AESTHETICS. Fillers A substance which is injected into the skin to restore volume and smooth out facial wrinkles.

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1 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 307 AESTHETICS MARKET REPORT AESTHETICS ECM s first aesthetics report will provide an overview and analysis of the aesthetics markets across Europe, spanning the usual Big 5 countries of France, Germany, Italy, Spain and the UK, plus reports from the US and Russia. This category is only just starting to be tracked by the main market research organisations and ECM has used its own interpretation of the definitions in the aesthetics market, which are detailed below Babor Invasive procedures Procedures that require entry of the body cavity and the interruption of normal body functions. General anesthetic is required. Non-invasive procedures Procedures that do not involve a scalpel but can include injections. This includes light to medium strength chemical peels and surgical treatments that can be performed under a local anesthetic. Fillers A substance which is injected into the skin to restore volume and smooth out facial wrinkles. These can include collagen, hyaluronic acid (HA) and other substances, with the HA fillers being most popular. Dermal filler brand names include ArteFill and Radiesse among others. Botulinum toxic A protein often known by its trade name of Botox, which is produced by Allergan. Variants are available, including Galderma s Azzalure. This is used to temporarily improve the appearance of moderate to severe lines with results claimed to last for up to eight months. Facial surgery Includes procedures on the face (facelift), nose (rhinoplasty) and eyelid area (blepharoplasty). Other common procedures are cheek augmentation, brow lifts and lip enhancement surgery. Body surgery Includes procedures on the abdomen (tummy tuck), buttock enhancement (buttock implants), mammoplasty reduction (breast reduction) and breast augmentation (breast enlargement). Liposuction Operation that removes fat from several sites on the body although largely focuses on the thigh, buttock and abdomen area. Takes place under a general anesthetic. Peels A chemical peel is a technique used to improve the texture of the facial skin using a chemical solution that causes the dead skin to eventually peel off. The regenerated skin is usually smoother and less wrinkled in appearance than the old skin. Energy-based treatments Treatments based on laser, light, radio frequency and ultrasound. Mesotherapy Multiple injections of pharmaceutical and homeopathic medications, plant extracts, vitamins and other ingredients into the subcutaneous fat. Combined therapy A combination of treatments (such as mesotherapy, peels and fillers) which are said to achieve collectively better aesthetic results than when used on their own. September 2011 ECM 307

2 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 308 MARKET REPORT AESTHETICS France Fill good factor The French aesthetics market is at once dynamic and highly innovative. Valued at approximately t200m in 2010, the market has benefited from the exponential growth of the filler and botulinum toxin segments in recent years alongside increasing social acceptance of cosmetic procedures amongst the French. In 2009, the total number of surgical and nonsurgical procedures reached 297,438, (ISAPS). Surgical procedures totalled 141,831, with liposuction being the biggest surgical procedure in France, followed by breast augmentation and blepharoplasty (eyelid surgery). Breast augmentation may have been the first cosmetic surgery ever performed but growth rates in France (and the rest of Europe) are now weaker than in the US (4% in France in 2010 to a value of t16m compared to 7% in the US market). The category was hit by some bad publicity in 2010; for example the closure of French breast implant company Poly Implant Prothese (PIP) after health authorities ordered a recall of its products for using nonauthorised silicone gel. In line with the global trend, more non-surgical (155,607) than surgical procedures are now performed in France, and this seems to be due to both the improvements made in non-surgical procedures and also the preferences of today s patients. Didier Tabary, president of dermocosmetic brand Filorga comments: Surgical procedures are painful, they require an anaesthetic and they are very expensive. The excesses of the 1980s and 1990s are behind us. Today the patient wants to look more natural, but they want results. They want to look younger but without it being obvious. Benoit Chardon, head of aesthetic procedures business, France, for global dermatology manufacturers Galderma and France: Aesthetics market value, 2010 Category wm %+/- est % Botulinum toxin Fillers Energy-based treatments* 40 n/a 12 Breast implants *Treatments based on lasers, light, radio frequency and ultrasound. Source: IMCAS Industrie & Innovation Tribune 2011/ Millennium Research Group / Medical Insights France: Number of surgical procedures performed in 2009 Abdominoplasty 9,192 Blepharoplasty 20,643 Breast augmentation 21,186 Breast lift 7,127 Breast reduction (women) 9,354 Buttock augmentation 1,067 Cheek implants 705 Chin augmentation 1,819 Facelift 7,280 Forehead lift 2,993 Gynecomastia, treatment of (male 4,060 breast reduction) Hair transplantation 3,132 Lip augmentation (other than injectable 3,253 materials) Liposuction 28,272 Lower body lift 1,049 Otoplasty 4,482 Rhinoplasty 12,593 Thigh lift 993 Upper arm lift 1,438 Vaginal rejuvenation 761 Total surgical procedures 141,831 Source: ISAPS Q-Med, adds: We can achieve a high aesthetic outcome with hyaluronic acid (HA) fillers and toxin. There has been much progress in terms of product quality and injection techniques and this means we can achieve better results than before. There is a great outcome without patient discomfort. Surgical lifts are still interesting, but for less indications than before. Indeed there are a far greater number of procedures performed for botulinum toxin and HA fillers than for any of the surgical procedures. These also represent the two leading non-surgical categories by value and have achieved impressive growth rates over the past year. According to IMCAS Industrie & Innovation Tribune 2011, the filler segment (which includes both HA injectables and long-term injectables) was worth t25m in 2010, growing by an astronomical 20% compared with 2009, while botulinum toxin was valued at t17m, an increase of 6% over Chardon explains: France is a country where most of the smaller filler companies (Filorga, Teoxane, Veraderm and many more) have their head offices, therefore the market is very competitive and dynamic. The non-surgical market benefits from the increasing levels of new product development from such aesthetic companies and there is also a tendency for these companies to invest a higher level of marketing spend in their domestic country Galderma for example is helping to drive growth with its high level of marketing spend so the French market clearly benefits from this. Filorga has also started investing in marketing; its first 308 ECM September 2011

3 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 309 AESTHETICS MARKET REPORT France: Number of non-surgical procedures performed in 2009 Injectables Autologus fat* 10,969 Botulinum (Botox Dysport) 51,829 Calcium hydroxylapatite 1,489 Collagen 877 Hyaluronic acid 41,681 Poly-L-Latic acid 1,893 Polymethyl methacrylate 636 Other fillers 780 Facial rejuvenation Chemical peel 6,556 Dermabrasion 1,494 Fraxel 2,162 IPL laser treatment 9,364 Laser skin resurfacing 2,283 Microdermabrasion 1,800 Noninvasive tightening 2,668 Other Injection lipolysis 1,165 Laser hair removal 15,126 Laser treatment of leg veins 1,109 Sclerotherapy 1,726 Total non-surgical procedures 155,607 *Though some may consider this a surgical procedure, it is classified as a non-surgical procedure in this data since its indications are approximately the same as fillers Source: ISAPS advertising campaign in June with Decaux represented a sign of the success and growth of the company in France. Today on the French market we are in 1,500 doors. For us this was the target to reach before advertising our products on a large scale, explains Tabary. And the fact that France is home to two major international exhibitions INCAS Congress in Paris and the Anti-ageing World Conference in Monaco also contributes to the dynamic image of the French market, believes Chardon. comfort. Amongst Galderma s new comprehensive range of nine HA fillers, Emervel, which launched in January, are formulations with lidocaine. The range is also claimed to feature an optimal gel texture due to Galderma s Optimal Balance Technology innovation, ensuring that fillers integrate completely into the appropriate skin layer, giving way to good skin tolerance and long lasting aesthetic outcomes to treat facial lines, contouring and volume loss. The Emervel range comprises fillers for different depths and areas of wrinkles and also lip enhancement which comes in a pre-filled, ergonomically-designed syringe, supplied with ultra thin wall needles for a smoother injection and more comfortable experience. Emmanuelle Bassmann, managing director of In- Trend Ltd, a consultancy agency specialising in anti-ageing and aesthetic medicine in Europe and the US, explains that manufacturers have also been developing biorejuvenation injections over the past couple of years, injectables that focus on hydrating the skin and preventing skin ageing. Restylane Vital from Q-Med, launched in early 2008, was the first product to start the trend of low cross-linked HA to be injected more superficially for skin revitalisation. Allergan directly competed with this product with the launch of Hydrate at the Anti- Aging Medicine World Congress & MediSpa (AMWC) Coming to light New categories which focus on facial rejuvenation through energy-based devices, using LEDs or Low Level Laser Therapy (LLLT), are also becoming increasingly popular and are a source of much recent innovation. Procedures which use these more gentle light or laser technologies are growing rapidly as they have a less invasive and long-term action on skin to help prevent and slow down signs of skin ageing. According to IMCAS, the entire energy-based treatment category (spanning a larger number of therapies and procedures such as laser hair removal) was worth t40m in 2010 and the Anteis New injectable technologies have made filler procedures less painful as they use softer needles and injector pens to avoid bruising, swelling and redness Gain without pain HA fillers have become increasingly sophisticated in recent years, with product development in part focusing on making treatments less painful, with fewer side effects such as bruising, redness and swelling through the introduction of soft needles and injector pens. Early last year Swiss company Anteis launched a new injection system designed to deliver natural results with less pain and fewer side effects than syringe-based methods. The Anteis Injection System is said to provide better control over the speed of injection and the volume of gel that is deposited and results in less muscle fatigue. Suitable for all types of aesthetic treatments based on injectable gels, the company claims that the system will become the industry standard. Another step forward in fillers is the inclusion of local anaesthetic lidocaine for greater patient September 2011 ECM 309

