I facial aesthetics _ Practice development

Developing a Facial Aesthetic Practice Author_ Paul Mendlesohn

new clients through the door. Demand is growing so quickly that some practice owners have already taken things one-step further and opened a dedicated skin-health spa. CODE AFA recommends that you start with nonpermanent skin rejuvenation techniques. For example, botulinum toxin lasts for three to fourmonths, dermal fillers last for six to nine months and Sculptra lasts for up to 18 months. Easy TCA peels are also a good starting point as the risk profile is low. Most of the serious problems arising from skin treatments are due to the use of permanent or long-term fillers, lasers and deep chemical peels. With experience though, you can expand your range of treatments. _Achievable beauty

_Non-surgical skin treatments with botulinum toxin type such as Botox®, dermal fillers such as Restylane® and chemical peels continue to grow in popularity and attract discretionary spend. Dentists, with their technical expertise, customer care skills and extensive knowledge of the head and neck, are in an ideal position to provide these treatments. Patients, who benefit from cosmetic dentistry, are likely to be interested in facial aesthetic treatments to complement their new smile, and similarly, clients who visit the practice for skin treatment are likely to opt for tooth whitening and cosmetic dentistry. The safe, professional environment of a dental practice provides the perfect setting for facial aesthetics, which generates additional income and brings

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According to patients, being beautiful is about making the most of yourself and looking your best, not about being glamorous or radically altering your appearance. From this perspective, patients’ expectations are not unattainable and the emphasis falls on the practitioner’s skill. In patient surveys, looking beautiful was characterised by: _Smooth clear skin _Fewer wrinkles _Fewer lines _Looking and feeling younger than your actual age Beauty therapy was seen as improving on the features that you already have by: _Regaining vibrancy _Undoing the effects of ageing _Maintaining a natural-looking appearance _Where to start?

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I facial aesthetics _ Practice development Hands-on courses in botulinum toxin and dermal fillers are the two most popular techniques, which compliment each other. Practitioners new to the field of facial rejuvenation are most comfortable using botulinum toxin on the upper third of the face and dermal fillers on the lower two thirds.

ers are also used for facial contouring; for example, cheek and chin dimples can be produced. Advanced practitioners may use fillers sub-dermally. Several types of filler are available:

On satisfactory completion of the hands-on courses you can obtain professional indemnity and begin to offer the treatments. While some wellknown dental indemnifiers will cover you, Hamilton Fraser can provide cover for individuals or a policy for the whole practice. Visit HamiltonFraser.co.uk for further information.

The original fillers were made from collagen, a substance that is found in skin and which gives it natural elasticity. Collagen decreases with age and sun exposure, which is one of the key factors of skin ageing. Patients must be allergy tested before collagen is used.

_Botulinum toxin Botulinum toxin is administered by injecting into specific facial muscles where it blocks the nerve transmission to selectively paralyse the muscle. There are three commonly used preparations for wrinkle treatments, Botox®, Azzalure® and Vistabel®. In the UK, Vistabel has a license for use in the glabellar region and other uses of Botox, Vistabel and Azzalure for wrinkle treatments are common practice, but are off-label. Botulinum toxin is effective in improving lines or wrinkles due to facial expressions. For example worry lines or frown lines on the forehead and between the eyebrows. In most cases the treatment will take between 10 and 20 minutes. Insulin syringes are used to inject the product and only small amounts are used. As a result any discomfort is usually minimal and short-lived. It takes seven to 10 days for the muscle paralysis to manifest. Two weeks after the first treatment, the effects are reviewed by the practitioner at which time any further treatments are discussed or a top-up is provided. Unlike some surgical facelifts, this kind of treatment is very specific and works only on those muscles that are involved in producing the facial lines. Other muscles are unaffected which means that the usual facial expressions will be unchanged. Initially the effects of botulinum toxin last from three to four months after which time the nerve supplying the facial muscle sends out new sprouts and regenerates. With repeated treatments the effects can last a month or two longer. _Dermal fillers Dermal fillers are injected into the dermis to soften and smooth facial lines and wrinkles. Fillers are commonly used around the mouth, eyes, nose and forehead and can enhance the lips giving them greater volume and a fuller appearance. Some fill-

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_Collagen containing fillers

_Hyaluronic acid fillers These fillers are the most commonly used today. Hyaluronic acid (HA) is found naturally in the skin, joints and eyes. The HA in fillers is cross-linked to inhibit absorption, this gives them a longevity of six to nine months. Restylane® and Juvederm® are probably the most well known products, but new ones are coming onto the market every year. _Chemical peels Chemical peels involve applying an acid solution to remove the upper layers of the skin. New skin growth with a smoother, more evenly pigmented appearance is stimulated. The acid delivers a controlled type of superficial tissue destruction; light peels affect the epidermis and deep peels may remove the skin down to the papilliary dermis. A chemical peel can restore a more youthful appearance to wrinkled, unevenly pigmented, sundamaged, or blotchy skin. There are three basic categories of chemical peels. Each type works differently, and produces different results. Light peels: Alphahydroxy acids (AHAs), Betahydroxy acids (BHAs) Light or lunch-hour peels are the mildest of the chemical peels. These peels include glycolic, lactic, and fruit acid peels (AHA) or Salicylic Acid (BHA). They aim to remove only the outer layers of the skin to smooth out fine wrinkles and/or rough, dry skin, or to improve the texture of sun-damaged skin, balance out skin pigmentation, or diminish some types of acne scars. The application of AHA and BHA peels is relatively fast and simple. The procedure is quite comfortable and patients will experience a slight stinging when the solution is applied. The treatment usually takes about 10 to 15 minutes. AHA peels generally cause some flaking, redness and dryness, or skin irritation which diminishes over time.

