There has been a significant growth in non-surgical treatments and hair restoration surgery in recent years. For many members of the public this has led to great confusion. The JCCP has published a series of information sheets to give a brief explanation of each procedure and the risks involved.
The JCCP currently recognises the following five procedures (modalities) that are performed by our Registrant Practitioners:
These procedures are grouped into five treatment areas or ‘modalities’ which relate simply to the treatments that we regulate currently according to a set of prescribed practice standards (as determined by the Cosmetic Practice Standards Authority – the CPSA) and formal educational qualifications that are set down by the JCCP.
In 2013 Sir Bruce Keogh presented his Government commissioned report into the cosmetic/aesthetic industry, which outlined a range of failings that present a risk to patients and service users. In response, the Government commissioned Health Education England (HEE) in 2013 to work with industry stakeholders (i.e. representatives representing the many interests of the aesthetic sector, such as practitioners, professional associations, education and training providers etc.) and professional regulators to develop a framework of agreed qualifications and standards, to address practitioner failings, to improve public protection and to reduce risks that might occur as the result of harmful practice.
Under the umbrella of Health Education England, multiple industry stakeholders and experts:
Identified the treatments areas (modalities) which were known to cause greatest concern and where risk is highest in relation to patient harm/safety.
Developed a qualifications framework for the five treatment areas ‘modalities’ noted above which set out the education and practice requirements necessary to undertake cosmetic medicine safely.
Defined the requirements for clinical oversight, paying attention to the role of the statutory regulated professional and, in particular, those professionals who are legally entitled to prescribe.
Agreed for the need (in the absence of statutory regulation) for an over-arching authority – the JCCP and its sister organisation the CPSA - which would further develop these standards and oversee their implementation, under a mechanism of voluntary self-regulation (i.e. through the JCCP Practitioner Register).
Whilst five areas of treatment/procedures (or modalities) are currently recognised by both the JCCP and by the CPSA, these are likely to increase in number in the future as new risks to person/patients are identified. It is the specific role of the CPSA to review new treatments as they emerge, to assess risk and where necessary to develop new standards.
For each of the modalities your JCCP practitioner is registered to provide, you can be sure that they:
As a patient you probably know botulinum toxins through a brand name – Botox®. However, there are 3 brands which are licensed in the UK for cosmetic purposes. They are Azzalure®, Bocouture® and Botox®. You may see other brands – Dysport® and Xeomin® - but these are licensed for non-cosmetic purposes. Botulinum toxins are legally classified as prescription only medicines (POM), and this imposes important restrictions.
All botulinum toxins are injected with the aim of targeting a specific muscle. The effect is to limit the movement of that muscle, leading to specific effects and potential side-effects.
This list of side-effects is not exhaustive. You should consult your practitioner for full details of risks as they relate to you and the intended treatment.
For the most common upper face treatments, this can cause ‘drooping’, and often involves the eyebrow and eyelid. In other treatment areas, the ability to smile normally may be affected, and where the lips are involved, eating, drinking and pronunciation may be more difficult.
For treatment of the neck muscles, or for sweating under the arms, this can affect the muscles of swallowing or breathing which, whilst rare, is much more serious.
Should these problems occur, they will resolve fully in a matter of weeks or months.
Tip. Don’t consider the risks simply as a list. Your practitioner should explain what they can do, and what you can do, to minimise these risks.
Tip. Don’t consider the risks (or benefits) in isolation. Your practitioner should work with you to weigh the risks against the benefits, and the decision should be an agreement between you.
Tip. Ensure that you write down any questions that you might have and ensure that you raise these during your initial consultation.
It is illegal to advertise a Prescription Only Medicine (POM), such as botulinum toxins. This includes all references to brand or generic names, in all forms of media (including social media), directly or indirectly i.e. by inference. As a patient you may decide to choose a practitioner on the basis of a register like the JCCP’s and you may also be influenced by their advertising. Illegal advertising may help you limit your choice and make safer choices.
It is a legal requirement that a POM is provided, subject to a prescription, by or as directed by a prescriber. For botulinum toxins, the prescriber is a doctor, dentist, nurse prescriber or pharmacist prescriber. The prescriber is responsible for:
Whilst botulinum toxins are medicines which target muscles, dermal fillers by contrast are injectable implants, that are presented in the form of a viscous gel. Where botulinum toxins target expression lines, dermal fillers can target all forms of lines. Further, they can target folds to lift them and they can add volume where required. The addition of volume is beneficial to address the volume loss that occurs as a natural process over time, or they can be used to augment natural features – the lips being a common example.