4 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 310 MARKET REPORT AESTHETICS category is forecast to grow faster than any other to 2014 an average of 12% year on year. Bassmann says: Aesthetic medicine started out by erasing wrinkles with Botox, then it became important to replenish volume so fillers were invented. Today we are focusing on the skin surface and texture by taking a more preventative approach to slow down ageing by rejuvenating the skin. The big trend is bio-revitalisation and biostimulation of the skin tissue as a preventative treatment not just corrective treatments such as Botox or HA fillers. The new trends also point towards more gentle procedures. Tabary believes that: the major development is LED medical devices. It s the new trend, more and more aesthetic practitioners are installing these devices into their practices, and we have new clinical data showing the efficiency of light for rejuvenating purposes. This is why we decided to launch Lumitherapist. Filorga s new home-use kit, which is launching this month, is a combination of a hand-held device that contains the latest generation LED technology with 13 diodes, capable of emitting blue, yellow and red light waves and a topical LED-Booster which contains photo-active ingredients to maximise the effect of the device. According to Filorga, the combined effect helps to stimulate cellular metabolism, fibroblasts, tissue regeneration and to replenish the skin, acting on both the main signs of ageing (wrinkles, age spots and skin slackening) and skin imperfections such as dullness, redness and enlarged pores. Tabary adds: We are looking for more efficacy and immediately visible results and with these kinds of devices we can achieve quicker and better results. Lumitherapist uses the same kind of LED used in medical devices by doctors for the first time. The launch follows Filorga s at-home mesotherapy treatment, Mesotherapist, a combination of a roller, which incorporates microneedles on its rotating head to stimulate the skin and Filorga s polyrevitalising NCTF solution, to improve the quality of the skin leaving it more supple, more elastic and looking more radiant. Elsewhere, French-Swiss laboratory Biolux Medical launched a home-use LED photomodulation device last December. LUXe incorporates three types of light emitting diodes to help illuminate the skin and improve its condition, and a 99.6% natural and organic moisturising cream and exfoliating gel which are claimed to optimise the light treatments. While the French home-use market is expanding, it is not as developed as in the US or Japan; there are a good number of French manufacturers developing these products and they are not only sold by doctors, but also in mainstream beauty outlets such as Sephora. Tabary says: More and more home devices are coming to market and we believe it s a healthy trend. Consumers want efficiency and the new generation of devices can give immediate results. Manufacturers are clearly starting to see significant potential in home-use devices in France, as they continue to do in the US. Unilever has been working with Cynosure to develop light-based devices for the home market, with plans to launch its first product in Its positioning as a consumer product will be undoubtedly helped by Unilever, with its array of trusted brands including Dove, Pond s and Vaseline. Consumers want safe, effective and dependable aesthetic products that they feel comfortable using at home, says Cynosure. Cynosure has also just rolled out its latest cellulite laser device to physicians and aesthetic doctors in France. Cellulaze is claimed to be the world s first minimally invasive surgical device to reduce cellulite by restoring the normal structure of the skin and the underlying connective tissue. The workstation uses Cynosure s SideLight 3D side-firing technology to direct controlled laser thermal energy to the treatment zones. The procedure, which is performed under a local anaesthetic, is designed to diminish lumpy pockets of fat, release the areas of skin depression and increase the thickness and elasticity of the skin. Bassmann believes that treatments that focus on the body will become increasingly important in this market in the near future: Body shaping procedures are expected to experience the greatest growth by 2014 in France. We have focused on the face, now we are trying to focus on the body. Losing weight and reshaping the body is in big demand. New treatments and new machines are being introduced to reduce the waistline, thighs, buttocks and arms, and tighten the skin but also to tackle cellulite and stretchmarks. Laser hair removal has become very popular in France, particularly among young working women. According to ISAPS, 15,126 procedures were carried out in France in 2009, making it the third most popular non-surgical treatment. The latest developments have worked on improving laser efficiency. In June, Candela (Syneron-Candela) launched Gentlelaser Pro in France for the removal of permanent hair and treatment of pigmented skin. The laser is said to be fast, more cost effective and easy to operate and with its Dynamic Cooling Device is able to deliver among the highest peak power found on any hair removal laser. Marie-Laure Favoulet, country manager of Syneron-Candela comments: The aesthetic laser Filorga has invested in LED technology with its new Lumitherapist product which stimulates cellular metabolism and replenishes skin 310 ECM September 2011

5 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 311 AESTHETICS MARKET REPORT market is very dynamic. The main indications are hair removal, skin rejuvenation and cellulite and there are many centres in Paris, for example, that perform these procedures. It s been a very special market through the crisis, which has continued to grow. However it is likely that lasers and light devices will be subject to heightened levels of regulation in the future, explains Bassmann. New regulations might introduce the need for a more surgical set-up to use aesthetic lasers (rather than a doctor s office) and this would be more costly for the doctor. More regulation might put the price up and restrict use. Some doctors are unhappy about this because they say it s not going to improve anything. Elsewhere in energy-based treatments, Radio Frequency (RF) technology is inspiring new innovations, such as eprime from Syneron- Candela, which is launching imminently in France. The minimally invasive aesthetic device is designed to deliver controlled amounts of RF energy deep into the dermis to produce new collagen, elastin and HA for a more youthful appearance. Mesotherapy, where microscopic quantities of pharmaceuticals such as HA, vitamins and natural extracts are injected into the surface of the skin, has a somewhat longer history in France, having been practised for over 50 years. It can be used to treat ageing and sagging skin, rejuvenate the hands and neck and even target cellulite. France is the biggest market for mesotherapy, and it continues to be a hotbed of innovation from the likes of Filorga (with its NCTF mesotherapy range) and Aesthetic Dermal, which has extended its mesotherapy product range Reparestim TD with a number of specific formulations to treat ageing eyes, hyperpigmentation, celulite, stretchmarks and alopecia. Facing the future Going forward, one of the most interesting approaches in the aesthetic market is combined therapy. Bassmann explains: Combining mesotherapy with a peel and HA dermal fillers is a very popular trend to rejuvenate the face. Peeling acts on the skin s surface, eliminating the superficial layers of the epidermis whilst stimulating cellular renewal. Mesotherapy is an intradermal injection, which revitalises all skin layers and boosts cell activity. Dermal fillers fill depressions (folds, medium and deep wrinkles) and provide volume to the areas that tend to get thinner (cheekbones and lips). By combining those three techniques we obtain the best non-invasive, 100% safe anti-ageing treatment with no downtime, but natural and long lasting results. Tabary agrees: It s about taking a global approach to beautiful skin not only filling wrinkles, but the elasticity, tone and density of the skin. Using combined therapy we will be able to act on each sign of ageing, and when we combine fillers, mesotherapy and peeling we get amazing results. Another area of future development is likely to be physician-led skin care to enable patients to maximise the benefits of the procedures they are having. This will mean that more doctors become skin care advisers, believes Bassmann. The market is currently not as developed as in the US, since a doctor in France cannot sell professional skin care products directly they can only recommend but more and more doctors are creating their own skin care products. It is coming to France but there are still regulatory issues. It seems that the French aesthetic market is in a much stronger position than many other categories in the cosmetics world and this looks set to continue, with predicted growth figures for this year and beyond reaching double figures. Chardon says: During the crisis growth was at 3-4% but now it s over this year should achieve 10% growth. The market could get up to 25% because of the huge potential pool of patients out there we just have to wait for the right environment for it to start. Chardon is referring to a marketing study by Galderma (on 1,500 women in France) which Injection perfection Gaurav Kukreja, analyst at Millennium Research Group, tells ECM why botulinum toxin and HA dermal fillers are the dominant segments in the French aesthetics market France and the UK are the only major facial injectable markets in Europe where the number of botulinum toxin (BTX) procedures outweigh dermal filler procedures including Hyaluronic Acid (HA) and particle and polymer fillers (PPF). One of the reasons for the popularity of BTX in France is that Allergan s Vistabel (Botox in the US) was first introduced in France in Europe. As a result, there is widespread physician familiarity with and comfort in using the product, as well as patient knowledge about it. Moreover, French company Ipsen, the manufacturer of BTX brand Azzalure, is one of the leading competitors in the French BTX market, and many consumers in the country prefer to use products supplied by local firms. In dermal fillers, HA dermal fillers will continue to dominate revenues earned in the dermal filler segment because these are shorter duration products with a higher safety profile than longer duration PPF products. HA fillers are the fastest growing segment in the facial injectable market because of low safety concerns. At the same time, however, PPF procedures, which offer long-term cost effectiveness, will remain popular in France and will climb robustly through to Overall, many French consumers are generally highly aesthetically conscious, leading to widespread social acceptance of cosmetic enhancement procedures. By the time we get to 2015, more physicians will be offering dermal filler and BTX procedures in France in order to boost their revenues. This will increase the availability of the procedures and further promote patient awareness of these treatments. September 2011 ECM 311

