the supply
of dermal fillers to anyone. These goods
are subject to 20% VAT.1
Prescription only medicines (POMs) such as
botulinum toxin, adrenaline, hyaluronidase
and IV sodium chloride can be purchased
directly from the manufacturer, a wholesaler
or a pharmacy via stock order by a doctor
or dentist. Supplies obtained in this way
are also subject to 20% VAT.1 Nurse
Independent Prescribers (NIPs) have
similar prescribing privileges to doctors
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@aestheticsgroup Aesthetics Journal
and dentists, however their handling of
stock is significantly different. NIPs cannot
order stock in the same way as doctors
and dentists as they always require a
prescription to be written and dispensed
prior to administering a POM to a patient.
Consequently, they are unable to treat
new patients at their first consultation. This
is unless they work in the same clinic as
a doctor or dentist, who is required to be
present when the nurse administers the
POM.
In my experience, practitioners tell me the
most convenient way to obtain the products
they need is to send a prescription to
a pharmacy. When writing a private
prescription for a patient, there are some
key points to bear in mind:2
• Once written, the prescription is the
property of the patient
• You must receive consent from the
patient to send and receive their
prescription
• The transaction is between the patient
and the pharmacy
• Once dispensed, the medication is the
property of the patient
• The original copy of the prescription
must be sent to the pharmacy within 72
hours
One key advantage of prescriptions over
stock-orders from a manufacturer or
wholesaler is that, in certain circumstances,
they are zero-rated for VAT. HM Revenue
Aesthetics | January 2015
Aesthetics aestheticsjournal.com
and Customs (HMRC) outline crucial points
that explain when goods provided on
prescription can be zero-rated for VAT
purposes:3
• The supply must be of ‘qualifying
goods’
• The goods must be dispensed to an
individual for that individual’s personal
•
use
The goods must not be supplied for
use for patients while in hospital or in
a similar institution or administered,
injected or applied by health
professionals to their patients in the
course of medical treatment
• The goods must be dispensed by
a registered pharmacist or under a
requirement or authorisation under a
‘relevant provision’
• The goods must be prescribed by an
appropriate ‘relevant practitioner’
The key point in the above legislation is
that if the supply is for a medical treatment
(exempt from VAT) then the prescription
should attract 20% VAT. If the supply is for
a cosmetic treatment (subject to 20% if VAT
registered) then the prescription is zero-
rated. This means that whether the treatment
is considered medical or cosmetic, HMRC
are expecting to receive VAT at some point
in the transaction.
The only exception to this is if the
practitioner is not registered for VAT and the
patient is receiving a cosmetic treatment.
The threshold for VAT registration is
currently £81,000, therefore the patients of
practitioners whose turnover falls below
this amount may not have to pay any VAT
in the course of their treatment.4 It is worth
remembering that when a prescription
is dispensed, the transaction is between
the pharmacy and the patient. This sum is
not part of the practitioner’s income and
should not be part of the equation when
considering whether you have reached the
threshold to register for VAT.
What records do pharmacists keep?
When we receive a prescription for a new
patient, we create a Patient Medication
Record (PMR) on our pharmacy computer
system. This will record the full details of
any prescription including who wrote the
prescription, the date it was written and
what was prescribed. We make an entry
in our private prescription register and
we scan the Rx and attach a copy to the
patient’s file.

