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VOLUME 7/ISSUE 10 - SEPTEMBER 2020

THE NEWEST TREATMENT FOR NON-INVASIVE FAT LOSS AND CELLULITE REDUCTION LASER via ELECTROMAGNETIC ENERGY TRANSFER! ALL THE BENEFITS OF FAT CELL MANAGEMENT COUPLED WITH CELLULAR ANTIAGEING!

SEE PAG FOR F E 12 URT DETA HER ILS

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Exploring Bone Ageing CPD Mr James Olding details how facial bones change over time

Special Focus: Improving Diversity

Exclusive insight from the Black Aesthetics Advisory Board

Creating Podcasts

Audio specialist Ben Anderson explores how to create podcasts for your clinic

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Opening a New Clinic

Dr Anna Hemming shares advice on establishing your own aesthetic premises


THE DIGITRX AWARD FOR P R O D U C T I N N O V AT I O N OF THE YEAR

Light Therapy


Contents • September 2020 06 News The latest product and industry news 16 Charity: Supporting Consultant Trips from the UK Raising funds for Facing the World 18 Advertorial: Hair Transplants, The New Growth Industry Exploring the popular new NeoGraft technique for hair transplantation 20 Special Focus: Voicing the Specialty’s Diversity Concerns Aesthetics exclusively highlights the results of three surveys conducted by

the Black Aesthetics Advisory Board

23 Special Focus: Improving Diversity in Aesthetics The Black Aesthetics Advisory Board provides exclusive tips on how the

industry can support both practitioners and patients with skin of colour

26 Advertorial: Using BELOTERO® Volume Dr Kim Booysen shares her experience of using the Merz Aesthetics filler

Special Focus Improving Diversity in Aesthetics Page 20

CLINICAL PRACTICE 27 CPD: Exploring Bone Ageing Mr James Olding details how facial bones change over time 31 Understanding Bruxism Dr Heather Muir details treatment options for teeth clenching and grinding 38 Case Study: Contouring the Lower Eyelid Consultant oculoplastic surgeon Mr Daniel Ezra details his approach to

treating ‘almond eyes’

40 Advertorial: Treating Cosmetic ‘Tech-Neck’ for Patients Post-lockdown with Thermage FLX Healthcare professionals are seeing more patients with neck and jawline concerns

41 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 42 Spotlight On: Smileworks An insight into the practice with the UK’s most elaborate theme 45 Considerations for Redundancy Employment associate Catherine Hawkes provides advice for

implementing staff redundancies

49 Getting Started in Aesthetics

Dr Sadequr Rahman shares his ‘ABC toolkit for aesthetic medicine’

51 Creating Aesthetic Podcasts Audio production specialist Ben Anderson explores how to create

podcasts for your clinic

57 Building Trust by Establishing Authority Business consultant Alan S. Adams discusses how authority can impact

In Practice Getting Started in Aesthetics Page 49

Clinical Contributors Mr James Olding is an aesthetic doctor and injectables trainer. He is training in oral and maxillofacial surgery in the NHS. He studied medicine at the University of Bristol, is a member of the Royal College of Surgeons. Dr Heather Muir is a dentist with more than 17 years’ experience in facial aesthetic treatments. She currently teaches facial aesthetic techniques to dentists, doctors and nurses and is the owner of Your Face Aesthetics in Uddington, Scotland. Mr Daniel Ezra is a consultant oculoplastic surgeon at Moorfields Eye Hospital and honorary associate professor at the UCL Institute of Ophthalmology in Central London. He is also the head of department and service director of Oculoplastic Surgery.

customer decisions

60 Opening a New Clinic Dr Anna Hemming shares her advice on establishing your own

aesthetic premises

63 Applying Skills from Dentistry to Aesthetics Dr Caroline McAuley explains how dental training relates to aesthetics 67 In Profile: Anna Gunning Aesthetic nurse Anna Gunning explains her journey to clinic owner 69 The Last Word: Before and After Images

 Nurse prescriber Natalie Haswell explores why she no longer uses before

and after photos for marketing

NEXT MONTH • In Focus: CCR • Permanent Threads • Understanding Eyelashes • Acne and Pregnancy

BO O K YO U R T I C KE T S N OW !