6 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 312 MARKET REPORT AESTHETICS found that four times the number of women who currently have aesthetic procedures would consider doing so in the future. This is an impressive figure. But when will all these people have their first treatment? Five years? ten years? We don t know. But while this boom in patients is waiting on the horizon, there is plenty manufacturers can do to encourage patients to try aesthetic treatments. Filorga is targeting doctors waiting areas with leaflets to encourage patients to ask their doctors about the products, something that the company has found works more successfully than explaining the procedures directly from manufacturer to patient. And last year Galderma organised a National Before and After Day in almost 300 medical facilities throughout France to encourage patients receive information and get their first injection. It recruited as many as 2,000 patients. There are several barriers to getting treatment. People are afraid of the pain, they think treatments are expensive and that there are no natural results. After the first injection they know it is not painful, worth the money and they can get natural results, says Chardon. Repeat business in this market is therefore very successful. Tabary says: Once a woman has her first procedure, in 90% of cases she continues because it is very efficient, not painful and not socially obstructive she can be back in her office or at home in 30 minutes. I think that one day men and women will go to fill wrinkles in the same way they go to the hairdresser today. When you bear in mind that one in two women born today will live to at least 100, you can see that the potential for this market is huge, remarks Tabary. One thing looks certain, aesthetic procedures will play a significant part in women s lives in the future. Germany Nipped and tucked The German aesthetics sector has definitely seen a resurgence of interest in the past few years and there has been a keen interest in improving oneself by using both invasive and non-invasive aesthetic procedures. The focus in Germany is very much on looking natural rather than done when it comes to aesthetics and there are many clinics springing up all over the country where consumers can go and have a bit of work done in their lunch hour and then simply return to their offices where they hope colleagues simply notice their revived and Galderma Intimacy and aesthetics Between 5-7% of French women currently have aesthetic medicine procedures, but what are their reasons for doing so, and just how far are aesthetic treatments acceptable? Benoit Chardon, head of Galderma and Q-Med s aesethetic procedures business in France shares his thoughts Contrary to the US and Brazil, the goal of French people is not necessarily to look younger, it s more to enjoy life and to feel good. French people have different objectives. Women say they feel less intimate with their children as they look older, but with a fresher look they feel they can be closer to their children. Similarly, some women and men get injected in order to feel closer to their husband or wife or to have a better social life. The common points here are about feeling better and enjoying life. Light corrections are seen as acceptable if they are part of a cosmetic routine, alongside creams and so on. What is not accepted in terms of the culture in France is to transform your face or to try to stop ageing. freshened appearance rather than suspecting they have had anything done. Increasing numbers of consumers are taking advantage of having non-invasive procedures, such as peels, botox and hyaluronic acid (HA) fillers which require much less downtime than when actually going under the knife. But having said that, figures show that surgical procedures are on the up and are predicted to continue to grow as both accessibility and affordability in the aesthetics category make the decision easier. Firm figures The latest figures on the aesthetics market for Germany were released last year by the German Association for Aesthetic Surgery (GACD) which is the largest interdisciplinary body for aesthetic surgeons in the country. These figures looked at the previous year, 2009, and are the latest figures available as this year s results have not yet been published. According to Dr Matthias Gensior, general secretary for GACD, there was a distinct increase in surgical operations for both men and women in Figures rose by 20% from 141,000 operations performed by GACD in 2008 to 171,000 operations in And this is a figure 312 ECM September 2011

7 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 313 AESTHETICS MARKET REPORT Germany: Most popular procedures performed on women, 2009 Procedure Number Facial laser surgery 38,117 Liposuction 16,599 Blepharoplasty 10,426 Rhinoplasty 7,331 Breast enlargement 6,553 Phlebosurgery (veins) 4,465 Abdomnioplasty 2,746 Tattoo removal 2,642 Ear conch surgery 2,637 Breast reduction 2,600 Facelifts 1,911 Lip corrections 1,766 Vaginal/labia surgery 1,454 Source: GACD which has continued to grow according to industry insiders. The most popular types of aesthetic procedures are identical with both male and female patients, according to the figures. At the top of the list are surgical laser operations in the facial area (80,740 procedures carried out in 2009), followed by liposuction (19,237) and then blepharoplasty (eyelid surgery) at 12,483. Gensior comments: The results show that more new patients, and especially younger patients, are having aesthetic procedures done than in previous years. A lively media interest in the topic of aesthetic surgery and increased coverage in respectable magazines and daily newspapers have increased the acceptance of these types of procedures as far as the patient is concerned. In our medical practices themselves we havealso noticed how well informed the patients now are about the procedures that are available to them. As in many European countries regulation is a contentious issue but this is improving with organisations such as the Akademie für Kosmetische Medizin (Academy for Cosmetics Medicine) organising training courses for many in the sector to become accredited. A spokesperson for the organisation told ECM: Our academy is responsible for the basic and advanced training of doctors and health practitioners in the field of aesthetic medicine. We run courses specifically about the administration of botox and fillers which are conducted by doctors and which teach attendees about the theory and practice of this type of aesthetic surgery. This involves everything from the basics of the substance being injected to the analysis of wrinkles and the techniques of injection to the treatment of the patients themselves. Previously there has been little or no control over the expertise of the people doing these injections and this has led to complications and negative connotations with botox and fillers. Along with ourselves, manufacturers and distributors, together with dermatologists, are forming Germany: Most popular procedures performed on men, 2009 Procedure Number Facial laser surgery 42,623 Rhinoplasty 3,473 Tattoo removal 3,338 Liposuction 2,638 Blepharoplasty 2,057 Ear conch surgery 1,182 Breast reduction 715 Phlebosurgery (veins) 578 Source: GACD networks to establish a controlled fellowship for injections in the aesthetics market. So now these products are only distributed to those who have a certificate from an organisation such as us who can prove that they took part in the correct training course. Working together The joining together of different parties within the aesthetics field in Germany is becoming more commonplace. Dermalogica is a very popular skin care brand in Germany and the products are also said to be suitable for use before and after aesthetic procedures because they have no synthetic dyes and scents, making use of many natural active ingredients, which do not irritate the skin as this can obviously be very delicate after surgery. Dermalogica products are used by accredited skin specialists who use the products in accordance with doctors in some cases. The brand has teamed up with the Asklepios Clinic in Hamburg to hold a congress for skin therapists where it highlights opportunities for how doctors and skin therapists can better work together. This year s congress in association with Dermalogica is being held on 29 October and the main issue for 2011 is body contouring with abdominal wall tightening and liposuction also Germany: Anti-wrinkle procedures performed on women, 2009 Procedure Number Botulinum toxin 62,795 Fillers 67,897 Dermabrasion 1,268 Total 131,960 Source: GACD Germany: Anti-wrinkle procedures performed on men, 2009 Procedure Number Botulinum toxin 8,380 Fillers 5,039 Dermabrasion 332 Total 13,751 Source: GACD September 2011 ECM 313