@aestheticsgroup Aesthetics Journal
This means that there is a full audit
trail detailing everything from the date
of consultation through to the time of
dispensing. Hamilton Fraser Insurance, a
UK-based specialist insurance company
and provider of cosmetic liability insurance,
warns that prescriptions written for a patient
subsequent to them having had their
treatment using stock from another source,
could leave the practitioner legally exposed
as their policy may not respond to any
claims.5
Medication for use in emergencies
Current good practice suggests that
practitioners should have immediate access
to a selection of medication for use in
the event of any complications during a
treatment. These include:6
• iv antihistamine
• iv steroid
• adrenaline
• hyaluronidase
• asprin
• glyceryl trinitrate paste
• medical oxygen
This again can be problematic for nurse
practitioners, as the rules on named patient
treatment would apply again. For example,
each patient would need these drugs
to be prescribed prior to any treatment
programme. This is obviously economically
unviable and an incredible waste of
medication as, hopefully, you will never
need to use any of it! There is, however,
another way to access most of these items
without breaking any laws.
Regulation 238 of the Human Medicines
Regulations 2012 allows for certain
prescription-only medicines to be
administered by anyone for the purpose
of saving a life in an emergency. The
medicines this concerns are covered in
Schedule 19 of the regulation and are listed
below.7
Medicinal products for administration by
injection by anybody for the purpose of
saving a life in an emergency:
• Adrenaline 1:1000 up to 1mg for
intramuscular use in anaphylaxis
• Atropine sulphate and obidoxime
chloride injection
• Atropine sulphate and pralidoxime
chloride injection
• Atropine sulphate injection
• Atropine sulphate, pralidoxime mesilate
and avizafone injection
Aesthetics aestheticsjournal.com
• Chlorphenamine injection
• Dicobalt edetate injection
• Glucagon injection
• Glucose injection
• Hydrocortisone injection
• Naloxone hydrochloride
• Pralidoxime chloride injection
• Pralidoxime mesilate injection
• Promethazine hydrochloride injection
• Snake venom antiserum
• Sodium nitrate injection
• Sodium thiosulphate injection
• Sterile pralidoxime
As long as you have access to a supply,
you can legally administer adrenaline,
chlorphenamine, or hydrocortisone to
any patient in an emergency. GTN paste
and aspirin are available to purchase over
the counter in a pharmacy, so you can
also keep that in your clinic stock supply.
BOC Industrial Gases, one of the largest
suppliers of industrial gases in the UK, will
open a medical gas account and supply
you with medical O2. Hyaluronidase is
currently the only drug that cannot be
legally used by a nurse in an emergency
situation without issuing a prescription first.
Finally, this is a quick reminder about the
legislation regarding unlicensed and off-
label use of medicines. There are clinical
situations when the use of unlicensed
medicines or use of medicines outside
the terms of the license (ie, ‘off-label’) may
be judged by the prescriber to be in the
best interest of the patient, on the basis of
available evidence.
It is advised by the MHRA8 that before
prescribing an unlicensed medication,
practitioners must be fully satisfied that
there is not any other medicine that could
meet the patient’s needs. There should also
be effective evidence to show the safety
and efficacy of the off-label medication, and
the practitioner must take responsibility for
prescribing it and overseeing the patient’s
care – this includes follow-up. It’s important
that all off-label medication is recorded
when prescribed, and, where this is not
the usual practice, also the reasons for the
prescription of this medicine.
It’s best to give patients, or those
authorising treatment on their behalf, the
ability to make an informed decision by
outlining enough information about the
proposed treatment – particularly regarding
serious or common adverse reactions.
Although it may not always be necessary to
draw attention to the license when seeking
Aesthetics | January 2015
Clinical Practice
Prescribing
consent for a medicine, it’s good practice
to give as much information as the patient
requires or sees relevant, even when
current practice allows the use of medicine
outside the terms of its contract. Be sure
to explain the reasons for prescribing a
medicine off-label where there is little
evidence to support its use.
The MHRA also reiterates that it is crucial
to report suspected adverse drug reactions
via the Yellow Card Scheme, which collects
this information in order to monitor the
safety of all healthcare products in the UK
and those medicines in clinical use.8
It would further be prudent to check with
your insurers before using an unlicensed
product on your patients.
Hopefully you’ve discovered something
beneficial for your practice in this article.
I would heartily recommend that you
establish a good working relationship
with your chosen pharmacy. We share a
duty of care with your patients and are
always more than happy to research any
pharmaceutical query you may have.
Brendan Semple is a
community pharmacist and
director of the TLC Pharmacy
Group, which has seven
branches, including TLC
Aesthetic Pharmacy which is based in Moss
Park, Glasgow. He is a member of the NHS
National Appeal Panel and a board member
of the Numark Pharmacy advisory board.
REFERENCES
1. UK Government, VAT for Consumers (UK: gov.co.uk, 2014)
<https://www.gov.uk/vat-consumers> [Accessed 9th
December] (p. 1)
2. Pharmaceutical Society Northern Ireland, Professional
Standards and Guidance for Pharmacist Subscribers
(Northern Ireland: PSNI.org.uk, 2009) <http://www.psni.org.
uk/documents/319/Standards+on+Pharmacy+Prescribing.pdf
> [Accessed 9th December] (Section 3.3.1)
3. HM Revenue and Customs, Health Professionals
and Pharmaceutical Products:
HMRC Reference:Notice 701/57 (July 2014) (UK: HM
Revenue and Customs, 2014) <http://customs.hmrc. gov.uk/
channelsPortalWebApp/channelsPortalWebApp.
portal?_nfpb=true&_pageLabel=pageVAT_
ShowContent&propertyType=document&id=HMCE_
CL_000121#P88_9161> [Accessed 27 November] (Section
3.2)
4. UK Government, VAT Registration Thresholds (UK:
gov.co.uk, 2014) <https://www.gov.uk/vat-registration-
thresholds> [Accessed 9th December]
5. Owen Wood, Aesthetics Journal Article, 14 November 2014
6. Christopher Inglefield, Fiona Collins, Marie Duckett, Kate
Goldie, Gertrude Huss, Santdeep Paun, and Stephanie
Williams, Expert Consensus on complications of botilinum
toxin and dermal filler treatment (UK: Aesthetic Medicine
Expert Group, 2014)
7. The Human Medicines Regulation (2012), Regulation 238,
Schedule 19 http://www.legislation.gov.uk/uksi/2012/1916/
pdfs/uksi_20121916_en.pdf [Accessed 27 November]
8. Medicines and Healthcare products Regulatory Agency,
Drug Safety Update (UK: mhra.gov.uk, 2009) <http://
www.mhra.gov.uk/home/groups/pl-p/documents/
publication/con043810.pdf>
37
 Clinical Focus
Diet and Nutrition
Incorporating a
dietician into your
practice
General practitioner and skin specialist Dr Anita
Sturnham shares her experience of incorporating
a dietician’s expertise to improve patient results
Nutrition is essential as part of an anti-
ageing skincare regimen. There are two
main processes that are thought to induce
skin ageing: intrinsic and extrinsic factors.8
Extrinsic ageing is caused by environmental
factors such as sun exposure, air pollution,
smoking and poor nutrition.
Intrinsic ageing generally reflects our genetic
background. Various expressions of intrinsic
ageing include thinning of the skin with
exaggerated expression lines. Extrinsically
aged skin is characterised by photo damage,
such as lines, wrinkles, pigmented lesions,
hypopigmentation and actinic keratoses.7
A network of antioxidants such as vitamins
E and C, coenzyme Q10, alpha-lipoic acid,
glutathione, and others can reduce signs
of ageing. Antioxidants are the body’s
defense against free-radical damage and
oxidative stress. They fight free radicals by
supplying them with the electron that they
lack, therefore neutralising their harmful
effects. Mitochondrial mutations of DNA
accumulate during ageing and can be
detected at elevated levels in prematurely
aged skin following chronic exposure to UV
light. In vitro data provides evidence that
dietary micronutrients such as β-carotene
interact with UVA in the cell and prevent
the induction of photoageing-associated
38
@aestheticsgroup Aesthetics Journal
mitochondrial DNA mutations.9 An antioxidant-
rich diet packed full of fruits and vegetables is
therefore a crucial component of any patient’s
anti-ageing plan.
My practice offers patients skincare,
healthcare and nutritional advice all under
one roof. It is a medical centre that offers
a comprehensive range of facial and body
treatments, skin treatments, GP health
reviews, nutritional support, skin cancer
checks and total body mole mapping, as well
as Health MOTs.
My clinical background allows me to provide
patients with a specialist medical and
skin assessment, looking not just at skincare
but also at their overall health. It is well known
that the appearance of your skin can often
reflect your inner health and wellbeing. To
have great skin, you need to have good
health – total wellness is the aim for all of our
patients at my practice.
As a general practitioner (GP) with a specialist
interest in skin, I understand the importance
of having a multidisciplinary approach when
managing most health conditions. Over the
years I have noticed a strong connection
between an individual’s nutrition and their
health. For example, those who consume
large quantities of sugary foods and drinks
have an increased risk of obesity and Type 2
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diabetes. In my own practice, I have noticed
a connection between diet and skin diseases
such as acne and eczema. For example,
those who consume diets high in sugar
seem to be more prone to outbreaks of
these inflammatory skin conditions. It makes
sense that if we feed our bodies with the right
nutrition, we can reduce our risks of many
diseases, including heart disease, strokes,
diabetes and even skin disease.
Following this philosophy, I created Nuriss
Skincare and Wellness Clinic. Nuriss comes
from the French verb ‘nourrir’ (to nourish),
meaning ‘to give a person or other living thing
the food and other substances necessary for
life, growth and good health’. Throughout my
career I have been left frustrated when seeing
patients in great need of nutritional support,
but who are unable to access it easily. In my
experience, access to a dietician has been
limited due to a lack of available funding and
resources. Even within hospital settings, a
small team of dieticians are usually spread
very thinly, allowing only a select number of
patients access to this service. Patients often
visit my clinic suffering from health issues
such as irritable bowel syndrome, polycystic
ovarian syndrome and acne vulgaris. I believe
that a well-balanced diet can improve such
issues so, as well as including nutritional
advice in patients’ treatment plans, I have
also incorporated a dietician into my clinic.
This service has always been available there
and I am fortunate enough to have worked
professionally with an excellent registered
dietician during my years of practice. Our
close working relationship has meant that
introducing the role of ‘the dietician’ into our
team of experts at Nuriss has been an easy
one.
Dietitians are the only nutrition professionals
to be regulated by law, and are governed by
an ethical code to ensure that they always
work to the highest standard.10 It is very
much my personal choice to work with a
dietitian rather than a nutritionist. Some may
say that a nutritionist is just as good as a
dietician however, although they have good
knowledge about nutrition, as they are not
regulated, my preference is to work with a
dietitian.
At Nuriss we have allocated two days of
every week for appointments designated to
general medicine and nutrition. Our dietician,
Lucy Jones, is employed by Nuriss on these
days. If required, she is also able to offer
consultancy-based work on other days of the
week. Every Monday our Nuriss medical team
also runs their health MOT clinic. The aim of
our MOTs is to identify current health issues
 Clinical Focus
Diet and Nutrition
By looking at inner wellness,
health nutrition and skincare
together, we can provide the
ultimate skincare programme
and screen for potential disease risk factors.
During the GP assessment, we talk through
all aspects of a patient’s current health,
screen for diseases, and perform blood
and urine tests. We offer an advanced body
composition analysis (called ‘Seca’ Testing),
which assesses a number of parameters,
including muscle and body fat percentage,
body mass index, hydration and cellular
activity levels.
This is followed by an in-depth consultation
with our dietician, who will advise on all
aspects of nutrition, review patients current
diet and lifestyle and recommend disease-
specific dietary plans. For example, patients
with irritable bowel syndrome may be started
on the FODMAP diet, while patients with
acne may be started on a low glycaemic
index diet and one favouring foods known
to be beneficial for the skin. According to
dietician Lucy Jones, “Your food intake
represents the foundations of good skincare.
The right nutrition can support healthy skin,
reduce acne and even skin ageing. For
those wanting to look and feel good, we
can address health from the inside out in our
comprehensive MOTs and health checks.”
Let’s use acne vulgaris as a case study; a
common issue seen both in general practice
and dermatology clinics. The literature
examining the link between diet and acne has
been very mixed over the years. However,
there is now a growing body of epidemiologic
and experimental evidence that suggests
there could be a strong relationship between
diet and acne.3
The evidence is more convincing for high
glycemic diets, compared with other dietary
factors such as the dairy-acne connection.1
Dairy ingestion appears to be weakly
associated with acne, and the roles of
omega-3 fatty acids, antioxidants, zinc, vitamin
A, and dietary fibre remain inconclusive.1
Dermatologists and dietitians continue
to debate and research the potential
relationship between diet and acne. Most
experts would agree, however, that diet does
have an impact for most patients and the best
dietary approach is to address each acne
patient individually, carefully considering the
possible benefit of dietary counselling.2
Personally, I have seen fantastic results in
40
@aestheticsgroup Aesthetics Journal
the management of acne vulgaris. As an
example, I have been seeing a 25-year-old
female (Patient A) from London, with a history
of acne vulgaris since the age of 17. She has
been treated with topicals, oral antibiotics
and Roaccutane in the past, unfortunately
with poor results. At the time of presentation
to me, she was taking oral Lymecycline
and using topical Benzylperoxide. A low
glycaemic index diet, rich in antioxidants and
omega-3 fatty acids has totally transformed
her skin.
Patient A said, “I have battled with my acne for
years. For me, medicine was just one part of
the puzzle. Good skin care was another part
of the puzzle. Nutrition was the missing piece
of the puzzle and now I have great skin.”
Nutrition and protection against
environmental exposure
Other examples of the benefits of using
nutrition in skincare can be found by looking
at the way in which nutrition can protect
our skin from environmental damage. A
diet rich in carotenoids is known to prevent
cell damage, premature skin ageing, and
even skin cancer. Cutaneous carotenoids
can be enriched in the skin by nutrition,
and a diet rich in antioxidants has been
shown to increase free-radical protection
after UVA/UVB irradiation.9 Antioxidants
naturally occurring in the skin are superoxide
dismutase, catalase, alpha-tocopherol,
ascorbic acid, ubiquinone, and glutathione,
and many of them are inhibited by UV and
visible light.4 The antioxidant diet should
contain large amounts of vitamins A, E, and
C, grape-seed extracts, coenzyme Q10,
and alpha-lipoic acid.4 The most highly
recommended foods include: avocados,
berries, dark green leafy vegetables,
orange-coloured fruits and vegetables,
pineapples, salmon, and tomatoes.
During the early planning stages of the
‘Nuriss’ brand and my clinic, I believed
that having input from a dietician was an
essential part of our patient journey. This
belief was based on my own working
experience, rather than in-depth research
on the matter. I wanted to give my patients
something that had always been missing
from practices where I have worked
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Aesthetics aestheticsjournal.com
previously. I was also aiming to create the
‘ultimate’ clinic where patients could access
healthcare, skin care and nutrition support
under one roof.
In recent years, our patients seem so much
more interested in the idea of using nutrition
as a medicine and are happy that we
endorse that ethos at Nuriss too.
The feedback from patients so far has been
fantastic and, whilst not every patient needs
to see a dietician, those that don’t need it
seem reassured that we are able to offer
them access to this service, if required. For
those that do need and want nutritional
support, the seamless transition from doctor
to dietician, works well here.
The only difficulty was working out how to
integrate this service into our practice. It was
unlikely that we would require a dietician
every day, so from a business perspective
I also had to assess the costs of time and
resources when setting up the clinic. The
solution seemed to be to allocate set times/
days of the week for this service, So far, this
seems to work well within our clinic.
In summary, I believe that the future of skin
care lies in a holistic approach. By looking at
inner wellness, health, nutrition and skincare
together, we can provide the ultimate skin
care programme.
Dr Anita Sturnham Dr Anita
Sturnham is an experienced
GP and a skin specialist. She
is an ambassador for Unilever
SkinCare and a medical expert
for Superdrug, previously appearing on
television to share her expertise. She
currently works as a General Practitioner,
combining NHS duties with private
practice, recently opening her own clinic,
Nuriss, in London.
REFERENCES
1. Thiboutot DM, Strauss JS, ‘Diet and acne revisited’, Arch
Dermatol, 138 (2002), p.1591-1592.
2. Anderson PC, ‘Foods as the cause of acne’, Am Fam
Physician, 3 (1971) p,102-103.
3. Katta R, Desai SP, ‘Diet and Dermatology: The role of dietary
intervention in skin disease’, J Clin Aesthet Dermatol, 7
(2014) p.46-51.
4. Fuchs J, Huflejt ME, Rothfuss LM, Wilson DS, Carcamo G,
Packer L, ‘Acute effects of near ultraviolet and visible light
on the cutaneous antioxidant defense system’, Photochem
Photobiol 50 (1989) p.739-744.
5. Solauri E, ‘Probiotic in human skin disease’, Am J Clin Nutr
73 (2001), p.1142-1146.
6. Pillai S, Oresajo C, Hayward J, ‘Ultraviolet radiation and
skin aging: Role of reactive oxygen species, inflammation
and protease activation, and strategies. Review’. Int J
Cosmet Sci 27 (2005), p.17-34.
7. H. Sies, W. Stahl, ‘Carotenoids and UV protection’,
Photochem. Photobiol. Sci, 3 (2004) p.749-752.
8. Yaar M, Gilchrest BA. Aging of skin. In: Freedberg IM,
Eisen AZ, Wolf K, Austen KF, Goldsmith LA, Katz SI, editors.
Fitzpatrick’s dermatology in general medicine, vol 2. New
York: McGraw-Hill; 2003. p. 1386– 98.
9. Eicker J, Kurten V, Wild S, Riss G, Goral- czyk R, et al. 2003.
Beta-carotene sup- plementation protects from photoaging-
associated mitochondrial DNA mutation.Photochem.
Photobiol. Sci. 2:655–59
10. Health and Care Professionals Council. http://www.hpc-uk.
org
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 Spotlight On
Vitamin C @aestheticsgroup
Vitamin C and the skin
Dr Firas Al-Niaimi investigates the
physiologic properties and mode of
actions of this key anti-oxidant
Abstract:
Anti-oxidants have become increasingly popular as cosmeceuticals
due to the beneficial effects that they exert on oxidative stress and
free radicals generated by exogenous factors such as pollution
and solar radiation. Vitamin C is the main anti-oxidant in the skin
and has been used extensively for this purpose. This article details
some of the physiologic properties of vitamin C, as well as its main
mode of actions.
Introduction:
Vitamin C is arguably the most well-known anti-oxidant in human
skin. Its importance in health was signified in 1937 by Dr Albert Goyrgi
who won the Nobel prize for identifying vitamin C as the main cause
of scurvy. Unlike plants and some animals, humans are unable to
synthesise vitamin C due to an absent enzyme called L-glucono-
gamma lactone oxidase and therefore rely entirely on external
supplementation either in the form of diet (citrus fruit and green
vegetables) or topical application in the case of cosmeceuticals.1 The
absorption of vitamin C in the gut is limited by an active transport
mechanism and therefore despite high-intake doses of oral vitamin C,
only a small fraction of it will eventually be biologically available and
active in the skin, hence for any discernible role of its actions in the
skin, it needs to be supplied topically.2
Bioavailability and kinetics of vitamin C:
Vitamin C is available in a number of active forms which include
L-ascorbic acid, ascorbyl-6-palmitate, and magnesium ascorbyl
phosphate of which L-ascorbic acid is the most biologically active
and well-studied.1 Although all three types exert biological activity
and an anti-oxidant effect, this is believed to be achieved, in part, by
the conversion to the active form of L-ascorbic acid once penetrated
through the stratum corneum. Unlike ascorbyl-6-palmitate and
magnesium ascorbyl phosphate, which are lipophilic and stable
but probably less biologically active; L-ascorbic acid in contrary
is hydrophilic and unstable. The rate-limiting effect in magnesium
ascorbyl phosphate is often its release from the vehicle and its
conversion to biologically-active L-ascorbic acid.3
The hydrophilic nature means that L-ascorbic acid is poorly
penetrated in the skin due to the impermeable hydrophobic stratum
corneum. Furthermore, L-ascorbic acid is a charged molecule which
42 Aesthetics | January 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
will further limit the penetration.4 The instability of the molecule
(i.e its degradation upon exposure to air and light) means that for
L-ascorbic acid to be able to remain stable and penetrate through
the stratum corneum it needs to be formulated in a way that provides
both stability and permeability. An effective method of achieving
this is by reducing the acidity (pH) of L-ascorbic acid below 3.5
which has shown to greatly aid in its penetration, largely due to
the transformation to the uncharged form of the molecule.5 In one
example of a currently available L-ascorbic acid product (from
SkinCeuticals), the addition of ferulic acid aids in both stabilisation of
the molecule as well as achieving an acidity of a pH below 3.5.4
The optimal concentration of vitamin C depends on its formulation,
however in most cases for it to be of biological significance it needs
to be higher than 8%.5 Studies have shown that a concentration
above 20% does not increase its biological significance and in
contrary may cause some irritation.4 The most available reputable
products of vitamin C today are therefore in the range of 10 to 20% to
exert an anti-oxidant effect and with lower concentrations for its role
in anti-inflammatory conditions.
Continuous efforts are being made to be able to enhance efficient
transepidermal delivery of the stable form of vitamin C. This includes
the use of nanoparticles, microspheres (for graded delivery), and
laser delivery.6
Vitamin C as an anti-oxidant:
It is now well known and accepted that environmental factors such
as solar radiation, pollution, smoking, etc. can cause damage to
the skin through the generation of so-called “oxidative stress”.7
This oxidative stress can cause damage to the skin in the form of
dyspigmentation, the formation of “sunburn” cells, thymine dimers,
solar elastosis, and up-regulation of a number of markers that lead to
impaired cell cycle division.8
Trans-urocanic acid is a by-product of fillagrin present in the skin
which acts as a chromophore for photons of radiation (mainly
ultraviolet and to a degree infrared) leading to the formation of singlet
oxygen. This will lead to a cascade of events leading to the formation
of so-called “reactive oxygen species” or “free radicals”.9 These are
highly toxic unstable molecules that can cause damage to the nucleic
acids (main component of DNA), proteins, and cell membranes.
Clinical manifestations of these effects include photodamage/photo-
ageing and predisposition to skin cancer.2
Anti-oxidants act by neutralising the singlet oxygen cascade
and therefore limiting the formation of reactive oxygen species.
This occurs predominantly by a process of electron transfer/
donation.1,2 Anti-oxidants include a range of natural and synthetic
products such as viamin E (alpha tocopherol), ferulic acid, phloretin,
idebenone, green tea (polyphenols), resveratrol, lycopene, grape
seed, niacinamide, ubiquinone, geinstein, silymarin, coffee berry,
polyhydroxy acids, carotenoids, kinetin, and glutathione. Vitamin C is
the most powerful anti-oxidant available for skin protection.10
In clinical and laboratory studies vitamin C has been shown to
improve all parameters of photodamage and predisposition to skin
cancer and these include, in particular, a reduction in solar radiation-
induced erythema, “sunburn” cells and “thymine dimers”.1,5
A number of important products that are produced as a result of
reactive oxygen species formation and cascade include: p53,
activation of AP-1 (activator protein-1), Langerhans cells CD1a, thymine
dimers, activation of Caspase-3 and Caspase-7.4
p53 is a cellular protein induced by solar radiation in response to
structural DNA damage. Upon radiation, its levels will rise to try and