The JCCP regulate their members for what are loosely termed the ‘temporary’ and ‘semi-permanent’ dermal fillers. The temporary products are most commonly made from a product that contains hyaluronic acid. The semi-permanent variety tend to last longer because they have an additional collagen stimulating effect. The JCCP do not regulate or approve the highest risk category of dermal fillers – permanent fillers.
Dermal fillers are classified as medical devices. This can offer a certain amount of protection in terms of product quality; however, the restrictions that are placed on the use and supply of dermal fillers are not as significant as those provided for prescription medicines (such as Botox®) even though risks can be significant.
Your practitioner will explain details of the full procedure to you.
Dermal fillers are presented as a gel in a sterile, pre-filled syringe. Your will have agreed the use of one or more syringes prior to treatment. You will also have discussed options, where required, for pain control.
There are various techniques available to inject the filler into or underneath the skin, targeting the specified area to achieve the agreed result.
The result is immediate, but several days are sometimes required for any swelling and redness to settle. The treatment should last between 6 to 18 months, on average, depending on the product used and the location of treatment.
You should be made familiar with the product used, where it has been used, and the specific aftercare instructions, including what side effects you should be aware of and the actions you should take to minimise their impact. You should also ensure that you have been provided with an emergency contact number should you need to use it following your treatment.
The effects can be as subtle or dramatic as required but should always be natural in appearance and proportion. Treatments can range from the injection of dermal fillers superficially into the skin to smooth out fine lines, through the slightly deeper placement to support folds, to the more demanding process of providing larger amounts of volume where required. The ‘liquid face-lift’ is so called because it targets specific areas to provide both volume and structural support in order to lift.
Your practitioner will discuss these complications with you and explain the measures to be taken to minimise or avoid harm being caused.
There are no legal advertising restrictions for medical devices. However, the JCCP and CPSA consider that promotions which are seen to entice the public, are unethical, and as such, contrary to their regulations.
There is no legal requirement for a face to face consultation with a prescriber. However, considering the potential risks, the CPSA and the JCCP have subjected dermal fillers to the same patient safety processes and procedures as prescription medicines. As such face to face consultations with a qualified clinical prescriber is always required for all of our registrants. This is because the management of dermal filler complications require timely access to prescription medicines.
Skin peels involve the use of a serum, often made up of several medical compounds, that is applied to the surface of the skin. The intent is to intensively exfoliate (descale) the skin by removing the outer dead skin to unveil a fresh layer of new skin. Skin peels predominantly target the facial area but can also be used on the body.
Chemical peeling is a procedure wherein a chemical agent of a defined strength is applied to the skin, which causes a controlled destruction of the original skin layers, followed by the regeneration and remodeling of the treated skin areas, with improvement of texture and reduction of any skin surface abnormalities.
The most common and most superficial peels are widely known as the ‘fruit acid’ peels because they are derived from various fruits. However, you may see other types that contain chemical agents such as Trichloroacetic Acid (TCA) and phenol. These agents are often used to target deeper skin problems.
Your JCCP practitioner will describe the full process to you. The peel should only be applied to the area(s) you have agreed with your practitioner, usually with a small brush or a cotton bud. A test patch is often performed first when deeper peels are being considered. The vast majority of peels performed fall into the superficial category, meaning they only target the outermost layers of the skin. Sensitive areas like the corner of the eyes or nose are protected with Vaseline. Depending on the chemical peel used, it may be washed off with water or a recommended neutralising agent.
Mesotherapy is a non-surgical skin rejuvenation treatment, aimed at areas on the face and body. It involves the injection of vitamins, enzymes, hormones, hyaluronic acid and natural plant extracts into the skin to nourish and rejuvenate skin following treatment.
The process of Mesotherapy involves the insertion of a series of superficial injections of the active ingredients into the skin. There are multiple different types of injection techniques that your practitioner can use. These target different areas in the skin that can lead to increased skin quality and skin renewal.
Micro needling is a rejuvenating skin treatment that is performed through the use of a ‘skin roller’ (also known as a ‘dermaroller’). The skin roller repeatedly penetrates the skin area to be treated, creating thousands of tiny microchannels that the skin perceives as micro-wounds or micro-injuries which stimulates the body's natural healing process. The result is smoother, healthier, and younger-looking skin.