8 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 314 MARKET REPORT AESTHETICS key issues on the agenda. During the break sessions participants can learn about Dermalogica s Body Mapping skin analysis technique. Dr Klaus Müller is medical director for the department for plastic surgery and aesthetic surgery at the Asklepios Clinic. He feels that there is still a fear of touch between skin therapists and doctors. Often the missing knowledge about the fields and methods is responsible on both sides, he comments. One key issue which Dermalogica has highlighted at the congress in the past year is hyperpigmentation and it has developed the new Chroma White TRx line to address this problem. Using no aggressive bleaching agents which can damage the skin, Chroma White TRx balances the pigmentation by influencing the melanin production with its combination of active ingredients. Solar irradiation undoubtedly has a negative effect on the skin so all Dermalogica products contain SPFs to guard against this. Chroma White TRx is said to have a double effect as existing hyperpigmentation is balanced out and further development is avoided. Aesthetics association Another company which pits its products as being good for use before and after surgery is Beiersdorf owned Skin Biology Therapy (SBT) which has worked in association with respected German dermatologist, Professor Volker Steinkraus, to create its popular premium skin line Cell Culture, where products are based on a cell nutrient fluid very similar to the skin s own. Of the products launched in the past year Cell Culture Cleansing Liquid & Oil, Cell Culture Eye Care Serum and Cell Culture Age Care Firming Serum it is the latter product which could be seen as the most suitable for preparing skin for any type of aesthetic procedure. Cell Culture Age Care Firming Serum is a quickly absorbable milky serum with a low lipid content which can be applied to the skin directly after cleansing, combating the loss of elasticity and volume in mature skin. Application is said to boost collagen production in the extracellular matrix and improve cell renewal and activity. Steinkraus feels that aesthetics is a growing market in Germany and he puts his faith in brands which have been created alongside dermatologists such as himself. He comments: I am in favour of skin care products that capitalise on mild formulations as well as ones that use classical dermatological ingredients which respect the cellular base of the skin. It is important that products that are applied to the skin post treatment avoid fragrances as this would be an irritant while moisturising the skin is naturally very beneficial to the healing process. When talking about the aesthetics market in Germany, Steinkraus is enthusiastic. There has definitely been an increased interest in aesthetic surgery in Germany and companies like SBT bridge the gap between procedures and a daily skin care regimen, particularly if being used post treatment. This interest has also been encouraged by the greater number of procedures available, particularly ones that promise a natural look. He adds that aesthetic surgery in Germany is a huge market these days and as a result the choice and quality available is outstanding. You will find fine private clinics throughout Germany s major cities, most of which offer world class treatments and services. After all, Germany is a country which relies on specialists, he concludes. Dr Marian Mackowski is an aesthetic plastic surgeon with the Mang Medical One Chain which has clinics across the country from Lindau to Hamburg. He agrees with Steinkraus that aesthetic procedures are definitely on the increase. Although the statistics differ weekly there is a definite increase although in comparison with the US market for example. German consumers are much more conservative and the rate of cases here is still much lower, says Dr Mackowski. For example the American Society of Aesthetic Plastic Surgeons (ASAPS) reported 355,671 cases of breast augmentation in the US in 2008 Professor Volker Steinkraus has worked with Skin Biology Therapy to create products which are suitable for use pre and post surgery The green approach Dr Christine Schrammek-Drusio is a leading dermatologist, well known in her native Germany and beyond for her innovative Green Peel treatment. She discusses why a more naturally based aesthetic treatment can be just the ticket Green Peel is our original method, developed by my mother and adapted by me with the latest scientific knowledge. During her work as a beautician in a skin clinic my mother became acquainted with chemical skin peels but they had many side effects. As her own parents had always treated any health problems with herbs and herbal compresses, she began to experiment with herbs with the goal of developing a skin peel based on only natural ingredients without any side effects. She carried out trials in collaboration with a professor of dermatology and that s how the Green Peel was born. Then after I joined the company I further refined this treatment method with my own medical knowledge. The special thing about Green Peel is its natural basis. A natural, plant-based formula, developed according to dermatological principles. With the help of mother nature the ageing process of the skin can be counteracted, the complexion refreshed, the regeneration of the skin triggered and its renewal initiated on a natural basis. There are three formulas for all application areas for the face and body at every age and for very different skin problems. What is also special is that the Green Peel is tailored to the needs of each customer. Varying the amounts of the herbal mixture depends on the condition of the skin and the skin type and this now makes it possible to individually tailor the treatment plan. Whether you need gentle refreshment, active revitalisation or an intensive peel the beautician decides on which level is appropriate. Dr Christine Schrammek-Drusio 314 ECM September 2011

9 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 315 AESTHETICS MARKET REPORT Preparing and perfecting Babor is a well known spa and skin care brand in the German C&T market and its Doctor Babor range has many products which are suitable for use before and after surgery. Dr Helmut Drees is the head of spa and medical division training for Babor and he talks to ECM about why preparation is of the utmost importance The better the skin is prepared for surgery the better it can heal as scars are less visible. We have tested the Doctor Babor range in cooperation with a leading facelift specialist to convincing effect. We saw a reduction in subjective skin tension in 95% of the patients tested, more rapid scar healing in 85% and a reduction in post operative itching in 80%. The results confirmed that the intensive preparation of the skin before cosmetic surgery is vital for regeneration and success. In particular the Doctor Babor Biogen Cellular Ultimate Repair Cream shows excellent results. Two factors make this so effective one is the specialised biogen plant extracts that consist of eight high quality herbal essences matched to augment each other in effectiveness. The other is the highly sophisticated biotechnical processes used in production. Meanwhile this autumn we are launching the Doctor Babor Neuro Sensitive line which has been created in collaboration with leading scientists and dermatologists. We have developed a blend of active neuro cosmetic ingredients that break through the itch/scratch cycle of very sensitive and dry skin. These new products have an anti-irritant effect, soothe itching and restore the hydrolipid mantle that protects the skin. while in Germany at that time we only saw about 45,000 cases. He adds that the most requested procedures he sees at Mang Medical One are breast augmentation, liposuction, blepharoplasty, rhinoplasty and facelifts. He also stresses the need for consumers to consult a qualified doctor rather than just walk in off the street to visit an unregulated clinic as people seem to be increasingly doing, seduced by quick fix surgeries and higher purchase payment schemes. Mackowski adds: Some people are very tempted to walk in off the street for a quick bit of work but many of them regret it later on. It is Italy Imitating nature Italy has a booming cosmetic surgery industry, so developed that the country ranks third in Europe behind the UK and France for the number of aesthetic surgery procedures performed, according to data from Industrie Farmaceutiche e di Dispositivi Medici (Pharmaceutical and Medical Implements Industries). Recently AGI, the Italian Journalistic Agency, revealed that an increasing number of Italians are therefore absolutely necessary to book an appointment for a serious consultation ahead of any surgery. In order to achieve a stable and predictable result and to avoid problems there is the need for an informed meeting prior to surgery. Clinical approach One clinic which does offer consumers more of a walk-in service, but which is fully regulated and operates to a very high standard, is the Belladerma chain of clinics which has two outlets in Berlin alone, with the biggest one on the prestigious shopping street Unter den Linden. It specialises in offering aesthetic treatments to consumers with a variety of different payment options, including a bank loan service with leaflets available there in the waiting rooms. Belladerma even advertises on the group discount site, Groupon.de, the adverts for which appear in newspapers and on billboards in the German underground system for maximum exposure. This style of clinic offers all manner of treatments from facial laser work to IPL (intense pulsed light) and permanent hair removal but with a more informal approach. There have certainly been a run of openings like this in major cities such as Berlin which indicates that German consumers are increasingly seeking ways to have procedures that they can access quickly, affordably and without drawing other people s attention to it. Whether they are doing it in their lunch hour with minimum downtime or having an extended stay at a private medical facility, one thing is for sure the German appetite for aesthetic surgery is on the rise. And with clinics and manufacturers alike rallying round to meet this need, things will only get easier for the German consumer who is not afraid to take the plunge with aesthetic surgery. giving up their holidays and are using their yearly savings to undergo a cosmetic surgery treatment instead. Certainly the attitude towards this kind of surgery has radically changed in Italy in the last couple of years, as data from Doxapharma Research confirms. In April/May 2011 researchers from pharmaceutical market research company Doxapharma interviewed a sample of 1,000 Italian women and 500 men, and a number of independent aesthetic surgeons were also consulted for the research, to get a glimpse of the aesthetics industry in Italy. (The trade body Unipro doesn t have data available for the aesthetics sector, which makes it hard to make sense of such a varied and continuously evolving category.) The Doxapharma report Behaviour, attitude and experience of aesthetic surgery in Italy was conducted for the Fondazione Italiana per la Medicina e Chirurgia Estetica (Italian Foundation for Medicine and Aesthetic Surgery). It found that the most popular centres for aesthetic surgery in Italy are LaClinique (49%) followed by Prof. R De Vita September 2011 ECM 315

10 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 316 MARKET REPORT AESTHETICS (32%), while according to the independent aesthetic surgeons interviewed, the most frequented centres in Italy are LaClinique (38%) followed by Dr Botti (38%). The research revealed that Italians have become more aware and knowledgeable about aesthetic surgery and the variety of procedures available today, with 61% of women and 54% of men knowing that they can make use of a series of organisations specialising in aesthetic surgery and that today having a job done is not just about trusting an individual aesthetic surgeon anymore. The consumers polled revealed what Italians look for in a surgeon, with the top three qualities being professionalism (87%), experience (79%) and being up to date with the latest trends (41%). Choosing a surgeon remains difficult, with 86% of Italians admitting that cosmetic surgery is still a complex field where misinformation is widespread. Indeed among the vast web of big and small aesthetic practices in Italy it is difficult to quantify the value of the sector in monetary terms. Entering the mainstream But one thing is certain cosmetic surgery is not a taboo in Italy any more. According to the study, only 5% of Italian women and 4% of Italian men are opposed to it today, while the number of Italian women who d go under the knife has grown from 32% in 2010 to a staggering 43% this year this figure is 29% for men. Looking at the demographics, it s particularly women in the are range who tend to openly endorse plastic surgery while women from years of age appear less inclined to accept it. When it comes to younger consumers, in Italy, unlike other more developed markets such as the US and Australia, the number of very young clients remains limited, with just a handful of under 18s (the legal age of consent for surgery) seeking procedures. Antonella Mistretta, from the marketing and communication department for LaClinique says: I d say demand is almost non existent unless there are evident functional needs for the younger patient and parental permission is always required. With regards to breast implants, in July last year the Consiglio dei Ministri (the Italian cabinet) approved a law that prohibits breast implants for girls younger than 18. But while demand is low for the under 18 age group, the market for those who are in their 20s and 30s is increasingly growing and so is the market for men. We have recorded a noticeable increase in the number of men who undergo cosmetic surgery, from 1% in 2009 to the current 17%. Today men represent almost 20% of our customers. The reason? It s a question of priorities, says Mistretta. Today men want to like themselves and look good just as much as women do. As a response to this need LaClinique has developed a division entirely dedicated to men s procedures, which are different from women s. For instance gynecomastia, the abnormal development of large mammary glands resulting in unwanted breast enlargement, only affects men and LaClinique has developed specific procedures to deal with that. When it comes to liposuction for men, the focus will generally be on the hips and stomach rather than on the legs as it is for the majority of women. Mistretta says that the procedures men undergo most frequently are those to treat gynecomastia. This is followed by liposculpture to remodel their body; rhinoplasty (nose); blepharoplasty (eyelids); and hyaluronic acid and botulinum (botox) injections. Despite all of this positive data, many Italian men and women in general seem to be still dubious about aesthetic surgery and wouldn t consult a surgeon about having their features altered. Some women believe treatments are too expensive and unaffordable while others are afraid of the physical pain connected to the surgery. Décolleté fascination Dr Pierfrancesco Cirillo, who represents Sicpre, Societa Italiana di Chirurgia Plastica, Ricostruttiva ed Estetica (Italian Society for Plastic, Aesthetic and Reconstructive Surgery), comments on the most requested treatments in Italy: In the nonsurgical department, consumers ask for botulinum toxin and hyaluronic acid for the face, laser and light treatments to promote skin rejuvenation, lipofilling, laser epilation and laser treatment to eliminate tattoos, in that order. When it comes to aesthetic surgery, breast enhancement and augmentation ranks in first position followed by liposuction, blepharoplasty (eyelid lift) and rhinoplasty. The findings from Doxapharma reveal that while the desire for breast enhancement in Italian women under 34 diminished in 2010, it was the over 35 age range and particularly women between 35 and 44 who were increasingly turning to cosmetic surgery to increase their breast size. According to the research this age bracket records the largest number of women who are not satisfied by their décolleté. Interestingly, data also shows that the number of Italian men in favour of their partner having a breast enhancement has doubled since the previous year. Cirillo says that the most in demand treatments for the body involve reshaping while on the face consumers prefer less invasive treatments that No shortcuts Dr Pierfrancesco Cirillo shares his thoughts on the differences between aesthetic and plastic surgery and explains why specialist training is advisable Aesthetic surgery is a specialist branch of plastic surgery, which means that in Italy plastic surgeons, after five years specialising, are supposed to undergo specific training of at least three years in aesthetic surgery, either in Italy or abroad. Unfortunately European legislation allows medical graduates who don t hold a five year basic specialisation to operate in all branches of medicine with the sole exception of anesthesiology and radiology. This brings about a rash of improvised surgeons, who define themselves as aesthetic surgeons but who aren t really, with possible negative consequences on patients. Dr Pierfrancesco Cirillo represents Sicpre 316 ECM September 2011