@aestheticsgroup Aesthetics Journal Aesthetics
Key points:
• Vitamin C is the most powerful anti-oxidant in the skin and
L-ascorbic acid is its most active biological form
• Stability and permeability are two important factors in the
delivery of vitamin C into the skin
• Solar radiation in the form of ultraviolet and some infra-
red rays cause “oxidative stress” and this is neutralised by
vitamin C
• “Oxidative stress” can cause a cascade of events in the skin
leading to what is clinically evident as “photoageing”
• Vitamin C exerts beneficial effects on the formation of
collagen in addition to prevention of collagen breakdown
caused by solar radiation
• Vitamin C has also shown to exert anti-inflammatory effects
through inhibition of the transcription factor NFĸB
• Interference with the enzyme tyrosine kinase means that
vitamin C exerts anti-pigmentation effects, albeit a bit weaker
than some of the other available products in the market
slow down the cell cycle allowing for repair of the damaged DNA
and the induction of a process of programmed cell death called
apoptosis.11 Therefore raised levels of p53 indicate solar radiation-
induced cellular damage and topical application of vitamin C has
shown to decrease the levels of p53 upon radiation, a testimony of
the photoprotective effects of vitamin C.4
AP-1 is a protein that is activated as a result of reactive oxygen
species formation and leads to up-regulation of a number of
proteases called matrix metalloproteases (MMPs).1 These proteases
act to degrade and damage collagen in the dermis leading to some
of the photoageing effects observed. Vitamin C has shown to inhibit
the activation of AP-1 which would lead to a reduction in MMPs and
a reduction in collagen damage. Langerhans cells CD1a are antigen-
presenting cells present in the epidermis, which act by initiating a
protective immune response. Their numbers are decreased upon
reactive oxygen species formation and hence solar radiation can
lead to a decrease in a particular cellular immune response. Products
containing vitamin C have shown to prevent the reduction of these
cells upon solar radiation, further demonstrating the anti-oxidant effect
of vitamin C.12
Other effects of vitamin C on skin:
In addition to the anti-oxidant effect achieved through neutralisation
of the oxidative stress, vitamin C has also demonstrated a number
of additional beneficial effects on the skin. Vitamin C is essential
for collagen biosynthesis and serves as a co-factor for prolyl and
lysyl hydroxylase, important enzymes responsible for cross-linking
and stabilisation of collagen fibres.13 Vitamin C has also shown to
activate transcription factors such as pro-collagen mRNA that lead
to collagen synthesis. Impairment of collagen has been observed
clinically in the presence of vitamin C, and Scurvy is a great example
of this.14 In summary, vitamin C exerts its beneficial effects on collagen
both through collagen biosynthesis as well as inhibition of collagen
breakdown through down-regulation of the activity of MMPs.
Beneficial effects of vitamin C on elastin were also observed. Elastin
is an enzyme that degrades elastic fibres leading to the characteristic
appearance of photoageing known as solar elastosis. In vitro studies
have shown that vitamin C inhibits the biosynthesis of elastin.15
An anti-inflammatory effect of vitamin C has also been observed
both clinically and in cultured human cells. Laboratory studies have
Aesthetics | January 2015
Spotlight On
aestheticsjournal.com Vitamin C
shown that vitamin C inhibits activation of transcription factor NFĸB,
a transcription factor responsible for the production of a number of
pro-inflammatory cytokines such as TNF-alpha, IL-6 and IL-8. These
cytokines are responsible for a number of inflammatory pathways
implicated in certain dermatoses.16 Despite these anti-inflammatory
effects, vitamin C is not primarily used in practice for inflammatory
dermatoses. Vitamin C also plays a role as an anti-pigmentation
agent. It interacts with copper ions at tyrosinase-active sites and
inhibits the action of the enzyme tyrosinase – the main enzyme
responsible for the conversion of tyrosine into melanin - and therefore
can be used in anti-pigmentation treatment.17
Conclusion:
Environmental triggers such as pollution, smoking, and in particular
harmful solar radiation cause damage to the cells through the
formation of reactive oxygen species. Vitamin C is the most powerful
anti-oxidant in the skin and is able to provide photoprotection through
neutralisation of the oxidative stress cascade. This photoprotective
effect is complimentary to the “sunscreen effect” provided by the
application of sunblocks, the latter absorbing or reflecting ultraviolet
light but not primarily neutralising free radicals. Objective parameters
studied in laboratory setting have shown a reduction in a number of
parameters that correlate to photoaging, all of which are reduced
by the use of vitamin C. Furthermore, vitamin C has shown to have
beneficial effects in collagen synthesis as well as anti-inflammatory
and anti-pigmentation effects. A number of different formulations
exist with L-ascorbic acid proving the most biologically active when
formulated appropriately.
Dr. Firas Al-Niaimi is a consultant dermatologist
and laser surgeon and works at sk:n clinics in London.
He trained in Manchester and subsequently did a
prestigious advanced surgical and laser fellowship at
the world-renowned St. John’s Institute of dermatology
at St. Thomas’ Hospital in London. He has authored more than 80
publications including chapters of books and is on the advisory board
for a number of respected journals. Dr Al-Niaimi is also a speaker and
advisor for L’Oréal.
REFERENCES:
1. Farris PK. Cosmetical Vitamins: Vitamin C. In: Draelos ZD, Dover JS, Alam M. editors.
Cosmeceuticals. Procedures in Cosmetic Dermatology. 2 nd ed. New York: Saunders
Elsevier; 2009. p. 51-6.
2. Traikovich SS. Use of Topical Ascorbic acid and its effects on Photo damaged skin topography.
Arch Otorhinol Head Neck Surg 1999;125:1091-8.
3. Austria R, Semenzato A, Bettero A. Stability of vitamin C derivatives in solution and topical
formulations. J Pharm Biomed Anal. 1997;15(6):795-801.
4. Lin FH, Lin JY, Gupta RD, Tournas JA, et al. Ferulic acid stabilizes a solution of vitamins C and E
and doubles its photoprotection of skin. J Invest Dermatol. 2005;125(4):826-32.
5. Pinnell SR, Yang H, Omar M, et al. Topical L-ascorbic acid: percutaneous absorption studies.
Dermatol Surg. 2001;27(2):137-42.
6. Lee S, Lee J, Choi YW. Skin permeation enhancement of Ascorbyl palmitate by lipohydro gel
formulation and electrical assistance. Bio Pharma Bull 2007;30:393-6.
7. Tyrrell RM. Solar ultraviolet A radiation: an oxidizing skin carcinogen that activates heme
oxygenase-1. Antioxid Redox Signal. 2004;6(5):835-40.
8. Fisher GJ, Wang ZQ, Datta SC, et al. Pathophysiology of premature skin aging induced by
ultraviolet light. N Engl J Med. 1997;337(20):1419-28.
9. Hanson KM, Simon JD. Epidermal trans-urocanic acid and the UV-A-induced photoaging of the
skin. Proc Natl Acad Sci 1998;95:10576–10578.
10. Shindo Y, Witt E, Han D, et al. Enzymic and non-enzymic antioxidants in epidermis and dermis
of human skin. J Invest Dermatol. 1994;102(1):122-4.
11. Meplan C, Richard MJ, Hainaut P. Redox signaling and transition metals in the control of the
p53 pathway. Biochem Pharmacol 2000;59:25-33.
12. Oresajo C, Stephens T, Hino PD, et al. Protective effects of a topical antioxidant mixture
containing vitamin C, ferulic acid, and phloretin against ultraviolet-induced photodamage in
human skin. J Cosmet Dermatol. 2008;7(4):290-7.
13. De Tullio MC. Beyond the antioxidant: the double life of vitamin C. Subcell Biochem.
2012;56:49-65.
14. Grosso G, Bei R, Mistretta A, et al. Effects of vitamin C on health: a review of evidence. Front
Biosci (Landmark Ed). 2013;18:1017-29.
15. Farris PK. Topical vitamin C: a useful agent for treating photoaging and other dermatologic
conditions. Dermatol Surg. 2005;31(7 Pt 2):814-7.
16. Murray JC, Burch JA, Streilein RD, et al. A topical antioxidant solution containing vitamins C
and E stabilized by ferulic acid provides protection for human skin against damage caused by
ultraviolet irradiation. J Am Acad Dermatol. 2008;59(3):418-25.
17. Matsuda S, Shibayama H, Hisama M, et al. Inhibitory effects of novel ascorbic derivative VCP-
IS-2Na on melanogenesis. Chem Pharm Bull 2008;56:292-7.
43
RSM ICG-7 Interventional
cosmetics: New and
controversial treatments
Date: Friday 27 - Saturday 28 February 2015
Venue: Royal Society of Medicine, London
CPD: 12 credits (6 per day - applied for)

Interventional cosmetics is the most

rapidly growing branch of medicine
and surgery today – attend this two day
symposium for an update on trends and
techniques and advance your skills and
knowledge.

Programme includes:
• Fillers - advanced uses & complications
• Botulinum - advanced uses & complications
• Cosmoceuticals
• New and controversial therapies
• A range of hands on workshops
• Live demonstrations of several treatments

Early bird rates expire on Tuesday 27 January 2015:

RSM members: £100 - £315
Non members: £150 - £400
Contact details:
www.rsm.ac.uk/rsmicg7
Email: rsmprofessionals@rsm.ac.uk
Tel: +44 (0) 20 7290 3928