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_Medium peels: Trichloroacetic acids (TCA) A TCA solution is used for medium depth peels. This is generally used to treat skin with moderate sun damage, surface wrinkles, and/or uneven tone or pigment abnormalities. There is a light medium peel called Easy TCA that is a good product for practitioners new to the field. A treatment consists of four applications, one week apart, which take approximately 15 minutes. After an ‘Easy TCA’ peel, there is no downtime and the patient can go straight back to work. There are deeper medium peels, but these, as with the deep peels below, should not be performed until the practitioner has gained the requisite experience. _Deep peels: Phenol acid Phenol acid is the strongest chemical peel solution, which is used for the deepest possible chemical peel. Phenol peels are used to treat skin with coarse wrinkles and blotchiness. They may also be effectively used to treat patients with pre-cancerous growths. _Cosmeceuticals

The term cosmecuetical means both cosmetic and pharmaceutical. It is a product which is marketed as a cosmetic, but which contains biologically active ingredients that have a pharmacological effect on the user. Examples are anti-wrinkle creams, baldness treatments, moisturisers and sunscreens. Cosmeceuticals aim to improve skin health by targeting prevention, protection, and correction. Most products are designed to prevent future damage and protect healthy skin, or to correct previous damage. It is worthwhile to stock a range of products for skin protection and rejuvenation. If you are offering chemical peels there will also be some products that the patient must use for a period before and following the peel procedure. Generally these products are expensive but they also have a good mark up and are not available over the counter.

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I facial aesthetics _ Practice development Sculptra fits into the class of volumising techniques that aim to achieve more than simply fill wrinkles. Sculptra was first tested and approved for use in facial lipoatrophy (facial fat loss) in patients with HIV. This gives a clue to its best application: in areas of fat loss beneath the surface of the skin that result in sunken cheeks, furrows and indentations. The patient will usually undergo three to four treatments spaced about one month apart. The treatment provides a new matrix or scaffold of collagen to support and restructure the face. CODE recommends that you gain experience with dermal fillers and botulinum toxin for a year and then learn to inject Sculptra, which is a totally different technique. Sanofi Aventis runs introductory courses which you must take before performing treatment. See the module on Sculptra (A 180). _Investing in equipment

_Promotion and marketing Treat your team members to complimentary procedures, they are your most visible advocates and whilst treating them you can gain valuable experience of the new techniques. Receptionists, nurses and hygienists who have undergone such treatment can then be encouraged to talk about the results with your patients, as their personal testimonials can generate a significant number of referrals. Female patients in particular are more likely to engage with female members of staff, particularly when they have noticed marked improvement following facial rejuvenation. The entire team should be well acquainted with product and treatment options and should readily suggest consultation appointments where appropriate. In addition, all staff members should be educated in basic skin care regimes such as cleansers, antioxidants and UV protection. Whilst you cannot advertise botulinum toxin, as it is a prescription-only drug, you can advertise facial aesthetic services such as skin rejuvenation and wrinkle correction treatments. There are no restrictions on advertising hyaluronic acid dermal fillers, which can be achieved through posters, educational leaflets and practice newsletters. CODEmarket.co.uk can provide patient leaflets and posters for your reception. You could also arrange an open evening for selected patients to view and discuss the new aesthetic techniques and services on offer, or inform them about skin rejuvenation during the recalls._

If your facial aesthetic practice is progressing well and patients are building up, you may decide to invest in laser, microdermabrasion or intense pulsed light equipment.

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_CODE AFA The growth of these treatments has led to a need for a professional association for practitioners who provide facial aesthetics. CODE AFA, the Association for Facial Aesthetics, acts as a reference point for practitioners and patients regarding the best practice in facial aesthetics, and develops standards for dentists who are offering these and other cutting-edge treatments. It also runs seminars and training sessions to enable dentists, doctors and nurses to gain the most up-to-date skills. To find out more about the Association for Facial Aesthetics, visit the website at the-FACE.co.uk _FACEplan CODEplan has teamed up with CODE AFA to create a payment plan to budget for aesthetic skin treatment. Spreading the cost enables clients to take advantage of more treatments to obtain optimum results, and it encourages regular attendance. With FACEplan your patient is entitled to a package of skin rejuvenation treatments, it is similar to a dental plan but it individually tailored to the practice. To find out more about FACEplan or membership of CODE Association for Facial Aesthetics please email info@ the-face.co.uk, call 01409 254 354 or visit the-FACE.co.uk. Follow CODE at Twitter.com/PaulCODE

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