11 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 317 AESTHETICS MARKET REPORT LaClinique, with sites in Milan, Rome and Turin, is one of the most popular places to get aesthetic surgery in Italy don t require a convalescence period and that leave a natural look. He says: The US remains a source of inspiration for the world in this field, but it s also a huge country with its own internal differences from west coast to east coast. In Italy we don t have consumers requesting operations to look like a particular celebrity, as is known to happen in the US, and we don t even have clients who want to be operated on several times. In Europe we tend to be more moderate. He adds: Aesthetic surgery in Italy is extremely acceptable now, but we are worried about commercial companies that sell surgical procedures as if they were any old thing and also advertising the option of monthly repayments for example. Mistretta says: In Italy the demands in terms of results of cosmetic surgery don t differ much from the US. Most consumers approach a surgeon because they want to improve their physical appearance and they want to achieve natural beauty, which generally means proportioned and harmonious features. According to data from ISAPS (The International Society of Aesthetic Plastic Surgery), based on over 20,000 aesthetic surgeons in 84 countries, most women who ask for plastic surgery quote the body of Brazilian model Giselle Bündchen. Meanwhile a body like Pamela Anderson s is somehow outdated today as women worldwide prefer a more natural beauty ideal. Future predictions While cosmetic surgery has evolved from somehow exaggerating the female body to enhancing its natural properties, at the same time the industry has started to explore less invasive procedures. In 2011, LaClinique introduced in its Spain Natural not noticeable centres in Milan, Rome and Turin two innovative body reshaping techniques, Coolsculpting and AQUA-lipo. Apparently they were both very successful in Italy as they offer many advantages in comparison to the traditional liposuction methods. Says Mistretta: Coolsculpting is definitely a treatment that stands half way between proper cosmetic surgery and a beauty treatment. It doesn t require anesthetic and in the postoperation period there is no need to stop working. With Coolsculpting we have recorded the most satisfactory results in the abdominal and hips area, with circumference reduction of between 4-8cm. The procedure was very effective especially when combined with a sensible diet low in fat and carbohydrates and with regular physical exercise. In 2006 when it was founded, LaClinique gave birth to what it defines as a new way of thinking about cosmetic surgery. Says Mistretta: We have a beauty path structured in eight phases: a free consultation, a medical visit with one of our specialists, pre-operation exams, anesthetics visit to ascertain if it s possible to perform the chosen procedure, intervention and finally post-operation treatments including talking the customer through the medication she should use. The client also has a right to planned control visits for up to 24 months after the operation. In the last five years the most requested procedure at LaClinique has been for breast augmentation surgery in this time we performed over 6,000 successful breasts operations, which represented over 60% of our activity at LaClinique. Beside this, there was a lot of interest in liposuction and abdominoplasty (tummy tucks for example) which were increasingly popular, says Mistretta. What will the future bring? We forecast that in future non-invasive facial anti-ageing methods like fillers based on hyaluronic acid and non surgical face lifting with botulinum will become increasingly interesting to Italians. Rhinoplasty is always going to remain one of the most popular procedures because it s not only about an aesthetic procedure but functionality too given the several breathing problems it can sort out, adds Mistretta. As cosmetic surgery becomes less and less taboo in Italy, it seems the sector will continue to thrive and develop as it learns from international players like the US and follows its example. Like almost every other sector of the Spanish economy, aesthetic surgery has not escaped the effects of the economic downturn. But it s not all doom and gloom and, as with other areas of the cosmetics industry, firms in this field still benefit from continued consumer interest in the way they look. Indeed, a recent multi-country survey by Merz Aesthetics, to which Spain provided the largest number of responses, found that more than 45% of women felt that aesthetic surgery was a necessity rather than a luxury and almost 60% said they would undergo some form of treatment. The aesthetics sector is worth some t900m each year in Spain and there are more than 100 different brands operating in the marketplace. September 2011 ECM 317

12 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 318 MARKET REPORT AESTHETICS According to data from Secpre, the Spanish Society for Reparatory and Aesthetic Plastic Surgery, some 105,000 aesthetic surgical interventions were carried out in 2009 in hospitals and private clinics alone, with a value of around t175m. Top choices These figures are the result of a survey carried out in the summer of 2010 to shed some light on aesthetic surgery in Spain because Secpre noted there was a considerable lack of data. While it does not include procedures that are non-invasive in nature, such as botox injections, the survey does provide some interesting insights. Liposuction was found to be the most popular form of surgery in 2009 followed by breast enlargement and surgery on eyelids and noses. In terms of cost, an average liposuction results in an outlay of t958, while surgery on the breasts costs t1,397. Perhaps unsurprisingly, aesthetic surgery is considerably more popular with Spanish women than men, accounting respectively for 88% and 12% of surgery that took place in By age group, surgery was most popular for people in the age group, who accounted for some 43% of all interventions. The over 45s underwent some 35% of all the surgery, while the under 30s accounted for 22%. Youth and beauty Younger consumers are nonetheless an increasingly important factor, according to medical aesthetics product specialist Solta Medical. Jeff Nardoci, vice president of global marketing, describes the Spanish skin care market Spain: Average cost in hospitals and private clinics by surgery type, y Body surgery 1,507 Breast surgery 1,397 Liposuction 958 Facial surgery 764 Source: SECPRE Spain: Facial surgery by type, % Eyelids 16.6 Nose 13.1 Facial Lifting 4.5 Dermobrasion 3.7 Laser restructuring 3.7 Fat refilling/lipostructure 2.8 Ear lobe surgery 2.6 Mini-lifting (face) 2.3 Deep peeling 2.0 Cervical lifting 1.9 Labia surgery 1.5 Other implants/facial filling 34.4 Other 10.9 Source: SECPRE as: One of the most progressive in Europe. The most evident trend at the moment is that clients/patients are younger than they were in the past. These younger patients are looking for solutions oriented to prevent the signs of ageing in the skin and they are determined to keep their skin looking younger for as long as they can. In the past 18 months, Solta Medical has launched its Clear+Brilliant concept that is all about prevention and maintenance of skin. The laser treatment is ideally suited for younger consumers looking to prevent early signs of ageing with a low downtime and is designed to be less aggressive than the alternative treatments available. Solta says that another important trend in Spain relates to reducing the effects of the sun on the skin. While the higher than average summer temperatures make it unsurprisingly a nation of sun worshippers, there has been an increase in the number of awareness campaigns in Spain of late, and indeed the effect of over exposure to the sun has become a subject for public discussion. In particular, says Nardoci: Younger women are becoming more conscious about the negative impact of prolonged exposure to the sun and the close relationship between sun exposure and the early signs of ageing. The recently launched Fraxel DUAL 1550/1927 is focused specifically on correcting sun damage. The treatment is a combination of two lasers in one that can be used independently depending on the client s particular requirements. One laser targets problems deep within the dermis, such as wrinkles and scarring, and the other more superficial ones that are related to exposure to the sun. Madrid-based clinic, H&H Medicina Estética, has treatments to handle the effects of the sun as well as ageing without the need to go under the surgeon s knife. H&H says that the best antiageing techniques are those that offer a combination of processes that can remove a decade from the patient s face. The combination of a facial bioplasty, facial biostimulation and intense pulsed light works to correct lost volumes while improving the skin s thickness and smoothness and generally revitalising the skin. The natural touch Sun is not the only trend though. Clínica Londres, which has a number of outlets across Spain, has noticed that while in previous years aesthetic treatments had perhaps overly visible results, the key word nowadays is natural. Little retouches that are hardly perceptible but result in a more defined face, revitalised skin or younger facial expression, says Dr Ángel Luis Sierra, specialist in aesthetic medicine at Clínica Londres. This natural trend is such that someone who is not aware of the aesthetic treatment simply sees the patient looking more beautiful without knowing why. Women want to look more beautiful but don t want other people to notice that they ve had aesthetic treatment. Sierra says that the clinic enables this through personalised treatments that could be a combination of various procedures to suit specific requirements. 318 ECM September 2011