@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Glycation
Lorna Bowes examines the concept
of glycation and reviews the evidence
behind various topical ingredients shown
to inhibit accumulation of Advanced
Glycation Endpoints (AGEs)
As we, aesthetic practitioners, cosmetic dermatologists and
cosmetic scientists, learn more about the ageing process, we
uncover new and improved ways to target the many signs and
symptoms of ageing skin. Sometimes, these new understandings
pave the way for new ingredients, and at other times we discover
that existing proven technologies have actions previously not
described or fully understood.
Glycation and AGEs
There are many processes implicated in ageing, however one
generating increased interest in both general and aesthetic
medicine is glycation.
AGEs, or Advanced Glycation End products, is the name given to
the irreversible damage caused to proteins by sugar molecules,
i.e. glycation. This is a negative process that is not exclusive to
the skin, but is found throughout the body where proteins are
present. Glycation differs from glycosylation, as glycosylation is
a normal process in which sugars are combined with protein in
a site-specific, enzyme-mediated process that is essential for
molecular function. Glycation, however, is an abnormal process;
a non-enzymatic joining of a sugar with a protein that impairs
molecular function and causes irreversible damage to proteins in
the skin, as well as other organs. The more we understand AGEs,
the more interest there is in finding the perfect AGE inhibitor. AGEs
are not only relevant in aesthetics; exogenous AGEs are formed
when sugars are cooked in combination with proteins and fats.
This is seen by the food industry as a very positive reaction as
they are able to use this to create a cooked effect. For example,
by adding sugar to food before cooking, the glycation process
creates the non-enzymatic browning reaction, which improves
the appearance of the food and is important for flavour.1 The food
industry terminology for this is ‘caramelisation’, first described by
Louis-Camille Maillard, a French chemist in 1912, and hence known
as the Maillard reaction, a non-enzymatic browning process.3
Glycation before using
maltobionic acid
Aesthetics | January 2015
Treatment Focus
Glycation
Glycation has been widely studied in relation to diabetes, with
results from multiple medical studies1 showing that not only is
there a link between obesity and the onset of diabetes, but that
there is a correlation between the quantity of food cooked at high
temperature and the development of type 2 diabetes and related
cardiovascular disease. Researchers have looked for possible links
between increased AGEs and a reduction in the body’s natural
defense against insulin resistance. It is this research which led
to new research being undertaken focusing on the skin ageing
effects of glycation.
How are AGEs formed in the skin?
The Maillard reaction occurs irreversibly in the skin, causing
protein crosslinking, which leads to yellow colouring and a sallow
appearance.2 The production of AGEs in skin is a slow three-step
chemical process; the longer the biological half-life of a protein,
the stronger the effect of glycation on the protein. Collagen is
a triple helical structure of protein, mostly glycine, proline and
hydroxyproline, which is essential for the structure of the Extra
Cellular Matrix (ECM) in the skin. Collagen has a significant half-
life in the dermis and is thus highly susceptible to the damage
potential of AGEs. In the presence of heat, the primary amino acid
component of the collagen triple helix is ‘grabbed’ by a sugar
(glucose) yielding glycation intermediates known as Schiff bases
(step 1), which in turn are oxidised and either disseminate or form a
further intermediate known as an Amadori product (step 2). Finally
in step 3, lasting several weeks, irreversible oxidative crosslinks are
formed by the Amadori products and AGEs are ultimately formed
causing slow deterioration of structural tissue.3,4,5
The damaged collagen is less susceptible to normal catabolism
and therefore AGEs accumulate in the skin, as described above in
the Maillard reaction. Additionally, with around 30% of the sugars
and AGEs that we eat ending up in the skin, accumulation of AGEs
is compounded. In addition, UV exposure, pollution and smoking
add to the production of AGEs. Likewise, increased accumulations
of AGEs are seen in certain diseases such as diabetes.6,7
Cosmetic Appearance of AGEs
AGEs accumulate in the upper dermis and this causes the yellowing
of skin known as sallowness. Due to the effect of the crosslinking of
the collagen and damage to the elastin in the skin, the skin becomes
brittle and inflexible, wrinkles develop and the loss of elasticity leads
to stiffness of the skin. The dermal processes involve the mid dermis
as well as the upper dermis, creating an immediate challenge to
formulators as the processes that active ingredients are required to
affect are protected by the skin barrier function.
Anti-glycating Ingredients
To create an anti-glycating
effect, scientists have studied
a selection of inhibitors.
For example, aspirin blocks
glycation by acetylating
lysine residues; there are
protein competitors that work
by inhibiting sugars, such as
aldose and ketose, which
prevent a Maillard reaction
Anti-glycation results after in the presence of proteins.
using maltobionic acid
This is in fact one of the
45
 Treatment Focus
An#-­‐Glyca#on
Glycation
E ffect
  o f
  PHA/Bionics
@aestheticsgroup Aesthetics Journal
An#-­‐Glyca#on
 Effect
 of
 PHA/Bionics
Percent Non-Enzymatic Glycation Relative to Water Control
No
effect 100
80
Positive
60 control
* 0.05%
40
* cosmetic ingredients available to us, in an
* even greater number of formulations. The
20
*
(100%
Complete inhibition)
0
inhibition
Aminoguanidine Gluconolactone Lactobionic Acid
*Significant inhibition of non-enzymatic glycation expressed as a % of water control, p<0.05.
Green B, Edison B et al Antiaging Bionic and Polyhydroxyacids Reduce Non-Enzymatic Protein Glycation and
Sallowness. Poster presentation 72nd Annual Meeting of the American Academy of Dermatology, March 2014.
key pharmaceutical approaches in diabetes, along with the use of
aminoguanidine and pyridoxamine.8
Aminoguanidine was one of the first substances shown to have
an effect on AGE formation. This is not routinely used in topical
anti-ageing formulations, but as well as being used in diabetes, it
is frequently cited as the positive control in studies of other AGE
inhibiting ingredients. The effect of aminoguanidine is attributed
to its trapping of early glycation products, although effects on
later stages of glycation have not been shown and it has been
associated with adverse effects when trialled in patients with
diabetes.
The challenge for topical anti-glyactors is to discover their efficacy.
In particular, whether they provide adequate dermal penetration
and tolerability. Metal chelation and anti-oxidative effects could,
theoretically, affect the oxidative steps in AGE formation. Zinc,
manganese, ascorbic acid, alpha lipoic acid, green tea and
Vitamins C & E have all been shown to have antioxidant and/or
metal chelation benefits. These ingredients are increasingly being
used in nutraceutical skin beverages and as topical antioxidants in
cosmeceutical formulations.9,10
Hydroxyacids have attracted much interest as antiglycation
ingredients. Second generation hydroxyacid, gluconolactone,
a so-called polyhydroxyacid, and third generation ‘bionic
polyhydroxyacids’ lactobionic and maltobionic acid were studied
and shown to reduce the visual measure sallowness. The key study 4. Bucalla R, Cerami A. ‘Advanced glycosylation; chemistry, biology and implications for diabetes
to assess antiglycation effects used aminoguanidine 0.01% as the
positive control, and compared gluconolactone at 0.05%, 0.10% and
0.50%, lactobionic acid at 0.05%, 0.10% and 0.50%, and maltobionic
acid at 0.05%, 0.10% and 0.50% over a 24-day incubation period.
A significant inhibitory effect was demonstrated, with results similar
in all cases to the positive control – aminoguanidine. These
hydroxyacids are known as antioxidants with powerful metal
chelation and lipid peroxidation effects. In addition maltobionic acid
has also been shown to inhibit UV induced hyperpigmentation.15
Of course, these ingredients are well known and highly respected
due to their other already well-documented effects of increasing
exfoliation, keratinization gently increasing cell turnover, improving
clarity and reducing spots, plumping and firming the skin, reducing
skin surface roughness, improving laxity, reducing pore size and
building the skin barrier by both improving dermal components
such as collagen and glycosaminglycans, thus increasing the skin’s
ability to retain water.11, 12, 13, 14, 15
46
Aesthetics aestheticsjournal.com
Conclusion
Glycation is a significant part of the
process that causes the visual signs of
photodamage such as sallowness and the
typical criss-cross pattern of fine lines seen
in severe photodamage. These are ageing
* 0.01% concerns that the vast majority of patients
coming in to our clinics demonstrate to
* 0.10% some degree. We have a wide array of
0.50%
* choices of both single active ingredients
with single or multiple potential actions,
Maltobionic Acid
and the selection of specific combined
active ingredients made by the formulators,
can make a vast difference to the effect
of topical products. Polyhydroxyacids and
bionic polyhydroxyacids come from the
dermatologist/dermatopharmacologist team who discovered
the first alpha hydroxyacid, glycolic acid, to be used in either
pharmaceutical preparations or cosmetic formulations.16 Alongside
the other proven anti-ageing actions of increased exfoliation
and keratinization (improved clarity and reduced acne lesion
count, improved skin depth and density, reduced skin surface
roughness, improved laxity, reduced pore size and improved skin
barrier function), polyhydroxyacids and bionic polyhydroxyacids
have been shown to effectively inhibit non-enzymatic glycation.
Long-term use of these advanced hydroxyacid ingredients will
therefore maintain healthy skin and reduce exposure to the
damaging and cosmetically distressing effects of AGEs.1
Lorna Bowes is an aesthetic nurse and trainer with an
interest in dermatology, formerly a committee member
of the Royal College of Nursing Aesthetic Nurse Forum
and a founding member of the British Association
of Cosmetic Nurses. With extensive experience of
delivering aesthetic procedures, Lorna trains and lectures regularly on
procedures and business management in aesthetics. Lorna is director
of Aesthetic Source.
REFERENCES
1. Green B, Edison B et al, Antiaging Bionic and Polyhydroxyacids Reduce Non-Enzymatic
Protein Glycation and Sallowness. Poster presentation 72 Annual Meeting of the American
nd
Academy of Dermatology, March 2014.
2. Ohshima H, Oyobikawa M et al. ‘Melanin and facial skin fluorescence as markers of yellowish
discolouration with aging’. Skin Res and Tech 15 (2009) 496-502.
3. Schmid D, Muggli R et al. ‘Collagen glycation and skin aging’. Cosmetics and Toiletries
Manufacture Worldwide (2002) 1-6
and aging’. Adv Pharmacol 23 (1992) 1-4.
5. Briden B, Sugar and The Skin, (London: Body Language, 2014) www.bodylanguage.net/sugar-
skin/ [Accessed 28 November]
th
6. Briden B, Sugar and The Skin, (London: Body Language, 2014) www.bodylanguage.net/sugar-
skin/ [Accessed 28 November]
th
7. Green B, Edison B et al. Antiaging Bionic and Polyhydroxyacids Reduce Non-Enzymatic
Protein Glycation and Sallowness. Poster presentation 72 Annual Meeting of the American
nd
Academy of Dermatology, March 2014.
8. Schmid D, Muggli R et al. ‘Collagen glycation and skin aging’. Cosmetics and Toiletries
Manufacture Worldwide (2002) 1-6.
9. Verbek P, Siboska G et al. ‘Kinetin inhibits protein oxidation and glyoxidation in vitro’. Biochem
Biophys. Res. Commun. 276 (2000) 1265-1270.
10. Paraskevi Gkogkolou & Markus Böhm (2012) ‘Advanced glycation end products’. Dermato-
Endocrinology 4:3 (2012) 259-270 <http://www.tandfonline.com/doi/pdf/10.4161/derm.22028>
[Accessed 28th November]
11. Berardesca E, Distante F, Vignoli GP, Oresajo J, Green B. ‘Alpha hydroxyacids modulate
stratum corneum barrier function’. British Journal of Dermatology 137 (1997) 934-938
12. Bernstein, EF, Brown, DB, Schwartz, MD, Kaidbey, K, Ksenzenko, SM. ‘The Polyhydroxy
Acid Gluconolactone Protects Against Ultraviolet Radiation in an In Vitro Model of Cutaneous
Photoaging’. Dermatologic Surgery, Inc 30 (2004) 1-8.
13. Grimes PE, Green BA, Wildnauer RH, Edison BL. ‘The use of polyhydroxy acids (PHAs) in
photoaged skin’. Cutis 73(suppl 2) (2004) 3-13.
14. Green BA, Edison BL, Sigler ML. ‘Antiaging effects of topical lactobionic acid: results of a
controlled usage study’. Cosmet Dermatol 21(2) (2008) 76-82.
15. Green BA, Edison BL, Wildnauer RH. ‘Maltobionic acid, a plant-derived bionic acid for topical
anti-aging’. Am Acad of Dermatol 54(3) (2006) AB37.
16. Van Scott EJ, Yu RJ: Control of Keratinization with a-Hydroxy Acids and Related Compounds.
Archives of Dermatology 110: 586-590, 1974.
Aesthetics | January 2015
Before After
16 weeks use of NeoStrata Skin Active 4 product regimen;
an advanced, comprehensive antiaging regimen,
to target all the visible signs of aging with state-of-the-art technologies 1
1.
Farris PA, Edison BL, Brouda I et al.: A High-Potency Multimechanism Skincare Regimen Provides
Significant Antiaging Effects: Results From a Double-Blind, Vehicle-Controlled Clinical Trial.
Journal of Drugs in Dermatology 11(12) 1447-1454, 2013

Cellular Ingredients
Restoration 5% Maltobionic Acid
a bionic polyhydroxyacid
5% Gluconolactone
Reduces the effects of glycation 2 a polyhydroxyacid