Editor’s letter Are you hesitant to treat darker skin types? Do you think more training is required? Given the fact that seven out of 10 black patients said they had difficulties in finding practitioners confident in treating their skin, it wouldn’t be surprising. Chloé Gronow Over the past few months, we have worked Editor & Content with the Black Aesthetics Advisory Board Manager to share surveys and gather statistics on @chloe_aestheticseditor the experiences of black consumers and practitioners in medical aesthetics. The results, detailed exclusively on p.20, offer some insightful reading. As well as informing our readers of the challenges faced by many, we wanted to advise you on how you can help solve the problem, so have included valuable suggestions from the members of the BAAB on p.23. The team and I will be continuing to work with the BAAB to deliver educational material to readers and event attendees, so if you have any other experiences or ideas to share, please do get in touch!

My next question to you is how do you find the commercial aspects of running a clinic? From speaking to many readers, we know this can be challenging for many. That’s why this issue is dedicated to business development. You’ll hear from a range of professionals on topics that include building trust with patients and considerations for opening your own premises! Yet unfortunately, there’s a sad reality that as a result of COVID-19, some companies may have to make some staff redundancies over the next few months. So we also cover how to do this appropriately on p.45. After that, if you’re looking for a bit of light-hearted reading, then check out our Spotlight On Smileworks on p.42. We chatted to Dr MJ Rowland-Warmann about why and how she created an airline-themed clinic! This unique concept is a really fascinating read with some great pictures, so do check it out! Finally, congratulations to everyone who submitted their Aesthetics Awards entry on time! Finalists will be announced in October, make sure you’re following our social channels to ensure you get all the latest updates as soon as we announce them!

Clinical Advisory Board

Leading figures from the medical aesthetic community have joined the Aesthetics Advisory Board to help steer the direction of our educational, clinical and business content

WE WANT TO HEAR FROM YOU!

Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with more than 20 years’ experience and is director of P&D Surgery. He is an international presenter, as well as the medical director and lead tutor of the multi-award-winning Dalvi Humzah Aesthetic Training courses. Mr Humzah is founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow. Mr Dalvi Humzah, Clinical Lead

Do you have any techniques to share, case studies to showcase or knowledge to impart?

Dr Raj Acquilla is a cosmetic dermatologist with more than 18 years’ experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer for botulinum toxin and dermal fillers.

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic nonsurgical medical standards. She is a registered university mentor in cosmetic medicine and has completed the Northumbria University Master’s course in non-surgical cosmetic interventions.

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon at the Cadogan Clinic in Chelsea, London. She specialises in cosmetic eyelid surgery and facial aesthetics. Miss Hawkes also leads the emergency eye care service for the Royal Berkshire NHS Foundation Trust.

Jackie Partridge is an aesthetic nurse prescriber with a BSc in Professional Practice (Dermatology). She has recently completed her Master’s in Aesthetic Medicine, for which she is also a course mentor. Partridge is a founding board member of the British Association of Cosmetic Nurses and has represented the association for Health Improvement Scotland.

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 AntiAgeing Experts. Dr Patel is passionate about standards in aesthetic medicine.

Mr Adrian Richards is a plastic and cosmetic surgeon with 18 years’ experience. He is the clinical director of the aesthetic training provider Cosmetic Courses and surgeon at The Private Clinic. He is also member of the British Association of Plastic and Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons.

Dr Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the clinical director of Revivify London, an honorary clinical teacher at King’s College London and a visiting associate professor at Shanghai Jiao Tong University.

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multi-award winning EUDELO Dermatology & Skin Wellbeing in London. She lectures in the Division of Cosmetic Science and has published more than 100 scientific articles, book chapters and abstracts.