13 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 319 AESTHETICS MARKET REPORT Kiehl s Double Strength Deep Wrinkle Filler is based on two types of hyaluronic acid to fill and smooth the skin I like to go little by little so the client can get used to the new look. There s always time to add more later, says Sierra. Women are also very busy and don t want the treatment to interrupt their daily lives. In 2010, Clínica Londres introduced its new Face Lift treatment that it said provides immediate, long lasting results without the need for surgery. Small injections of calcium hydroxypatite in areas such as the edge of the mouth and eye or the nose generate tension in the face and encourage the production of collagen. The treatment is said to be ideal for clients from the age of 40 when the face starts to lose volume. Depending on the patient, the effects can last up to 18 months, but are immediately visible. H&H has also introduced an anti-wrinkle treatment that uses a CO 2 fractional laser. By applying the high energy laser, the treatment causes coagulation in the blood vessels to reduce the wrinkles in the area where it is applied, without affecting the surrounding skin or causing pain to the patient. Another recent arrival on the Spanish market in terms of anti-wrinkles is Radiesse Volumising Filler (Merz Aesthetics). The calcium-based microspheres and gel in the product are designed to reduce the signs of ageing by stimulating the skin s natural collagen, boosting its volume and reducing wrinkles. After a simple injection, the results can last for up to a year and, in some patients, longer. Kiehl s (L Oréal), meanwhile, has introduced its Double Strength Deep Wrinkle Filler that is based on two types of hyaluronic acid to visibly fill out and smooth skin without silicone. Spain is also set to be an important market for Bayer Healthcare, through its Intendis arm, and Kythera Biopharmaceuticals in the coming years. After signing an agreement to jointly develop and commercialise ATX-101 last year, the companies plan to bring the adipolytic agent to Europe by ATX-101 is designed to reduce small UK Best face forward The UK s obsession with looking good goes way beyond simple skin care and today s consumer is increasingly likely to turn to the UK s burgeoning aesthetic market to improve their appearance. From a glycolic peel to a full blown face lift, aesthetic surgery has grown from an area once shrouded in secrecy and embarrassment to a multimillion pound mainstream market offering every conceivable nip and tuck to a variety of budgets. volumes of facial fat through aesthetic applications and is currently at the testing phase. On the equipment side, Allergan Europe has launched its Easyflow water and ultra-fine cannula injection system that has been created specifically for the Juvéderm Ultra dermis-filling range. The thin wall technology on what is otherwise a standard needle makes for better control and easier injections. Syneron Candela, meanwhile, is targeting new mothers with its VelaBaby that is designed to help return stomach and thighs to their pre-pregnancy state without the need for invasive treatment. Incorporating the VelaShape II technology that combines four techniques bipolar radiofrequency, infrared light, suction and a mechanical massage the VelaBaby helps slowly reduce cellulite. It is said to be more powerful than its predecessor meaning fewer sessions are required and, depending on the patient, can lead to reductions of 4-6cm in a month. A final technology to hit the Spanish market in the past year comes from IT firm Cloud Remote Control Technologies. The programme is said to be a first for the sector and is designed to bring together information on the various aspects of the sector clinics and machinery manufacturers to allow for better servicing of equipment and, ultimately, a better result for the client. It seems then that, in line with a number of major markets, aesthetic surgery in Spain is going from strength to strength, despite the economic setbacks. According to the Secpre survey, the majority expect surgical treatments to increase, or at least remain constant. The trend is unlikely to be different for the more non-invasive forms of treatment such as filling. As Solta s Nardoci puts it: Spain has, for a long time, been setting trends in art, fashion, music, and even culinary culture. Now, Spaniards are also setting the trend in regards to skin care. And despite the squeeze on many consumer budgets due to the recession, the market is holding up. The British Association of Aesthetic Plastic Surgeons (BAAPS) notes the number of aesthetic surgical procedures showed a slow but steady rise, up 5% in 2010 to a total of 38,274 procedures, while the Harley Street Medical Group reports a 100% increase in enquires about dermal fillers since 2008, and a 14% rise in injections of fillers since May The cosmetic surgery market offers so much potential for growth, however only 0.2% of the population are having surgery, explains Rajiv Grover, consultant plastic surgeon and BAAPS president elect. The barrier to having work done though is not money, it s the fear of having an operation, not looking natural and people finding out you have had it done. The good news is that cosmetic surgery has had more media exposure in the last ten years and people are more open in the press about having had it done. The internet too has helped create understanding which is a great way to break down some of the fear associated with treatments. The growth rates for surgical September 2011 ECM 319

14 000 ECM0911 market report.qxp:layout 1 22/9/11 15:37 Page 320 MARKET REPORT AESTHETICS UK: Top UK surgical procedures (men and women), 2010* Procedure Number %+/- Breast augmentation 9, Blepharoplasty (eyelid surgery) 5, Breast reduction 4, Face/neck lift 4, Rhinoplasty 4, Liposuction 3,399-4 Abdominoplasty 3, Brow lift 1, Otoplasty (ear correction) 1, *carried out by BAAPS members Source: British Association of Aesthetic Plastic Surgeons (BAAPS) facelifting, breast augmentation and rhinoplasty now show double-digit percentage rises. People are more exposed and comfortable with the concept of aesthetic procedures, adds consultant dermatologist, Dr Susan Mayou. But we are still a conservative nation compared to the US. Without doubt people don t want to look frozen or done. They just want to look better and softer, making the best of themselves. This exposure has certainly helped consumers see procedures, both invasive and non-invasive as more acceptable. According to a survey of 2,900 women in the UK, France, Italy, Spain and Russia, conducted by Harris Interactive on behalf of Merz Aesthetics, more than nine in ten women (95%) would like to improve or alter a facial feature, while nearly four in five (78%) believe it is acceptable for women to invest in aesthetic procedures to enhance their beauty as they age. Furthermore 69% of UK women said they believe beauty can be shaped and enhanced and that it is under everyone s control to achieve beauty. Uncertain economic times have however restricted this market to a privileged few with urban areas such as London, Birmingham and Manchester representing the locations where the majority of treatments are undertaken. The story outside of London and other metropolitan areas is very different, explains Dr Nick Lowe, consultant dermatologist and professor of dermatology, UCLA Medical School. In wealthy clusters like London which caters for the high end consumer there is very little change since the recession, and waiting lists remain full at the best clinics, but the cosmetics surgery chains which operate all around the country must have seen a slowdown. Dr Bryan Mayou, consultant plastic surgeon and founder of the Cadogan Clinic, a private day clinic in London, estimates that the number of plastic surgery procedures undertaken outside of London may have fallen by as much as 50%. It s the top end of the market that is really doing well, he explains. Over the last decade we have seen lots of clinics spring up with the emphasis on the hard sell. These clinics are reliant on people spending their last penny on plastic surgery. UK: Top UK surgical procedures (women), 2010* Procedure Number %+/- Breast augmentation 9, Blepharoplasty (eyelid surgery) 5, Face/neck lift 4, Breast reduction 4, Rhinoplasty 3, Abdominoplasty 3, Liposuction 2, Brow lift 1, Otoplasty (ear correction) *carried out by BAAPS members Source: British Association of Aesthetic Plastic Surgeons (BAAPS) UK: Top UK surgical procedures (men), 2010* Procedure Number %+/- Rhinoplasty Breast reduction Blepharoplasty (eyelid surgery) Otoplasty (ear correction) Liposuction Face/neck lift Brow lift Abdominoplasty *carried out by BAAPS members Source: British Association of Aesthetic Plastic Surgeons (BAAPS) Avoiding the knife Today s aesthetic market offers a wide range of treatments, from cosmetic peels to a full-blown facelift, and as such has a unique positioning in the wider skin care market. Non-surgical treatments such as IPL (intense pulsed light), dermorollers, fillers and Botox have helped bridge the gap between topical skin care and invasive plastic surgery and the number of treatments is on the up. Fifteen or 20 years ago there was nothing for a lady to have done between a face cream and a facelift, explains Grover. Non-surgical procedures have certainly drawn in a large number of people who didn t want surgery but want an improvement in their appearance and the results have given them the confidence to go further. People I have treated for non-surgical procedures have graduated to surgical procedures as a result. Aesthetic surgeon and founder of!qms Medicosmetics, Dr Erich Schulte believes nonsurgical treatments are so effective they can help postpone the need for surgery. It is important to distinguish between surgery for deformaties, for which cosmetic procedures can do nothing and surgery for ageing, he explains. If you are looking to halt the ageing process, non-surgical procedures can help Nubo s latest offering helps to guard against the telltale signs of surgical procedures by restructuring the skin s connective tissue 320 ECM September 2011