Formulated to synergistically 5% Glycolic Acid

restore skin’s essential cells an alpha hydroxy acid

Designed to rebuild the deep Peptides

matrix for skin that is firmer and SuperFruit Antioxidants including
more lifted Chardonnay Grape Seed Extract
Reduces oxidative damage Apple Stem Cell Extract
A poster presented to the American academy of
dermatology in 2014 showed that polyhydroxyacids and
bionic polyhydroxyacids effectively inhibit non-enzymatic
glycation. 2 Therefore long-term use of these advanced
hydroxyacid ingredients will maintain healthy skin as well
as reducing exposure to the damaging and cosmetically
distressing effects of AGEs. 2
2.
Green B, Edison B et al, Antiaging
Bionic and Polyhydroxyacids
Reduce Non-Enzymatic Protein
Glycation and Sallowness. Poster
presentation 72nd Annual Meeting
NeoStrata Skin Active NeoStrata Skin Active Aesthetic Source of the American Academy of
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 Techniques
Mole Removal @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Using radio-wave A patient must not wear jewellery or be in contact with metal
due to the risk of burns caused by an alternate current path or

surgery for mole “capacitive coupling”. Radiowaves are non-ionizing, thus cause
no damage to animal DNA or surrounding tissue, just like mobile
phones.4 However, all general rules of safety with electro-magnetic
removal equipment must be followed. This includes making sure no alcohol
Dr JJ Masani explores the science and is used for cleaning and there is no presence of ignitable gases in
the operating room.
technique behind removing moles
using radiosurgery
WHAT IS RADIO-WAVE SURGERY?
Radiosurgery (synonymous terms: radio-wave surgery, micro-wave
surgery, high- frequency surgery, electro-surgery, Bovie’s Current)
has a high frequency current of 2 to 4 MHz (million times/sec), and
is cold to touch at the cutting electrode, thus produces less tissue
damage.1 Domestic mains electric current of 50Hz (1 Hz = 1 wave
form per second) creates copulation with high temperature, as well
as tissue damage.1 The cutting electrode has less lateral heat than
most lasers, creating excellent cutting ability, less tissue damage,
less post-operative pain and above all, less scarring when removing
moles. As there is no necrosis or carbonisation, the specimen can
be sent for histopathology. There is also no pressure applied to skin, The first principle of all electromagnet wave form is that electrons move in an
Figure 1: Image demonstrates the electromagnet circuit
as with a scalpel. Radiowave surgery should not be confused with
electric cautery, where the equipment uses heat (50 to 400 Hz) – the SCIENCE BEHIND RADIOSURGERY
cutting electrode of radiosurgery is stone cold.1 Besides excision of The first principle of all electromagnet wave form is that electrons
2

moles, radio-wave surgery can be used (with no scarring to minimal
scarring) in senile angiomas, xanthomas, keloids, rhinophymas,
spider veins, epilation of hair and skin tightening). In my opinion
we are, as aesthetic physicians, dermatologists and surgeons,
underusing this innovative technology. There seems to be a lack of
knowledge on radiosurgery as it is not yet taught in medical schools.
Compared to scalpel technology, the equipment is expensive and
the technique is quite different.
HISTORY
The application of heated stones to obtain haemostasis has been
used since ancient times.2 Later, during the nineteenth century,
surgeons used cautery and electricity within medicine. Although
radiosurgery was introduced before the 1920s, credit is given to
physicist William Bovie, who developed the first prototype of the
modern radiosurgery generator for diathermy. This allowed Dr
Harvey Cushing, a neurosurgeon, to successfully remove a vascular
myeloma from the head of a 64-year-old patient on 1st October 1926
in Boston. Liebel-Flarsheim Co then purchased the patent for the
Bovie Unit for $1, and proceeded to make millions.2
move in an electromagnetic medium, always completeing a circuit.2
See Figure 1 where the lead wire from the generator producing
radiowaves (2 MHz to 4 MHz high frequency) passes to the active
electrode with a loop, which is used in a feathering manner to cut
the mole. The loop is at room temperature. The radiowave then
travels through the body on to the antenna (like the aerial of a radio
or mobile phone) and back to the generator. The second principle
to understand is that there is a frequency and a wavelength to
consider in any electromagnetic radiation, with domestic power
having a long wavelength, low frequency and is hot to touch.
Radiofrequency, on the other hand, is a shorter wavelength with
high frequency and is cold to touch. Up to visible light the infrared
Figure 3: The electromagnetic radiation spectrum

COMPARISON OF LATERAL HEAT AND TISSUE

DAMAGE BY ENERGY SOURCES2

1. Radio-Wave Surgery 0.02 mm damage

2. CO2 Laser 0.5 mm damage
3. Holmium Laser 0.5 mm damage
4. ND:YAG 2.3 mm damage

CONTRAINDICATION
Patients with cardiac pacemakers are an absolute contraindication
as radiowaves interfere with cardiac pacemakers – they too work
on the principles of electromagnetic radiation.3 Some newer
pacemakers are not altered by radiosurgery wave forms, and this
should be checked with the cardiologist prior to treatment. Figure 2: The Electromagnetic Radiation Spectrum

48 Aesthetics | January 2015

 Techniques
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Mole Removal

spectrum is non-ionising to our DNA, and beyond UV light it is Case Study

Figure 4: Case study
ionising to our DNA and harmful.2 To understand the principle
of an electric circuit, one could compare it with our WC where a. b.
the cistern, which is full of water, has potential energy (voltage),
and when we pull the flush, water runs down the pipe (current-
measured in amperes) and the force with which it runs is classed
DE
as watts or power, or if timed in one second, a joule. Thus Voltage
x Amperes = Watts. (Remembered by the pneumonic: VAW) Ohms
is the resistance offered by what we clear in the WC, or in case of c. a. DERMOSCOPY
radiowave surgery, is our body offering the resistance. The soiled b. POST SURGERY
water then goes to the cesspit, gets purified and returns to the c. SIX WEEK LATER
cistern, thus completing the circuit. (As demonstrated in Figure 2)

EXCISION OF BENIGN NAEVI (MOLES)

Once the naevi is diagnosed as benign, one can use the
radiowave generator and tungsten loop to feather and shave the
naevi until the pigment is removed without hitting the dermis to
avoid scarring. The tissue scooped can be sent for histopathology
as there is no carbonisation of tissue. Similarly senile angiomas,
xanthomas, keloids, rhinophymas, spider veins and warts can be
excised without scarring.1

Patient Histology Report

Clinical Data:
Possible Seborrhoeic keratosis. Excised by radio surgery. Present
for one month.
Macroscopic:
Lesion from scalp: A rough pale hairy slightly friable skin lesion 5 x
4 x 3 mm. Bisected.
Microscopic:
Skin shows an irritated seborrhoeic keratosis. There are no
Figure 3: Mole examination using a Dermascope and an iPhone
atypical features, and the lesion has been excised.
RECOGNITION OF MOLES (NAEVI) USING DERMASCOPE Diagnosis:
After taking a detailed medical history and carrying out an Skin from scalp – Seborrhoeic keratosis.
examination of the patient, I proceed to use the Dermascope to
distinguish between benign and malignant moles (BCC, SCC,
melanomas). Appropriate training and experience in the use of the
Dermascope brings about a better diagnosis of the naevi and its
nature, prior to excision. Good quality images can now be taken
using a Dermascope with the iPhone 4, 5 or 6, and other smart
phones with an adaptor costing less than £30.00. See Figure 3.

If the lesion is recognised as malignant, or after histopathology

is diagnosed as malignant, then the general rules of surgical Before Straight after Procedure 8 weeks after Procedure
principals apply and excision has to be wider than the margins, as
well as deeper, to reach subcutaneous tissue. This too could be
carried out by radiosurgery using a tungsten wire instead of a loop,
but the patient must then be told that a scar will result owing to a
wider and deeper excision, and sutures or a skin graft may apply.
Dr Jamshed (JJ) Masani runs the Mayfair Practice, a
combined GP and aesthetics clinic in London. He trained
as a doctor in Southern India, before moving to the UK in Before Dermoscopy Straight after treatment
1978. Dr Masani is well known across the industry as one of
the leading aesthetic doctors to specialise in mole removal.
REFERENCES:
1. Dzingel, R, ‘Radio Surgery in Dermatology’, Cosmetic Medicine, 25 (2004), p.1430-4031.
2. Masarweh, N et al, ‘Electro-Surgery: History, Principles and Current and Future Uses’,
American College of Surgeons Publications, (2006), p. 520.
3. ‘Electromagnetic interference’, MHRA, (2014) http://www.mhra.gov.uk/Safetyinformation/
Generalsafetyinformationandadvice/Technicalinformation/Electromagneticinterference/
Last accessed: 12/12/14.
4. ‘Cell Phones and Cancer Risk’, National Cancer Institute, (2013) http://www.cancer.gov/cancertopics/
factsheet/Risk/cellphones Last accessed: 12/12/14. Before After
6

6
Aesthetics | January 2015 49
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The daytime serum, CE Ferulic, is a combination of L-Ascorbic
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It has also been proven to protect skin from infrared radiation
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A particular type of IR, called IRA, reaches the skin’s dermal layers daily, and
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Contain pure L-Ascorbic acid (derivatives cannot be used by the skin)
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50 Aesthetics | January 2015