The microneedle device contains fine needles that work to eliminate scarring, marks and lesions on the face and body. The skin responds by filling the wounds with collagen and elastin, which are natural proteins that can effectively strengthen the skin and reduce the appearance of scarring. The needle length varies, and this variation has an impact on the benefits and risks of the treatment. Micro needling and mesotherapy are often delivered as combined treatments.
Some practitioners may use a variety of applicators to perform micro needling. This includes the use of a simple syringe with a needle, a manual roller, or one of many electronic medical devices that deliver a series of adjustable fine needles at a controlled depth, typically in the format of a pen. Anaesthetic cream will usually be applied for at least 30 minutes prior to treatment. This treatment works to have an effect on the health, nutrition and quality of the different layers of the skin.
Tip: If targeting a specific skin lesion, especially if it may be caused by exposure to sun or Ultra Violet light, ensure your practitioner is qualified to diagnose the lesion (an area of abnormal tissue), or that they refer you to your GP or dermatologist before you commence any procedure.
Tip: This is an ideal opportunity to discuss your use of sun protection cream, and methods of sun avoidance (including sun-beds), with your practitioner.
Tip: Ask for recovery time after the procedure – discuss how long will it take for your appearance to return to normal. Make sure that you know what chemicals are being used in your peels and whether there are any risks or side effects associated with their use. Ask what aftercare is required.
Tip: If you are over 65, of darker skin type or have very fragile skin beware of treatments as the risks may outweigh the benefits.
Tip: In addition to your medical history, ensure your practitioner knows the skin products you are currently using, as this may affect your response to treatment.
All skin rejuvenation treatments are designed to improve the quality of the skin. After treatment you may perceive that your skin has improved in texture and has a more even tone. Chemical peels can also be effective for cosmetic acne but should complement, not interfere with treatment prescribed by your GP. Fine lines may or may not improve, depending on the nature of the treatment you receive. Your practitioner may be able to target specific concerns that you may present with, such as stretch marks, scarring and specific blemishes.
Adverse effects (that you should be aware of)
There are no specific legal restrictions to the use of peels, mesotherapy or micro needling. These treatments are often delivered as a course of treatments. The JCCP would warn patients to ensure that they discuss their treatment plan with their practitioner prior to commencing either singular or a course of treatments to ensure to avoid being ‘enticed’ into multiple treatments that might not be necessary. All skin rejuvenation treatments pose various degrees of risk, depending on the nature and extent of the product used. All JCCP registered practitioners are qualified to the required level for the treatments that they offer and, where treatment risks are considered to be higher, the JCCP will state clearly where your practitioner must work under supervision.
Laser and light therapy (LIPLED) / Energy based devices
Lasers are a medical device that emit light, but unlike a light bulb which has a rainbow of colours, lasers produce light at a single colour with a specific wavelength and direction. Many patients consider lasers and light therapy to be effective treatments for a variety of skin conditions that can have cosmetic implications. Lasers and IPL stand for ‘Light wave Amplification by Stimulated Emission of Radiation’ and ‘Intense Pulsed Light’ respectively.
Lasers can be delivered through a range of different mediums (a substance that makes possible the transfer of energy from one location to another, especially through waves) to give different wavelengths:
Different wavelengths can be used to target different depths within the layers of skin and are therefore used to treat a wide variety of different skin problems and conditions.
LED - Light-emitting diode (a diode is an electrical device that allows an electrical current to pass through it) therapy is an increasingly popular methodology for the treatment of sun damage and for the signs of aging. It can be used to help soften lines and aid in a more youthful look.
The JCCP seeks to regulate lasers used for treating cosmetic procedures such as hair removal, skin resurfacing / rejuvenation, treatment of vascular (relating to blood vessels in the skin)/ pigmented (coloured)/ scar / acne lesions/skin abnormalities and tattoo removal.
The effects and benefits of laser and light treatments are as diverse as the devices used. However, they all have in common the highly effective ability to remove unwanted cosmetic concerns that relate to the skin.