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Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Chloe Carville, contact@aestheticsjournal.com

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© Copyright 2020 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


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Education

Talk #Aesthetics Follow us on Twitter @aestheticsgroup and Instagram @aestheticsjournaluk

#ClinicVisit Dr Nestor Demosthenos @dr_nestor_d Fantastic seeing @chloe_aestheticseditor from @aestheticsjournaluk last week. The team gave her some tips on what she HAAAAAD to see while in Edinburgh. Needless to say, Chloe fell in love with Edinburgh. #Surgery Dr Paul Banwell @paulbanwell Happy to be working again and in a more familiar environment! Working with a great team at #theharleystreethospital and @thebanwellclinic. It is our second theatre day this week so things are getting busy again! #Wellness Francesca White @francesca__white With last night’s fabulous @the_beauty_triangle panel for our “Zoom Grooming” webinar. A big thank you to @kaymontano, @drjacquelinelewis and @zoeirwinhair for showing us how to navigate our newly virtual world... as well as empowering us to feel more confident on camera. #Rebrand Dr Raj Aquilla @rajacquilla Exciting times ahead with my awesome team planning a full rebrand for both patients and medical professionals

#Opening Dr Vix Manning @drvix.manning A very proud day for #teamriver and an extremely emotional one. After months of planning, building and tweaking our journey has ended my smile then became happy tears. We can now take Bournemouth by storm #lovingit #teamwork #weareonlyasgoodasourteam

New aesthetics charity conference launches Aesthetic practitioners Dr Lara Watson and Dr Priyanka Chadha are launching the Aesthetics United Charity Conference (AUCC), taking place on February 27 in London. Dr Watson explains that Aesthetics United is a newly founded non-profit organisation, created with the intention of bringing together the aesthetics community. The event will be delivering free educational sessions whilst raising money for Refuge UK and NHS Charities Together. She said, “We wanted to unite the aesthetics world behind a charitable cause and support those working in our sector to get people back on their feet post COVID-19. We want our speakers to share their own personal journeys, so rather than just pushing new products it’s going to be about the trials and tribulations of the industry and how we overcome them. It’s going to be honest and uncensored – we want to learn about individuals.” Dr Chadha added, “The event is for practitioners and by practitioners, with a number of exciting health and wellness groups exhibiting and offering unique opportunities to attendees.” Speakers at the event include aesthetic practitioners Mr Ash Labib, Dr Benji Dhillon, Dr Nina Bal, Dr Maryam Zamani, Mrs Sabrina Shah Desai, nurse prescriber Sharon Bennett, consultant plastic surgeons Mr Paul Banwell and Mr Naveen Cavale, journalist Alice Hart-Davis and the founders of Glowday, Joby and Hannah Russell. Dr Watson also explains that they will be pairing these headline speakers with new and upcoming practitioners or ‘rising stars’, with sessions featuring collaborative work between the two. Business support

Galderma funds discounts for management software Global pharmaceutical company Galderma will fund discounts of up to 100% for the Consentz practice management software, as part of its new Bounce Back initiative. The initiative was started as a support programme to help Galderma’s customers get back on their feet once restrictions lift and clinics can open again. Consentz is designed to manage all aspects of the practice; from patient access and consultations to billing and stock reporting. Toby Cooper, business unit head at Galderma UK, said, “Galderma is committed to doing everything we can to help clinics bounce back. This Galderma-funded discount will help clinics to trial a paperless system at very little or no cost, helping them to focus on treating patients and rebuilding their business.” Galderma explains that it will also pre-load the entire Bounce Back suite of materials onto Consentz. To access the discount, clinics will need to request a code from Galderma which must be redeemed on the Consentz website by September 30.

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Celebration

Aesthetics Awards finalists to be announced in October

Vital Statistics Only 15% of 3,600 surveyed adults would apply sunscreen when outside in the sun, and only 39% would take the precaution while sunbathing (Sanofi Genzyme, 2020)