@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
A summary of the latest
clinical studies
Title: Comparison of the effect of diode laser versus intense pulsed
light in axillary hair removal.
Authors: P Ormiga, CE Ishida, A Boechat, M Ramos-E-Silva.
Published: Dermatologic Surgery, October 2014
Keywords: IPL, diode laser, hair removal
Abstract: Devices such as diode laser and intense pulsed light
(IPL) are in constant development aiming at permanent hair
removal, but there are few comparative studies between these
technologies. The objective was to comparatively assess axillary
hair removal performed by diode laser and IPL and to obtain
parameters of referred pain and evolution response for each method.
A comparative prospective, double-blind, and randomized study
of axillary hair removal performed by the diode laser and IPL was
conducted in 21 females. Six sessions were held with application of
the diode laser in one axilla and the IPL in the other, with intervals
of 30 days and follow-up of 6 months after the last session. Clinical
photographs and digital dermoscopy for hair counts in predefined
and fixed fields of the treated areas were performed before, 2 weeks
after the sixth session, and 6 months after the end of treatment. A
questionnaire to assess the pain was applied. The number of hair
shafts was significantly reduced with the diode laser and IPL. The
diode laser was more effective, although more painful than the IPL.
No serious, adverse, or permanent effects were observed with both
technologies. Both diode laser and the IPL are effective, safe, and able
to produce lasting results in axillary hair removal.
Title: Facial rejuvenation: combining cosmeceuticals with
cosmetic procedures
Authors: JD Wisniewski, DL Ellis, MP Lupo.
Published: Cutis, September 2013
Keywords: facial rejuvenation, cosmeceuticals, injectables,
anti-ageing
Abstract: Cosmetic patients are looking for a more youthful
appearance without spending a lot of money, feeling any pain, or
experiencing any post-procedure downtime. New cosmeceutical
therapies can be used adjuvant to chemical peels, lasers, and
injectables, making anti-aging regimens less painful and requiring
less post-procedural healing time. Adjunctive agents can be used
to enhance chemical peels and decrease post-inflammatory
hyperpigmentation (PIH). Topical retinoids used prior to ablative
laser treatments can aid in faster post-procedure healing and re-
epithelialization. Cosmeceuticals that contain both antioxidants and
anti-inflammatories can help reduce post-procedure inflammation.
Acetyl hexapeptide-3 is an effective topical agent for decreasing
wrinkles and can be used as an adjunct to intramuscular botulinum
neurotoxin, which may reduce the number of injections needed.
Topical hyaluronic acid also would help patients who are averse
to needles or are just starting to get wrinkles and are looking
for noninvasive therapy. This article reviews combinations of
cosmeceuticals with cosmetic procedures that dermatologists may
want to consider discussing with their cosmetic patients.
Title: Anti-aging and filling efficacy of six types hyaluronic acid
based dermo-cosmetic treatment: double blind, randomized clinical
Aesthetics | January 2015
Clinical Practice
Clinical papers
trial of efficacy and safety.
Authors: V Nobile, D Buonocore, A Michelotti, F Marzatico.
Published: Journal of Cosmetic Dermatology, December 2014
Keywords: facial rejuvenation, dermal fillers, anti-ageing, volume
Abstract: Human skin aging is a multifactorial and complex
biological process affecting the different skin constituents. Even if
the skin aging mechanism is not yet fully unravelled it is evident
that epidermis loses the principal molecule responsible for binding
and retaining water molecules, resulting in loss of skin moisture and
accounting for some of the most striking alterations of the aged skin.
This Study investigated the cosmetic filling efficacy of Fillerina(®)
in decreasing the skin aging signs and in improving facial volume
deficiencies. A placebo-controlled, double-blind, randomized clinical
trial was carried out on 40 healthy female subjects showing mild to
moderate clinical signs of skin aging. The effect of the treatment on
skin surface and on face volumes was assessed both in the short-term
(3 h after a single product application) and in the long-term (7, 14,
and 30 days after continuative daily use). Three hours after a single
application and after 7, 14, and 30 days of treatment the lips volume
increased by 8.5%, 11.3%, 12.8%, and 14.2%. After 7, 14, and 30 days:
(1) skin sagging of the face contours was decreased by -0.443 ± 0.286,
-1.124 ± 0.511, and -1.326 ± 0.649 mm, respectively; (2) skin sagging
of the cheekbones contours was decreased by -0.989 ± 0.585,
-2.500 ± 0.929, and -2.517 ± 0.927 mm, respectively; (3) cheekbones
volume was increased by 0.875 ± 0.519, 2.186 ± 0.781, and
2.275 ± 0.725 mm, respectively; (4) wrinkle volume was decreased
by -11.3%, -18.4%, and -26.3%, respectively; and (5) wrinkle depth
was decreased by -8.4%, -14.5%, and -21.8% respectively. This study
demonstrated the positive filling effect of Fillerina(®) in decreasing
the clinical signs of skin aging and in improving the face volumes.
Title: Safety and efficacy of combining microfocused ultrasound
with fractional CO2 laser resurfacing for lifting and tightening the
face and neck
Authors: JA Woodward, SG Fabi, T Alster, B Colón-Acevedo.
Published: Dermatologic Surgery, December 2014
Keywords: ultrasound, skin tightening, laser
Abstract: Microfocused ultrasound (MFU) and ablative
fractionated laser (AFL) resurfacing techniques have been used
separately to noninvasively improve skin laxity and rhytides on
the face and neck. Simultaneous combination treatment would
be anticipated to provide further improvement but has not
previously studied. A retrospective analysis of 100 combination
face and neck treatments from 3 centers was performed, including
collective treatment protocols, postoperative recovery, side effect
profile, and clinical results. Skin laxity and photodamage (rhytides
and texture) showed significant improvement with combination
MFU + AFL treatment. Except for increased facial swelling in
a small percentage of patients, postoperative recovery and side
effects were comparable with those obtained after application of
individual treatments. Combination MFU-AFL on the face and
neck is a safe and effective method for targeting multiple facets of
facial and neck skin aging and can be safely performed in a single
treatment session.
51
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@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
How To Maximise
Your Marketing
Budget
Michelle Boxall looks at strategies to
ensure you get the most value when
marketing your clinic
For most businesses, the New Year brings renewed efforts and
inspiration to make improvements and grow sales. Planning for the
year ahead can be an exciting activity; but new ideas, unfortunately,
often have to be tempered by the constraints of a small budget. Many
clinics have modest marketing budgets, and even the larger chains
and services within the aesthetics industry have to look for good return
on investment (ROI) in the current economic climate.
Marketing budgets are often the first cost to be cut in times of austerity.
The short-term gain, however, can often deliver long term pain when
it impacts on sales further down the road. When businesses finally
come back round to the idea that ‘something’ has to be done in order
to grow or maintain revenue, the question over what that ‘something’
should be can be challenging.
Clinic owners may find themselves trapped in a cycle of indecision,
running in circles looking for that something that will transform their
business, but never making any long-term commitment. Decision
makers can be frozen by the fear of investing in a strategy that doesn’t
work, trying to avoid wasting money that they simply cannot afford to
lose. This vicious cycle may actually precipitate poor decision-making;
where clinic owners will only trial a marketing activity for a short period,
with minimum financial investment alongside little or no personal
investment of time. It is not surprising then, that these marketing
quick-fixes don’t usually work and only add fuel to the fire of marketing
uncertainty. You should recognise that while it is easier to swallow
small budget losses, these can quickly add up to significant financial
losses when considered over a number of years.
Fail to Plan and You Will Plan to Fail
The first place to start when considering any
marketing activity is in understanding and/or
establishing your business goals and objectives. It is
not enough to say that you just want to grow sales. If you don’t take
Aesthetics | January 2015
Marketing
Strategic Advice
the time to look closely at your business and devise a clear business
strategy, then the scattergun approach to marketing will likely lead to
failures within any outcomes.
Your business plan should provide the structure for your marketing
plan. The more detailed your business objectives, the more accurate
you can be in your promotional planning. For example, when looking
at sales objectives, you should clarify the value of any increase in
sales; what treatments or product lines will provide this increase and
which type of customer.
If you have decided that your increase in sales is going to come from
a new body-contouring treatment, when most of your clientele only
buy in to facial anti-ageing, then an exercise in targeting your current
customers could be worthwhile. However, if you have already sold
body-contouring treatments to your customer base and are looking
for a 100% increase in sales, then it is obvious that you need to
find brand new customers. If you then look to explore where these
customers can be found and who they are, you are more likely to
predetermine improved marketing accuracy.
The importance of business planning is paramount. It is still surprising
to me, how many aesthetic companies look to promote their
treatments with no fixed decisions on which treatments, market
segments and points of differentiation to target.
Marketing Plan
Once you have your business objectives, you can
start to plan your marketing programme. It is usually
impossible to promote every aspect of your product
portfolio and, therefore, deciding on which products should take
priority is key. If your business objectives lie in differentiating your
business from your key competitors, then choosing products that do
this could be important. If, however, your sales targets are paramount,
choosing to push your best-selling hero products could be a good
strategy.
Take some time to analyse your sales data from the previous year.
Which treatments made you the most money; if you want improved
profitability? Which treatments and products sold the most and when;
if you want increased revenue? Where are you losing clients to your
competitors? Any activity that can help you to avoid the scattergun
approach to marketing will improve your chances of success. Here
we will explore various marketing tools and look at different ways to
approach maximising your budget and ROI.
Marketing Audit
Take a look at everything you are already doing.
Consider marketing materials such as leaflets, your
website and social media, and see how you can
improve. Do an assessment to find out what is actually working and
what is not. Ask your clientele how and why they buy from you, and
assess whether there are any inconsistencies in their perceptions and
your communication aims.
Look at what you are doing in-house and what activities you are
outsourcing. If there are tasks you can do internally, leave the
expensive consultants to activities that really require their expertise.
Get the most out of your content and printed collateral: This can
include anything from posters, leaflets, business cards and invites to
events. Be sure that all your collateral is brand coherent and keep to
the same style, use of logos, tone of voice and key messages. Your
marketing materials can work harder for you when they present a
brand, and not just information. Furthermore, clients can be confused
by too much information, and therefore excellence in copywriting is
53
 Marketing
Strategic Advice @aestheticsgroup
equally as important as design and style.
Content should include case studies, alongside before and after
photos, and up-to- date prices. Technical and medical information
should be short and concise, with a focus on service and customer
care. Maximise any creation of content and images by using them
across all relevant activities. Content for a press release can also be
used in a blog and newsletter.
Social media
Social media is increasingly offering cost effective tools
that can raise consumer awareness and even drive
customer enquiries. Building a Facebook and Twitter
group can be a powerful tool to interact with your customer base. A
business can engage with people online, with whom ordinarily they
could not have access to.
Bear in mind that social media can be time consuming; especially if
you are creating original and informative content. To maximise cost
benefits, you should try to use this content across all your marketing
platforms, and vice versa. In particular, your PR campaigns should
provide engaging material for your social conversations.
Ensuring that your content reflects the message you want to promote,
correlates with your brand, and is current and engaging, is important.
Outsourcing the social media activity alongside PR or advertising is
therefore becoming commonplace. A more cost effective exercise,
however, might be to send an administrative member of staff on a
short social media course, and then ask any outsourced agencies to
contribute extra content from activities they are already undertaking,
preferably without extra charge. Free treatments and competition
prizes or half price offers are a few atypical ideas, but can work to
engage potential customers, increasing their motivation to interact with
your clinic. Furthermore, extracting client data can be likened to finding
pots of gold, and if your audience feel they are getting something
they want for free this can often provide the motivation for them to
positively engage with your promotion.
Database management: newsletters, texts
and email campaigns
Once you have built a client database, you can
communicate with them through newsletters and
texts etc. Information can include promotions and offers, and this
activity can be relatively inexpensive. Weekly or monthly newsletters
are a great way to showcase new treatments, products and services,
as well as being another way to engage with your customers on
trends and case studies. Events to promote new treatments will also
utilise your database. Quarterly or seasonal invites to clients for clinic
events can be a very cost-effective way of marketing and interacting
with new and loyal customers. Wherever possible include a call to
action that links to your website.
Networking
Networking with health and beauty professionals
outside of your business can be effective to gain
mutual clients. If you have colleagues that offer
complementary services such as holistic practices, dentistry etc.,
sharing client promotions can offer greater scope for growth and
reach of audience. Smaller towns can especially benefit through
not competing but joining forces.
In addition, local businesses can provide a low-cost route for new
business. Local offices and shops near your premises can be
targeted through flyers, leaflets, email campaigns and social media.
54 Aesthetics | January 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
When you find a
marketing activity that
works, then stick with it
Outsourcing PR
PR is a marketing activity that can cost a lot of money,
without delivering any return, and can have a bad
reputation in terms of ROI. When it is done correctly,
however, the results can be fantastic – delivering huge uplifts in sales
and new enquiries. In my experience, the relationship, co-ordination
and actions of the aesthetics business has as much to do with any
successful outcome as the skills of the agency. Clients on small
retainers can produce high-value and high-impact press coverage
when they work well with their agency. Similarly, clients on huge
retainers can drive poor outcomes. So, how do you get the most
value from your PR agency? A good working relationship goes a
long way. In my experience, team members work hard for clients that
apply pressure, but not so much that the work is no longer enjoyable.
Providing case studies, exclusive angles on products and treatments,
alongside charismatic and credible spokespeople with expertise,
will help your PR campaign deliver a return. Undertaking some of the
work will also benefit a small PR budget; particularly when it comes
to ideas generation.
Advertising can work for the tough
negotiator
Advertising is not always a viable long-term option
for the small marketing budget. However, local
magazines can be inexpensive and can work for some clinics,
dependent on location and the quality of readership. Negotiating
editorial alongside any paid - for promotions can be a worthwhile
effort – as is a test campaign. Again, a call to action should always be
included in the copy.
If it’s not broken don’t fix it
When you find a marketing activity that works, then
stick with it. A common mistake can come from
changing working practises for the sake of trying to
find improvements or just for a change. Realistic expectations and
targets are important to ensure a programme is not thrown out in
pursuit of the impossible.
New Year’s resolution
The year ahead is exciting. According to the review
of the regulation of cosmetic interventions in 2013 by
the Department of Health1, the value of UK cosmetic
procedures was set to rise to £3.6 billion in 2015, with non-surgical
procedures accounting for 75% of the market value. Take the time to
plan now. Any investment of time will pay dividends later.
Michelle Boxall is the managing director of Image Box
PR, one of the UK’s leading marketing communications
agencies, specialising in aesthetic PR. Michelle holds a
bachelor degree in public relations and has more than
19 years communications experience working across
health, beauty and aesthetics.
REFERENCES:
1. Gov.uk, Independent Report: Review of the Regulation of Cosmetic Interventions (www.gov.uk, 2013)
< https://www.gov.uk/government/publications/review-of-the-regulation-of-cosmetic-interventions>
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 Business Building
Commercial Knowledge @aestheticsgroup
Building a
better aesthetic
business
Dr Hugo Kitchen shares his vision
for business success in the field of
aesthetics today
The value of the UK cosmetic procedures market is growing. It
was worth £2.3bn in 2010 and is estimated that it will grow to
£3.6 billion by 2015.1
If the effects of the economic downturn are still being felt in
some industries, the cosmetic and aesthetic sector has never
looked healthier. As we climb out of recession, the percentage of
disposable income which is being freed up for self-enhancement
is making the outlook rosier than we could have predicted even
a year ago. This, coupled with the launch of some new and
innovative treatments over the last couple of years which have
given practitioners a plethora of new ways to treat their patients,
means that practice owners such as myself have many good
reasons to feel positive about the future.
Of course, running a dermatherapy practice does not come without
its challenges – as my brother and colleague James Kitchen, my
wife Carron and I have experienced over the years. No successful
venture in the sector is alike but I am convinced that the most
successful practice owners share a similar business mindset, and
that the key business drivers are invariably the same.
First of all, the business model that you are adopting today –
however sound it may be – may not be applicable in a few years’
time, and it is therefore essential that anyone entering this sector
remains open-minded about embracing changes. Whilst your
clinical skills may make you feel very confident, and your patients’
praises may stroke your ego and reassure you that you are doing
Take time to listen to
what patients have to
say, as this is a fantastic
way of keeping abreast
of new procedures
56 Aesthetics | January 2015
Aesthetics Journal Aesthetics aestheticsjournal.com
everything right, this unfortunately does not mean you have what it
takes to build a successful business.
Competition is fierce and there is an abundance of procedures
on offer from a multitude of providers. Patients are increasingly
knowledgeable about the latest in cosmetic surgery and aesthetic
treatments , and they will make a point of researching them from
any available source and comparing procedures. You can’t out-
spend the big players, but you can out-think them by knowing your
local market and harnessing local knowledge to gain the edge.
Take time to listen to what patients have to say, as this is a fantastic
way of keeping abreast of new procedures which are no doubt
being heavily promoted to them. Make sure you do your research
too as patients will expect you to be fully conversant with these
to help them make the best choices. This means you need to
remain abreast of all the latest treatment developments, so when
asked you can talk about them knowledgeably, even if you don’t
offer them. It’s then possible to talk convincingly about why the
procedures you do offer are the most applicable to their needs.
What’s more, patients are not just looking for the best results
anymore. They want the whole journey to be flawless, with minimal
pain and effort. Patients expect an outstanding level of care from
the moment they come through the door and throughout the
treatment. They are entrusting you with what matters to them the
most and are prepared to pay big money, which warrants a golden
service every single time.
What I have observed over the years is that the skills of one
clinician alone is not sufficient to keep the business buoyant. It is
about the clinical and interpersonal skills of every member of the
team. It is about how unique the whole patient experience has
been. Empowering your staff, working as a team and promoting
regular feedback and an open dialogue will go a long way.
Relationship building – with patients and with your team – is
another key factor to your success.
Cosmetic surgery and aesthetic treatments are no longer seen as
the preserve of rich celebrities; patients from all walks of life want
to feel as special as the stars. The ‘popularisation’ of cosmetic
procedures is actually giving practice owners an ever increasing
number of consultation opportunities, so the main challenge is to
maintain very high safety and quality standards whilst striving to be
innovative and forward thinking, keeping your finger on the pulse
whilst not falling for all the fashions.
One important pitfall to avoid is to become complacent with how
your clinic is set up; assuming that it cannot be improved and
that your patients are 100% satisfied. With endless technological
and clinical advances, practice owners cannot afford to settle
into a happy equilibrium. At the Stratford Dermatherapy Clinic, we
have embraced new treatments when these made sense for the
business – for the short and long term. Beware of taking on any
new treatments merely because they are proving popular, trendy or
rumoured to be lucrative.
We recently introduced four contemporary innovations – Pellevé,
PelleFirm, Vaser Lipo and Bodyjet – into our business model. We
invested in these treatments because the companies behind them
demonstrated a strong commitment to support us and our patients,
because their strong clinical evidence is irrefutable, their safety
and quality standards are very high and our patients have reported
tangible visible results within a short timescale. These have proved
brilliant adjuncts to the business, ensuring we stay ahead of the
curve. It is crucial to assess all these factors before choosing to
invest in any new technology or treatment.