Laser resurfacing is a very controlled procedure in which a laser removes superficial layers of facial skin. It can remove not only wrinkles and lines caused by sun damage and facial expressions, but also acne scars. Cosmetic lasers work by heating tissue which stimulates the new growth of tissue for example new collagen in the skin. Skin resurfacing can be performed via ablative (i.e. the removal of a layer (or layers) of tissue with the aim of restoring normal function) or non-ablative methods. Ablative lasers visibly remove layers of skin which poses greater risk and recovery time.
For laser vein removal, the blood within a blood vessel is heated and the resulting injury of the blood vessel wall makes it eventually disappear. This is how cosmetic lasers can be used to remove superficial blood vessels on the face e.g. in rosacea (a long-term skin condition that typically affects the face, resulting in redness, pimples, swelling, and small and superficial dilated blood vessels), leg veins and in skin treatments applied to many other areas of the body.
Laser hair removal is a treatment that uses a laser or IPL to remove unwanted hair. IPL (intermittent Pulsed Light) uses a wider range of wavelengths, so it is less focused and may require more treatment.
This laser heats and destroys hair follicles in the skin, disrupting hair growth. Common areas to treat are the face, legs, arms, underarms and bikini line. It can be helpful for women with hirsutism (excessive hair growth).
Laser Scar Treatment
Laser scar treatment uses laser to reach deep into the skin’s layers in order to break down the thick scar tissue present. Often ablative lasers can be used for this.
Cosmetic lasers can target tattoo ink pigment with a high intensity and focused light beam causing the ink to break up into smaller molecules. The ink is then naturally absorbed by the body, resulting in the potential fading of the tattoo.
Although, some types of pigmented lesions exist at birth, often new pigment can represent one of the first signs of aging. Lasers can be set to an optimal wavelength of light to remove pigmented lesions by targeting melanin. The laser treated lesion is then naturally removed by the skin’s healing
Low-Level Light Therapy (LLLT) has numerous applications and the benefit depend on the wavelength of the light being absorbed. Differing wavelength of the light energy applied there are numerous reported benefit such as reducing inflammation, helping tissue repair and regeneration.
On the day, your skin will be cleaned and you will wear specially designed goggles to protect your eyes during the procedure.
Local anaesthetic injections are not necessary however you may have some topical numbing cream applied. The practitioner usually applies a cool gel or cooling air spray to the area of skin. The practitioner may then press a hand-held device to your skin and trigger the laser.
For Light-emitting diode (LED) therapy goggles are worn as you lie under the light source.
Cosmetic lasers treatments do come with some risks: risks for the laser operators and the patients undergoing therapy. As with any medical procedure, patients must be aware that they might experience certain complications which could be temporary or permanent. These could include:
Tip: For lesions or skin abnormalities that may be caused by sun damage, ensure your practitioner is competent and experienced to diagnose the lesion or that they refer you to a specialist before treatment before commencing any course of treatment.
Tip: Make sure you know the recovery time needed after your treatment with the laser being used
Tip: Make sure you know if a course of treatment is needed and that you are fully informed of the costs of the complete course costs before you agree to receive the treatment.
Tip: You should always have a patch test (a small testing area with the laser) prior to any treatment to ensure you do not have an adverse reaction to the lasers and to ensure that your treatment will be performed at safe and optimal settings.
Tip: Beware of clinics and practitioners advertising procedures on offer on a website at a reduced rate. Some clinics and practitioners do not have the appropriate training and devices required to treat you safely.
Tip: Ask if the device being used if is CE (European Conformity quality assurance kitemark) marked to confirm that it is in fact safe to use.
Tip: If you have a darker skin type you may be more at risk of burns and changes to pigmentation in your skin e.g. lighter or darker patches may appear on the skin which can be irreversible – we advise consulting with a GMC registered doctor prior to the commencement of any treatment under these circumstances.
Tip: Ensure that you carefully follow the pre and post care information that you are given (ensure these have been explained to you!) You will probably need to avoid sun exposure or use sunblock for several weeks following treatment.
Lasers and light-based devices do not have advertising restrictions; however, statutory regulated professionals (such as doctors and nurses) consider that publicity promotions which are seen to entice the public, are unethical, and as such, contrary to their regulations. This standard is applied by the JCCP and CPSA.
The JCCP considers that it is best practice that you have a face to face consultation with a qualified practitioner before you commence any laser procedure. It is important to understand the risks that can occur in both the short and longer term with lasers and also how and who to contact if you have an adverse side effect following your treatment.