15 000 ECM0911 market report.qxp:layout 1 22/9/11 15:38 Page 321 AESTHETICS MARKET REPORT UK cosmetic clinic sk:n has launched a range of five skin care lines which help optimise and prolong the benefits of the non-surgical treatments it offers postpone the need for surgical intervention by up to ten years. And as more techniques evolve, results and treatments will become even more sophisticated. What people want are non-invasive treatments, adds Susan Mayou. They are wary of the knife and they don t want the downtime associated with surgery. Fillers, botox and lasers are getting better and better and people are starting earlier with treatment, continues Bryan Mayou. Before these treatments were available, people would have just wanted a facelift but now half have had a filler or laser treatment before they come to us about surgery. In fact such is the demand for nonsurgical procedures, Mayou tells ECM, that The Cadogan Clinic is to open a dedicated clinic for this purpose. It will be a place where you can have a non-surgical procedure done by an aesthetician or qualified nurse and will provide an umbrella for approved treatments that work, he explains. Treatments will include lasers, botox, fillers and various skin tightening procedures such as thermage and it is hoped to be up and running by Christmas. One trend that is becoming more widely used in aesthetic circles is the use of combinations of nonsurgical treatments. Lowe advocates the use of multiple non-surgical treatments to achieve a desired look. People need to know that no one system can treat all skin concerns. A combination of nonsurgical treatments for synergistic rejuvenation can actually be a great alternative to surgery. They can replace some surgical procedures or at least delay the need for them. The benefits include no need for a general anaesthesia so there is no prolonged recovery time. Combining treatments such as lasers for surface skin rejuvenation and botox to relax the muscles that cause creases is very effective. Susan Mayou meanwhile extols the virtues of using botox in areas on the face other than the forehead. The use of botox to the upper face is huge but less people know it can be used about the lower face and neck. Combined with fillers to the lower face and cheek it s possible to lift the area, she explains. Schulte says there are opportunities for combining aesthetic procedures and topical skin care. A combination approach, using skin care products alongside any cosmetic treatment is the best way to get the most out of your treatment, he explains. A face lift does nothing for the quality of your skin and it s important to invest in regular skin care maintenance such as peels to get the best results. Lowe agrees: Treatments such as lasers require the patient to use a sunscreen with UVA and UVB protection afterwards and using skin specific creams can optimise the effects of the treatment, he explains. As a result, the aesthetic trend is also beginning to filter down to the high street with several nonprofessional brands launching products specifically targeted at the post-operative market. NuBo introduced a highly concentrated serum designed to act against the telltale signs of aesthetic procedures such as botox, filler injections, microdermabrasion, chemical peels and mesotherapy. It is claimed to act against irritation, helping to restructure skin's connective tissue, reducing redness, bruising, swelling and puffiness. La Roche Posay (L Oréal) meanwhile has launched Cicaplast Pro-Recovery Skincare, designed for flaking, chapped skin and skin that has undergone a cosmetic peel. UK cosmetic clinic sk:n has also seen the potential to grow its business with the launch of sk:ncare, a range of five skin care lines which help optimise and prolong the benefits of the nonsurgical cosmetic treatments it offers in its 37 clinics. The lines include cleanse & exfoliate, anti-ageing, anti-blemish, corrective and repair & protect. More than skin deep Within the surgical market, breast augmentation, blepharoplasty (eyelid lift), breast reduction and face and neck lifts were the most popular surgical procedures amongst women, according to BAAPS, while for men, rhinoplasty (nose), gynaecomastia (breast reduction) and eyelid surgery topped the charts. In fact within the men s surgical market, the number of breast reductions, or moob jobs grew 28% to 741 procedures. Men have been suffering in silence but there has been a lot of media attention to this problem with well known personalities such as Tony Blair, Simon Cowell and Jack Nicholson all pictured with moobs. It s made people aware of what can be done. There is no new surgery for it, just a lot more awareness that the problem can be solved, explains Grover. Grover believes there is great potential to grow the male plastic surgery market. Men have lagged behind in recent years but there is a change in attitude among men now. Men s lifestyle magazines and advertising campaigns coupled with a competitive workplace have pushed the message that you need stamina and edge to succeed and appearance is a big part of this, he adds. Liposuction also remains a popular treatment for both men and women in the UK, according to Bryan Mayou. I see a lot of people wanting liposuction. There is certainly as much now as there ever was but the problem is that in certain establishments it gets done badly which is not good for our trade. More and more I am seeing patients who have had work done elsewhere coming in to have bad lipo corrected. The problem is that there is no regulation. Cleaning up its act Despite its growth in popularity the aesthetics market has no regulation so undertaking a procedure can turn into a game of Russian Roulette. Fillers in this country for instance require no prescription so anyone can take a short course, as little as half a day, and start injecting patients. There is still no control in the surgery nmarket anyone who has a license can pick up a September 2011 ECM 321

16 000 ECM0911 market report.qxp:layout 1 22/9/11 15:38 Page 322 MARKET REPORT AESTHETICS knife and do whatever they want, says Schulte. There should be a compulsory certification for practioners. It s a very sensitive area, says Susan Mayou. There is no regulation so it s absolutely critical that the people who are doing these procedures have integrity and are well trained. They are good cosmetic procedures but they can be done badly. The problem, continues Schulte, is that most aesthetic treatments are undertaken as private procedures so the government is not interested. It s your decision to go. The government has washed its hands of it, says Lowe. There should definitely be more regulation in all aspects of aesthetic surgery. Therapists should not be allowed to use botox or fillers and nurse practitioners should be under the supervision of a dermatologist or specialist skin care physician. These treatments can be very dangerous if not performed by a properly trained person. But there are some small pockets of progress in this area. In May this year the Independent Healthcare Advisory Services (IHAS) launched the Register of Injectible Cosmetic Providers, a patientfocused register which it is hoped will clean up the muddied name of the injectibles market. Practitioners will be screened and their credentials assessed before being added to the register. US Aesthetically pleasing There s little doubt that the recession and the current climate of economic uncertainty here in the US has reduced trips to the dermatologist s office or the aesthetician s spa. But there are still consumers out there who are willing to pay more for these high tech solutions. According to a recent study by Kline & Company, US sales of cosmetics and toiletries rose by 2.4% last year to $36.5bn at the manufacturers level. Skin care accounted for 25% of sales and sales of high tech anti-ageing formulas did particularly well. And when coupled with a trip to the aesthetician or dermatologist, the results are even better. Why do so many of these procedures work so well? In one word, inflammation! There are several states of inflammation from the highly visible (red sunburn, pimples or rashes) to the invisible, which are indeed responsible for the ageing process. All of these procedures, including acid peels, dermabrasion and laser resurfacing, work to beautify the skin because they induce a low level of skin inflammation. Sculpta Clinic The rest of the non-surgical market and the majority of the surgical market remain unregulated. In order for this market to keep its credibility however there needs to be more focus on regulations. As Lowe concludes: We are in a cycle of non-government intervention but I hope this will swing back one day to a focus on the sensible aspects of regulation. I would like to see the professional bodies clamping down but there needs to be a careful balance we don t want to shut down new product development and treatments but patients should expect a safe and effective service. When it comes to reversing the signs of ageing and sun damage, we dermatologists have the advanced tools of the trade to efficiently rejuvenate the skin and remove hyperpigmentation, explains Dr Amy Derick, a dermatologist and founder of Derick Dermatology LLC. The ideal dermatologist will offer a variety of cutting edge therapies using laser and light with combination treatments to improve the health and appearance of the skin. According to Dr Derick, when combined with prescriptive approaches using retinoids and hydroquinone, the results can be dramatic. IPL (intense pulsed light) can be used to treat multiple skin issues at once such as photo damage, uneven skin tone and weathered texture. Another effective method uses a carbon dioxide laser, which causes ablation of the skin tissue known as resurfacing. This device uses the latest fractional technology so that healthy tissue can be left intact. According to Derick, it is perfect for refreshing the tone and texture of photodamaged skin. In addition, a laser that emits multiple wavelengths of light can target different ranges of colour in the skin and therefore help remove freckles, age spots and other forms of photodamage. What s in use? What materials are dermatologists using once they ve reworked the skin canvas? Botox, hyaluronic acid (HA), particle and polymer dermal fillers and collagen dermal fillers are all key facial aesthetic materials. According to a study by Research and Markets, the global market for facial aesthetics is expected to grow 9% a year to reach about $4bn by Meanwhile, the US market for cosmetic surgery, facial aesthetics and medical Tom Branna Tom Branna is editor of Happi, (Household and Personal Products Industry), a US monthly trade magazine. Happi looks at the market for soaps and detergents, cosmetics and toiletries, waxes and polishes, aerosols and related chemical specialities. To subscribe, visit ECM September 2011