Tips for product or treatment selection
The aesthetics sector is evolving at a fast pace and patients
always want you to anticipate their needs and excite them with
the latest new treatments and products. To identify new and
clinically-sound treatments or products to complement those
you currently offer, here are fourteen key criteria to look for
when making your final decision:
1. Unique selling points with benefits which are easy for the
patient to understand (this frees up expensive chair time
explaining the treatment, and costs less to promote).
2. The non-invasive nature of a procedure can be preferable
as it taps into the current zeitgeist for minimal intervention.
3. Favourable reviews with no bad press reports – nationally
and internationally.
4. Take into the account the views of reputable clinicians
who have already performed the procedure and who have
given their views on potential obstacles and risks.
5. Training must be efficient and carried out within a
reasonable time frame, or if a longer training period is
required then it must considerably enhance a clinican or
staff’s skill set.
6. Assessment of profitability (length of procedure, chair
time required, price of equipment, seniority of staff
required during treatment).
7. Expenditure for consumables needs to be limited or easy
to factor into the treatment cost.
8. Patient compliance should ideally be easy (pain-free, no
or minimal side effects, no or minimal preparation, minimal
downtime with fast return to normal life).
9. Initial results need to show immediately or in a relatively
short space of time to help with word of mouth
recommendation – a fast and impressive outcome also
motivates patients to trust you with other issues they may
have, resulting in more treatments being carried out.
10. A win-win outcome, working with a reputable brand which
delivers the promised results and has been backed by
clinical research and/or successful number of cases.
11. Marketing support from product and treatment companies
12. A quick return on investment is always a benefit and is
important to factor in.
I feel privileged to be awarded complete trust by my patients and
it is my duty of care to provide them with the best advice and best
treatment options. The rapport I have built over the years has
helped elevate my reputation and turn my practice into a healthy
profitable business. 90% of my patients have had two or more
treatments and 95% of my entire client base has confirmed their full
satisfaction. This is what makes good business sense.
Dr Hugo J Kitchen is a cosmetic physician with
26 years’ experience. He is a member of several
organisations including the British College of Aesthetic
Medicine and the American Institute of Aesthetic
Medicine. Dr Kitchen is the clinical director of Stratford
Dermatherapy Clinic and specialises in facial aesthetics and body
sculpting.
REFERENCES
1. Parliamentary Office of Science and Technology, Cosmetic Procedures (UK: Houses of Parliament,
2013) <www.parliament.uk/briefing-papers/POST-PN-444.pdf> [Accessed 5th December 2014] p. 1
Aesthetics | January 2015
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@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Many practitioners looking to purchase medical lasers are often
confronted with the issue of deciding whether or not to buy
directly from the manufacturer or possibly consider purchasing
a used system from a broker.
This can be a daunting task for some, and I’ve spoken to many
laser consumers over the years who have struggled with this
decision. It is a little like trying to decide whether to buy a new or
used car, however, most people are a bit more familiar with cars
than they are lasers. Some buyers are obviously more comfortable
purchasing a new laser for the peace of mind and perks that come
with buying new and don’t mind paying a premium. Others are
hoping to spend the least amount of money possible and just want
to find a great deal. Each option has several issues to consider.
My aim is to make you a better-educated consumer and help you
feel more comfortable when choosing a laser, whilst limiting the
sometime unpleasant surprises that can arise. This is by no means
a comprehensive guide, but should give you a good idea of some
important things to consider.
Advantages of buying a new laser
When buying new, you will get the latest and greatest version of
whatever’s on the market. That can be very important, especially
in an industry as dynamic as aesthetic laser treatments. Patients
and consumers are often looking for breakthrough treatments so
it can make a big difference if, in your clinic, you have the newest
technology and most innovative treatments on the market. The
other big advantage of buying from the manufacturer or the
official distributor is getting up-to-date training, marketing support,
and general ongoing support from the company and sales
representative.
In regards to training, some lasers are more operator-dependent
than others and the trainer supplied by the manufacturer or
distributor should be more knowledgeable than anyone else.
Certain cosmetic laser treatments are very much about the art of
the treatment, as well as the science, so the practitioner needs to
be trained well enough to be confident and somewhat artistic in
their approach to getting the best results for patients. Each patient
is different, so the practitioner needs to adapt their laser treatment
accordingly.
Aesthetics | January 2015
Product Selection
Buying a Laser
Aesthetic lasers:
should you buy
new or used?
Laser sales consultant Don Berryhill
shares his advice on purchasing a
reliable laser for your clinic
If you like to be an early adopter of new technology, the laser
company should be willing to give you extra support in order to
make sure you’re successful. For them, it’s important you give
good recommendations of their laser to other potential buyers.
I would advise having a number of face-to-face meetings with
the sales representative to establish exactly what the company is
willing to do to support you. Many options are negotiable before
you make a purchase and you should remember; you’re the one in
the driver’s seat. The price of a laser is likely to drop in a relatively
short period of time so you should insist on getting the most for
your money if you’re investing in a company’s newest technology.
Disadvantages of buying new
Cost: Buying a new laser is similar to buying a new car; as soon as
you drive it out of the showroom, its value depreciates significantly.
Even though high quality lasers are usually in the £30,000 range
and up, they’re still not as expensive overall as they were 10-15
years ago and the quality is much better now. Having worked
directly for a laser manufacturer and distributor for several years,
I’ve come to understand and appreciate the costs that go into
making a laser available for sale and the support needed after
the sale. It’s a pricey operation to take a laser from the drawing
board to the consumer. If the laser being bought is one that’s been
around for a while, the pricing should be lower or more negotiable.
If you’re considering purchasing a brand new model, sometimes it’s
better to wait for the second version. There is then usually enough
feedback for the manufacturers to see what needs to be changed
and there’s also a good chance it will be less expensive. If you buy
a company’s first laser model, you may want to try and negotiate
some upgrade options over the first year. The company may not be
willing to give it to you at no charge but you might be able to lock in
a better price whenever a better version becomes available.
Obsolescence: Laser technology has consistently marched forward,
with improvements made on a fairly regular basis. It’s somewhat
like buying a computer. Within a couple of years many companies
will come out with a modified or improved version of whatever it is
you bought. Occasionally, it doesn’t even take that long because
sometimes companies will push to clear out their initial inventory
as there may already be another version in the works that they are
59
 Product Selection
Buying a Laser
preparing to launch. Even if a laser is
considered obsolete, it doesn’t mean it
has to be immediately carted off to the
dustbin (unless you can no longer get
parts for it). If the laser is still performing
well and both the practitioners and
patients are still happy, keep on
zapping. The differences between
many of the older lasers and the newer
ones are usually speed, software,
system size, hand piece options, or
additional wavelengths. Hence the old
lasers can still be effective for years
to come, maybe just not as fast or as
comfortable to use as newer versions.
Advantages of buying a used laser
Saving money: New lasers are
expensive so if you can find the
right deal, you could end up saving
a bundle. If you already have a laser
that you are comfortable with using
and are just looking to add another
one to your clinic, the used market
may be the place to go. You will
need, however, to make sure it can
be serviced by a third party if you
don’t want to pay the extra fees
most manufacturers now charge.
Sometimes an older model may be
better to consider because it’s likely
to be a more basic system, making it
easier to work on and get parts for.
Also, there are typically more of them
on the market and you can usually get
a more reasonable price.
Disadvantages of buying used
Buying a used laser can either be a
really good, or a really bad thing. I’ve
seen it go both ways. Two big issues
to consider when buying used are:
Can you get the laser completely
serviced? Is what you assume you’re
buying, exactly what’s going to be
delivered? Ask a lot of questions,
get references, records of service,
a checklist of any work that’s been
done, and verify what you’re being
told is true. There can be hidden
pitfalls and unanticipated costs when
buying used compared to buying
new. Potentially the worst surprise
someone buying a used laser may
encounter is having to go back to the
manufacturer for repairs and being hit
with recertification fees that could cost
anywhere from £1,000-£16,000.
Unfortunately there are a few bad
apples wherever you go. Some
60
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Compliance with laser safety standards
Laser protection advisor, and director of Bioptica Laser Aesthetics, Mike Regan explains
that there are particular standards that lasers must adhere to in order to be classed as safe.
He says, “Recent years have seen a significant amount of work being done by the various
international and European bodies responsible for the definition of laser product safety
standards. The main International Electrotechnical Commission (IEC) standard for medical
and aesthetic laser products is IEC 60601-2-22.” Regan also explains that, with regard to
laser safety eyewear in Europe, the standardisation body is CEN (European Committee for
Standardisation) and the relevant standard required is EN 207.
Laser consultant and technical officer at Lasermet, Peter Fishwick, details what these
standards mean for practitioners looking to buy a laser.
All laser products that are introduced for sale in the UK must comply with various
standards. The current laser standard is BS/EN 60825-1:2014 ‘Part 1: Equipment classification
and requirements’. Medical laser products must comply with the additional requirements
in BS/EN 60601-2-22:2013 ‘Medical electrical equipment: Particular requirements for basic
safety and essential performance of surgical, cosmetic, therapeutic and diagnostic laser
equipment.’
These standards are functionally identical to the international standards produced by the
International Electrotechnical Commission (IEC) of the same number. This means that products
that comply with the international standard will also comply with standards in the UK. As
the United States is not a signatory of the IEC, devices made in the US do not necessarily
comply with BS/EN 60825-1 and 60601-22. In theory, the standards are enforced by various
enforcement bodies such as Trading Standards to detect non-conformances and intervene
where necessary. However, as manufacturers are able to self-certify it is very difficult for
Trading Standards to find non-compliance in products that are coming in from overseas unless
a product is reported to them by a consumer. When buying a laser these are the type of things
you should be looking out for:
What class is it? All laser products are classified from Class 1 to Class 4, where Class 1 is safe
under normal operating conditions and Class 4 is potentially hazardous to both direct viewing
and diffuse (scattered reflection). Class 4 is the most hazardous class and a large number of
medical lasers fall into this category. Lasers in Class 1C, 3B and 4 will require additional training
and safety infrastructure (LPS, LPA etc.)
Is it correctly labelled? All lasers should have labelling or user information that details the
output of the laser. This should include the wavelength and power as well as any pulse
information (if required). Along with the class of the laser this information should be available to
you before you buy the laser.
Does it have the required safety features? For example, for a class 3B or 4 medical laser
these include: interlock connectors, emission indicators, and requirements for any foot-
operated switch. There are also requirements for a remote interlock connector and key control.
Viewing optics must have an emission below the Class 1 Limits, and there must be a Laser
Ready indicator to tell you when the device is powered up, as well as an emission indicator to
tell you when the device is emitting.
The laser must have a target-indicating device and, if this is another laser, it must be less than
Class 3R (Class 2 for Eyes). Also required are “Stand by/ready” controls, an emergency-stop
facility, and a means of identifying emission levels. Approved laser safety enclosures are
required to prevent unintentional exposure.
Eyewear for laser protection should meet EN 207 and the wavelength and power density of
the laser will determine the type of eyewear required. Consequently, different lasers require
different eyewear and advice should be sought from a laser safety specialist.
Certain products will require more training and an increased safety structure. Advice from an
LPA, LPS or LSO should be sought when buying a Class 1C, 3B or 4 Laser. This will ensure you
are compliant with the Control of Artificial Optical Radiation at Work regulations.
If you need to know if a product you own, or are looking to buy, meets these standards you
should contact Trading Standards or a UKAS approved test house that specialises in IEC
60825-1 and 60601-2-22. Many products are certified through test houses such as UL, ITS,
SGS and BV, and these test houses will make sure that any product that bears their ‘mark’
will meet the required standards. Independent test houses such as Lasermet will provide
information to both consumers and manufacturers alike.
Aesthetics | January 2015
 Product Selection
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Buying a Laser

may pay a bit more for this service but it could be worth it. Their
Ask a lot of questions, inventory may be limited but it is possible that they can still find
you a suitable product, which can be serviced prior to sale –

get references, records something you should insist upon. Some may claim they have
the resources to fix any problem you might have with a laser,
when in reality they can’t. Ask detailed questions about how any
of service, a checklist service issues will be addressed. Will service just be a phone call
from a technician trying to walk you through a fix? If you’re not
of any work that’s been comfortable working on equipment, it would be wise to figure this
out up front.