Some conditions require more than just laser treatments (e.g. scars resulting from burns or surgical wounds) and may require different forms of treatment. In these situations, it is advisable to consult with a GMC registered doctor.
Cooling off period
The JCCP advises you to receive a consultation prior to commencing treatment and a cooling off period of two to five days before treatment actually commences. You should always remember that a patch test should be offered to you prior to the commencement of your initial treatment.
It is important to discuss details of the treatment you are about to receive when enquiring about laser treatments. Most ablative lasers are associated with longer recovery times e.g. 1 to 2 weeks resulting in immediate redness and crusting of the skin surface in the area treated. This can have a negative psychological impact in the short term before the longer-term potential benefits are fully realised. Be sure you know what the recovery time is and tailor your diary to your needs.
Hair Transplant Surgery is one of the commonest male cosmetic procedures and is usually requested for genetic male pattern hair loss. It is also commonly requested by women with hair or eyebrow hair loss, by male to female transgender patients wanting to create a feminine hairline, and for other aesthetic/cosmetic indications. It can be used for reconstruction to restore hair to scars and for some dermatological conditions that cause alopecia (hair loss). There are two methods of harvesting donor hair – Follicular Unit Excision (FUE) and Strip Follicular Unit Transplantation (Strip FUT).
In the FUE method, individual follicular units are extracted using one of a variety of manual, motorised or robotic punch devices. The extraction sites leave small round scars and there is a reduction in donor zone hair density. Whilst the donor location is usually the scalp, in men, body hair can be extracted from the beard and chest.
In the Strip FUT method, a strip of skin is removed from the scalp and dissected into individual follicular (hair cell) units. This leaves a linear surgical scar, so the hair needs to be worn long enough to hide the scar. In general, more follicles can be harvested using the Strip FUT method, both in one procedure and over multiple procedures, so this technique might be more suitable for those patients with a low donor: recipient ratio.
In both methods, the harvested hair follicle grafts are then inserted in the recipient site. This can be done using sharp implanters where the incision in the skin is made and the graft inserted in one step or using dull implanters where the grafts are inserted into pre-made incisions. Insertion of grafts can also be done into pre-made incisions using forceps.
Hair Transplant Surgery should not be described as ‘painless’, ‘scarless’, ‘non-invasive’, ‘not requiring incisions’, ‘no cutting’, ‘no touch’, ‘hair multiplication’ or ‘eliminates the need for further procedures’ and is not without risk.
The general risks and complications of surgery are bleeding, infection and pain. Risks specific to the donor site for FUE include donor hair depletion, extensive punctate scarring and skin necrosis. Risks specific to the donor site for Strip FUT include wound healing problems, skin necrosis and widened unsightly scars. Risks related to the recipient site include incorrect hairline design, low density, suboptimal aesthetic appearance (hair direction/angle), and scalp pitting/cobble stoning.
Some Prosthetic Hair Fibres are legal in the UK and can be implanted to simulate real hair. However, they do not grow, are prone to getting infected, produce scarring, and implantation results in some lifestyle restriction. The long-term implications of implanting artificial hair have not been evaluated in the UK. The JCCP recommends that only Hair Transplant Surgeons implant prosthetic hair fibres.
Additionally, poor patient selection, failing to take into account on-going hair loss, can result in an unnatural appearance with transplanted hair isolated from receding hair especially in the hairline, temples and crown in men. As with any cosmetic procedure, failure to manage expectations can result in patient dissatisfaction.
Hair Transplant Surgeons are supported by Hair Transplant Surgical Assistants who prepare follicular unit grafts, place follicular unit grafts, and remove Follicular Unit Excision (FUE) grafts from the donor zone where the FUE incisions have been made by a doctor or doctor-run robotic device. These assistants may be nurses, but they may also come from backgrounds with no medical training. Assistants should not perform any of the surgical steps of a hair transplant procedure such as making FUE incisions or recipient site incisions, including those incisions made by sharp implanters. Patients should be clear to whom they have given consent to be operated on by, should ask who will be performing the various elements of their hair transplant surgery, and should be aware during the procedure of who is operating on the back of their head when they cannot see them.
Hair Restoration Surgery in England must be performed in a Care Quality Commission (CQC – the health and social care quality regulator in England) registered facility and the CQC licence should be clearly displayed for patients to see. In addition, all clinics advertising hair restoration surgery on their website should be CQC registered even if the surgery is performed in a separate location that is CQC registered.
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