17 000 ECM0911 market report.qxp:layout 1 22/9/11 15:38 Page 323 AESTHETICS MARKET REPORT laser devices is expected to jump by nearly 100% to top $3bn by Sales of botulinum toxin (botox being a key example) will grow to an estimated $543m by Clearly there s a trend towards high tech skin care, but consumers don t have to pay a visit to the doctor to benefit from all this technology. In January, Ariel Laboratories, a custom product development laboratory headquartered in New Jersey, launched a complete line of glycolic/salicylic acid skin care products, which target acne prone skin, ageing skin and hyperpigmentation conditions and which promote skin rejuvenation. Glycolic is a natural fruit acid or alpha hydroxy acid (AHA), derived from sugar cane. It works as a highly effective exfoliant to slough off dead skin, which results in a more youthful glow and minimises the appearance of fine lines. When combined with salicylic acid, glycolic also combats acne. Ariel goes a step further by adding non-kojic and nonhydroquinone whitening compounds to reduce skin blotching caused by hyperpigmentation. Ariel Labs 10% active glycolic skin care system consists of a cream exfoliant; an acne control wash with salicylic acid; a facial scrub that contains aluminum oxide; a non-abrasive ingredient commonly used in dermabrasion; and hydrolite, a non-hydroquinone product with skin lightening properties that helps skin achieve an alabaster look, inhibits formation of melanin and evens skin tone. These products can be used in the home, either individually or as part of a complete skin care regime, according to the company. Smooth operators Also in January, Israel-based Christina, brought its cosmeceutical treatment and home care collection to the US professional aestheticians market. Introducing seven multi-stage treatments, creator Christina Zehavi and her team of scientists worked together to offer synergy between professional treatments and at-home treatment products, according to the company. A new line of skin care products, called Eraclea, featuring the patented HylaSponge System has also been launched on the US market. The line comprises products that cleanse, moisturise, exfoliate, repair, nourish and rejuvenate the skin and service every skin type. All of them feature a patented delivery system that utilises HA in a proprietary combination to enhance the skin s hydration for younger looking, healthier skin. According to co-founder, Dr Janet Denlinger, the system utilises hyaluronan, one of the molecular building blocks of our body s intercellular matrix, to create a functional second skin via a network of HylaSponges. Developed by the Matrix Biology Institute, the HylaSponge system is a combination of three forms of HA, also known as hyaluronan. The system is made up of HylaSponges, particles capable of retaining and releasing large amounts of water, much like a sponge, and both high and low molecular weight hyaluronans. The complex forms an elastic equilibrium barrier on the surface of the skin and delivers water and other biologically active ingredients, including vitamin C, towards the deeper layers of the skin. The HylaSponge System is said to hydrate more effectively than HA solutions alone and can hold 100 times its weight in water. Prices range from $35 for a gel cleanser to $95 for a skin peel. Although no one would confuse an Avon Lady with a dermatologist, that hasn t kept Avon from launching the Anew Clinical Derma-Full X3 Facial Filling Serum earlier this year. The product is said to contain three times the level of injectable grade HA for filling and plumping skin. The green machine Skin 2 Skin Care products are focused on antiageing and its products use the highest recommended concentrations of peptides, alpha lipoic acids, antioxidants, moisturisers and antiinflammatory ingredients to achieve quick, noticeable results without the use of carcinogens, according to the company. Consisting of serums, cleansers, moisturisers, masks and creams, Skin 2 Skin Care is recommended for men and women, aged 20 and upwards and of all skin types from sensitive to dry. Using a combination of cutting edge peptide technology and 20 certified organic botanical extracts, Skin 2 Skin Care is redefining what it means to be green. For example, the company recently incorporated a new honeysuckle preservative system into its products. Its latest rollout is 24/7 Rejuvenation, a cream formulated specifically for maturing skin to prevent signs of premature ageing. With four Smart anti-ageing peptides (Tego-PEP 4-17 at 5%, HyaCare50 at 2%, Melanostaine5 at 4% and Eukarion134 at 0.5%), these 21st century megacomponents stimulate and facilitate collagen and HA production to increase and maintain volume and elasticity while tightening and lifting, according to the company. Distribution has grown by 120% in recent months, and company executives say that the distribution plan is to be in doctors offices, medical spas, resorts and day spas, e-commerce and high end speciality stores inside and outside of the US market. Skin 2 Skin Care is also expanding its distribution into the UK, Canada and Brazil by the end of Meanwhile Oxygen Biotherapeutics Inc markets several oxygenating products that are only available at Oxygen treatments have emerged in the past few years as a new form of skin care. From creams to spray treatments (including oxygen inhalation), many spas and dermatology offices across the country now offer oxygen-based products and treatments to clients. Previously, the only way to deliver oxygen to the skin was through hyperbaric oxygen chambers. Recently, Oxygen Biotherapeutics introduced Dermacyte Oxygen Concentrate, a skin care product that provides high concentrations of oxygen directly to the skin without side effects, according to the company. The cream is absorbed rapidly without leaving an oily residue. Dermacyte Oxygen Concentrate was created by a team of scientists who worked for 15 years to develop oxygen-based treatments for life threatening medical conditions. Helped by the September 2011 ECM 323

18 000 ECM0911 market report.qxp:layout 1 22/9/11 15:38 Page 324 MARKET REPORT AESTHETICS miracle of modern technology and after extensive research, they discovered a unique and highly effective carrier that allows the transfer of large amounts of dissolved natural oxygen without the use of chemical activators like hydrogen peroxide, which is known to dry skin. Financial markets around the world may be Russia Filling the gap The market for botox, dermal fillers and other minimally invasive procedures is growing in Russia, according to experts, at a rate of 20% annually. So far there has been no broad-scale research on botox injections in Russia though there were some local surveys done. After some bad celebrity experiences with injections followed by adverse reactions, clinics were expecting a decrease in demand for any kind of injections. But to their astonishment, this unfortunate example didn t scare away Russian women. By expert estimations, the cheapest botox procedures are on the chin and nose area. The price for botox here is estimated from $25-$50 for women and from $50-$100 for men. The most expensive area for injections is the neck, from $250-$400 for women and from $300-$500 for men. The statistics show that more and more men have become concerned about their appearance, especially politicians, businessman and celebrities who are often seen in the public eye. So in order to look younger they are ready to try different antiageing treatments including botox. Making changes According to recent research conducted by the majority of patients making facial corrections with the use of fillers are women at 85% while men make up the other 15% Irina Balashova, head of the RHANA Zhukovka clinics department, and consultant cosmetologist, comments: Generally patients want to correct facial contours or to make up for their subcutaneous fat with a special cocktail of ingredients. In the younger age group patients are interested in lip correction. First of all, they ask what kind of fillers we use and if they lead to any complications. Age becomes her Talking about the age of clients applying for filler services, the statistics show the following data: before 35 years old interest stands at 10%, from tumbling and economies are still struggling, with people cutting back in all areas of their life, but there are many innovative chemists and entrepreneurs out there who are convinced that consumers remain vain enough to spend money on procedures and products that make them look even just a few years younger it is 75% and after the age of 55 it falls back to 15%. Olga Dubovik, dermatologist and cosmetologist of Russia s chain of Beauty Surgery clinics says: Patients from years old usually want to erase expression wrinkles to prevent more serious effects. At the age of people usually notice the first signs of ageing especially those who have thin skin. The majority of our patients are women from years old which makes up about 80% of the total. The absolute leader among the contour treatments based on hyaluronic acid (HA) on the Russian dermal fillers market is Restylane, according to the survey conducted by Nearly half of respondents surveyed prefer to use Restylane (47%). This is due to its long history on the Russian market and strong promotional campaigns and moreover the product has showed good results among the patients who have used it. Radiesse won the second place recommendation (16%) followed by Surgiderm (14%). The fourth place went to Juviderm while the fifth went to the French product Stylage which has recently appeared on the Russian market. Alexey Terehov, Merz Pharmaceuticals aesthetics dermatology department director comments: Restylane is a gold quality standard product but with the development of science and medicine we are seeing new and advanced products appearing on the market. For example, Belotero is a new age filler, based on CPM technology, which has many advantages over the previous products available. It s already widely used in Europe and its popularity grows every year. We find the trend in creating and improving products which stimulate natural collagen production also very useful, considering the increasing number of ageing people in Russia. That s why Radiesse is the future product for providing non-surgical face lifting over a long period of time. But so far it hasn t gained much in popularity both in Europe and in Russia. Nevertheless, we are pursuing an ambitious goal supporting this product on the Russian market. Today the majority of international cosmetology and aesthetics brands are brought to market by small and medium scale distributors. But experts predict that the future of the dermal fillers market belongs to large manufacturing companies who pay lots of attention to the quality of their production methods, treatment safety and patient satisfaction. The Russian market for botox, dermal fillers and other injectable procedures is actively developing, anticipating huge success in the future. Anna Dycheva- Smirnoff Anna Dycheva-Smirnoff is editor in chief of www. cosmeticsinrussia.com, an English language internet newsletter that covers all aspects of Russia s fragrance and cosmetics market. She is also business development director for Intercharm livejournal.com/ 324 ECM September 2011

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