done, and verify what Financing

you’re being told is true
brokers selling used lasers have virtual inventories and work by
getting a deposit from you and then searching for a laser that is
similar to what was originally advertised. Sometimes what shows
up is substantially different from what you thought you ordered; be
cautious and ask the right questions. I’ve known of a few instances
where no product is delivered and the broker has avoided all
phone calls and kept the consumer’s deposit. As a consumer, you
should know exactly who you are dealing with and make sure you
have more than one way to contact the seller if need be.
Some brokers stock their inventory and have their own service
specialists inspect and repair the lasers before selling them. You
Obtaining finance can be difficult so it’s a good idea to get
approved for a loan before you begin your laser search. I’ve
seen many practitioners who decide what they want, then get
the unpleasant surprise of not being able to get funding when
they are ready to buy. Another good reason to get your financing
approved upfront is that it will put you in a better negotiating
position if you’re buying new. If you’re buying used, that killer deal
on a laser you just found could go quickly, so you’ll want to be
able to make the purchase straight away.
Don Berryhill is the founder of Lasercoach, a
consultancy agency specifically aimed at cosmetic
and medical practitioners. He aims to be an unbiased
information source, to help practitioners and business
owners become better educated consumers, and choose
lasers and related equipment that best fit their practice needs.

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 In Profile
Dr Tina Alster @aestheticsgroup Aesthetics Journal
“There is no elevator to
success, you have to
take the stairs”
Washington DC’s Dr Tina Alster is a true Renaissance
woman in the field of laser dermatology. After two
decades in private practice, she continues to break
new ground. Wendy Lewis speaks to her about her
journey into aesthetics
A pioneer in laser dermatology, Dr Tina Alster broke through the glass ceiling
early on to claim her place in a field largely dominated by male engineers and
scientists. Her leadership and innovation in cosmetic laser surgery has afforded
her a global reputation. Dr Alster founded the Washington Institute of Dermatologic
Laser Surgery in 1990, as the first private practice in the world exclusively dedicated
to the development and delivery of advanced laser skin treatments. Dr Elizabeth
Tanzi became co-director in 2001, and the Institute has since grown to include Drs
Terrence Keaney, Tania Peters, and Rebecca Kazin. A large part of the practice is
also devoted to clinical research. Dr Alster’s career spans two decades of honours.
She has been listed in America’s Best Doctors, Town & Country’s Best Cosmetic
Surgeons, America’s Elite 1000, Washingtonian’s Best Doctors, Marquis Who’s Who in
Medicine and Healthcare, Who’s Who of American Women, amongst others. She was
selected as Allure’s Influencer of the Year and received the Women’s Dermatologic
Society Legacy Award. She has served as a consultant to Lancôme, Clarisonic, La
Mer, and continues to influence new product development and industry direction.
Alongside her professional accomplishments, Dr Alster has managed to live a life of
balance. She and her husband, Paul Frazer, a Canadian political-affairs consultant
and former Canadian ambassador to the Czech and Slovak Republics, have
one son who recently started university. Dr Alster’s modern facility on K Street is
frequented by many, and in 2013 she created W for Men, along with Dr. Keaney, as
the world’s first clinical practice dedicated exclusively to laser and skin treatments
for men. W for Men features a private entrance and services catering specifically to
male clients. According to Dr Alster, coming next is a new location in the suburban
area of Chevy Chase, Maryland, opening in early 2015. But what first sparked Dr
Alster’s interest in lasers and light? “I was always a bit of a science nerd,” she says.
“Physics and chemistry were two of my favorite subjects, so it was natural that I
was attracted to lasers and light.” However, while she was a dermatology resident,
Dr Alster had a memorable patient interaction which propelled her into the field.
“She was a 44-year-old who had a dark facial port-wine stain. She had never
displayed her birthmark to her husband or teenage son and would only remove
a small portion of her camouflage makeup for me to assess her condition. Upon
her urging, I investigated further an article I had recalled reading about a new laser
62 Aesthetics | January 2015
Aesthetics aestheticsjournal.com
procedure that targeted blood vessels (which are in
numerous supply in port-wine stain birthmarks). The
more I researched the subject, the more interested
I became. I got so interested that I applied for a
specialised laser surgery fellowship in Boston in
lieu of my final year of dermatology training at Yale
University. I was so fortunate that I was introduced
to this burgeoning field of medicine at such an
early time in my career. The patient’s persistence
paid off for both of us – I found my calling and she
ended up having her vascular birthmark removed.”
A close-knit team is crucial to the success of the
Washington Institute of Dermatologic Laser Surgery.
Dr Alster’s current key employees have been at the
clinic for at least ten years, some of them for as long
as 22 years. “Each of them is smart, hard working,
considerate, and trustworthy,” says Dr Alster. “After
an initial screening by my chief medical administrator,
Georgina Eva, who has been my longest-standing
employee, each applicant is interviewed personally
by me. In addition to confirming his or her proper
education and training for the job at hand, I make
sure the applicant is a good “fit” for the team. While
there are a number of objective measures that can be
used, I often go with my ‘gut’. A pleasant personality
and a degree of humility are just as important as an
extensive knowledge base. I have chosen great team
players who make the work atmosphere pleasant
for me and for my patients.” Dr Alster founded and
created her own SKIN IS IN skincare range in 2011.
“SKIN IS IN was conceived with the realisation that
most people are confused with the wide array of skin
care products on the market,” she explains. “After
decades of cherry-picking skincare products for me
and my patients, I wanted to take the confusion out
of skincare. Knowing that good basic skincare is
the foundation for healthy looking skin, I developed
separate daily skincare kits for children, teens, men
and women that each contain a cleanser, a daytime
antioxidant moisturiser with SPF, and a night time
peptide rejuvenating cream.” Having assembled
her strong team, Dr Alster is proud of creating a
practice that is regarded as world-class, delivering
technically advanced treatments and technologies
to patients. Dr Alster also combines clinical practice
with research, teaching and mentoring, receiving
many professional accolades, including the Women’s
Dermatologic Society mentorship and legacy awards.
“I believe in paying it forward’,” she says, “and have
established undergraduate and graduate scholarship
endowments for women pursuing careers in
medicine at my alma mater, Duke University.”
Wendy Lewis is president of Wendy
Lewis & Co Ltd, Global Aesthetics
Consultancy, the author of 11 books
on anti-ageing and cosmetic
surgery, and founder/editor in chief
of Beautyinthebag.com. She is an international
presenter and lecturer and has written over
500 articles for medical journals and consumer
publications.
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RAD120/0914/LD
Date of preparation: September 2014
 The Last Word
Record Keeping
The last word
Dr Askari Townshend argues the importance
of a skilful and thorough approach to
handling inevitable legal complaints
In the last decade of performing aesthetic
treatments, I have had two patients take
legal action against me. As I believe I have
treated over 15,000 in this time, I don’t think
I’m doing too badly. If you treat enough
patients, regardless of how good you are,
the nature of the aesthetics industry means
that you will probably receive a letter from
a solicitor at some point in your career. If
you don’t, either you haven’t done enough
treatments, or you’ve been extremely lucky.
The fear of receiving one of these letters
affects our practice, whether we admit it or
not. A clear example of this is the detailed
paperwork we often use when delivering
a simple, safe and relatively comfortable
procedure such as botulinum toxin. This kind
of procedure often has a consent form far
longer and more detailed than those I used
to use in the NHS for painful operations that
resulted in permanent scarring, risked serious
complication or even death.
Although many of us call them patients (I now
do this less and less), most of our aesthetic
clients (implying a more intimate relationship
than a ‘customer’ making a quick and simple
transaction) are in good health. They are not
seeking treatment for a medical complaint,
but are making a decision as a consumer to
access a paid-for service. In the NHS (which
many of us trained and worked in, and still
do) patients often do not have that choice
– they are seeking medical assistance,
which is free at the point of delivery. If they
endure pain and suffering during this time, it
is often accepted as a price worth paying in
exchange for cure or improvement of their
medical health. When seeking private, paid-
for treatment that is often to simply improve
appearance, the pain and suffering they are
prepared to accept decreases dramatically.
64
@aestheticsgroup Aesthetics Journal
Most complaints are received by the
practitioner or clinic in the first instance
where, once again, the fear of the solicitor’s
letter affects behaviour. In most cases,
detailed and informed consent has been
gained and a careful treatment performed.
If a problem occurs, clients may decide that
although they accepted the risk, they have
changed their mind and want a refund.
The potential damage to our reputations,
headache of possible legal action and the
loss of a client lead many to issue this refund.
If you do, I would recommend being wary
of setting a precedent and indemnifying
the client, in addition to paying for medical
liability insurance. The refund could also be
interpreted as an admission of fault when we
know that complications will always occur,
regardless of care and skill. In reality, the
refund is unlikely to protect reputation in any
way – I suspect that these clients will share
their experience regardless.
In my own practice, I rarely give refunds
in these situations. I do all in my power to
prevent and treat the complication, and to
provide the client with all the support (and
more) that should be expected of a diligent
and caring medical professional – this is
part of the service we should all offer and
feel a professional and moral obligation
to provide. In addition, dealing with and
resolving a complaint in a compassionate and
empathetic manner is something we should
all do for our clients. This is crucial in bringing
the matter to an amicable conclusion. Do this
poorly and do not be surprised to receive that
letter containing a legal complaint, which may
well come months (or even years) after you
have forgotten about it. Indeed, it is possible
to receive this letter even when you thought
an amicable conclusion had been achieved.
Aesthetics | January 2015
Aesthetics aestheticsjournal.com
When complications or complaints arise, it is
vital to carefully document the entire process,
including all communications (such as calling
and leaving a message if there is no answer)
both in writing and by taking photographic
evidence of the problem. If the client then
wishes to pursue a legal path, you should
have all that you need to defend yourself. In
my experience, patients rarely keep good
records of their experience, though with the
popularity of camera phones they will often
have graphic evidence of any injury.
When receiving a complaint or legal letter,
our human response is to feel hurt, attacked
and then defensive. This is to be expected
when you have done your very best to
help someone who then pursues you for
recompense. However, it is important to
keep things in perspective: do not confuse
the law and legal system with justice and
truth – these things can often be quite
different! In any event, it is extremely unlikely
that the case is going to be thrashed out in
front of a judge in a courtroom – out of court
settlements avoid even bigger legal fees that
can sometimes overshadow the payment to
the claimant.
If a client has suffered unduly or unexpectedly
after a treatment (regardless of how carefully
or skilfully it was performed) they may
well be entitled to compensation, and for
this we shouldn’t begrudge them. Stating
complications clearly on a signed consent
form doesn’t mean that you are able to avoid
all future legal recourse. These situations are
why you pay for medical liability insurance –
just ensure that you have all of the information
needed to enable your team to represent you
to the best of their ability.
You may be the best, most thoughtful
practitioner, and yet still receive that solicitor’s
letter. This in no way reflects on your skill or
practice. It is vital to bear this in mind if you
do find yourself in the position that I was
in, reading the dreaded letter. Thorough
documentation and providing your client with
the careful care and support required will
mean that this kind of incident is dealt with
correctly and efficiently, ensuring the best
outcome for both parties.
Dr Askari Townshend
With over 10 years injectable
experience, Dr Askari
Townshend’s interests also
include lasers and peels. Until
2013, as Director of Medical Services at
sk:n, Dr Townshend was responsible for
overseeing medical complaints. He is now
lead trainer and medical consultant for
Sculptra UK and is currently teaching on an
MSc Facial Aesthetics Course.
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66 Aesthetics | January 2015

 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,
INDICATION
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.
1180/BOC/OCT/2014/LD Date of preparation: October 2014
PURIFIED1• SATISFYING2,3,4 • CONVENIENT5
Botulinum toxin type A
free from complexing proteins
 Experience all the benefits of VYCROSS™ technology.
Treat various areas of the face using only 3 products.
It’s that versatile.

Instructions and directions for use are available on request.

Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK
Date of Preparation: August 2014 UK/0880/2014