Finalists for the Aesthetics Awards will be revealed in October, celebrating clinics, practitioners, products and companies ahead of the official Aesthetics Awards ceremony on March 13. Aesthetics is also delighted to announce that online aesthetics training website, Summit, run by aesthetic practitioner Dr Raj Aquilla, has been confirmed as the sponsor for one of this year’s new categories; Rising Star of the Year. The award will recognise the doctor, dentist or nurse who is deemed to have contributed most to the profession, and/or has provided the most outstanding care and treatment to their patients in the last 12 months, who has less than five years’ experience in the industry. Dr Acquilla commented, “It’s an honour to put my name to this award. The Aesthetics Awards are a big deal, there are a lot of young injectors that I mentor that are so talented that deserve this recognition. I want to support the next generation of superstars who are clever, have a good eye, are artistic and creative and have the right ethics and moral framework to be successful. I want to support the new generation of practitioners entering the field and help them to thrive and prosper.” Conference

BACN launches online regional meetings The British Association of Aesthetic Nurses (BACN) will be hosting its autumn regional events in September and October on a virtual conference platform. The association states that despite being online, it is keeping its usual regional structure so that delegates have a familiar setting for peerto-peer review, sponsors can introduce them to the relevant company representatives, and regional leaders can present news and information. Locations and dates include: Birmingham, September 2; Newcastle, September 7; Southampton, September 14; Leeds, September 17; Manchester, September 18; Cambridge, September 24; London, October 13; Bristol, October 14 and Belfast, October 20. Despite the events being separated by region, all of the digital conferences will be open to BACN members from any area. Sharon Bennett, chair of BACN, commented, “COVID-19 has presented the BACN with many challenges this year not least what to do about our annual conference but also our bi-annual regional meetings. The BACN board, and more especially our dedicated administrative team, have grasped the opportunity with both hands to be innovative and creative so as to deliver high quality presentations and education from industry leading speakers and sponsors. The BACN team have worked so hard to bring our digital conferences to our membership, and they are now free to book.”

62% of practitioners are confident their business revenue will return to prepandemic levels within 12 months of restrictions being lifted (Cynosure, 2020)

77% of 2,006 women, aged 18-59, wish their physician would tell them more about treatment options that target root causes for cellulite (The Harris Poll, 2020)

69% of respondents said that smaller influencers with between 1,000 and 5,000 followers boosted consumer engagement with their brand and were more successful compared to influencers found in the higher tiers (Influencer Intelligence, 2020)

90% of 300 rosacea patients and 318 psoriasis patients felt their disease was partially or totally uncontrolled, and over 50% felt their disease significantly impacted their daily lives (medicalresearch.com, 2020)

One fifth of 5,000 18-24-year-olds surveyed said they had deactivated their social media accounts in the past year (Dentsu Aegis Network, 2020)

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Events Diary

1 2 RCH & 1 3 12 M A&R C H 2 02 L O N D ON ON MA 13, 20 2 11 |/ LOND AESTHETICSCONFERENCE.COM

Ageing

SkinCeuticals releases neck cream Cosmeceutical company SkinCeuticals has released the Tripeptide-R Neck Repair cream, designed to target visible neck ageing. The company explains that the corrective cream contains glaucine (yellow poppy extract) to stimulate lipolysis, tripeptides to unify collagen and elastin fibres, and retinol to strengthen collagen fibres. According to SkinCeuticals, the Tripeptide-R Night Repair can be used as at-home support for clinical procedures such as Kybella, Thermage, Coolmini and Ultherapy. Miss Jonquille Chantrey, aesthetic surgeon, commented, “Until now it has been difficult to find a topical retinol that patients can tolerate on thin neck skin. The new Tripeptide-R Neck Repair is an exciting option as it contains 0.2% retinol which has been well tolerated and shown efficiency in early studies.”

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Fat reduction

Erchonia launches new green laser Cosmetic and medical laser manufacturer Erchonia Corporation has launched a new low-level green laser designed for body fat reduction. Erchonia explains that the Emerald device emits 10 green lasers onto the skin, aiming to emulsify the adipose tissue and release excess fatty materials. The company also states that the laser was FDA cleared in three separate clinical trials, with no known side effects. Julie Davies, events manager at Erchonia, said, “Emerald is the only laser in the world that has been given FDA market clearance for overall body circumference reduction in patients with small pockets of fat, to individuals with a BMI up to 40. The laser works as a natural alternative for fat loss by using low level lasers and electromagnetic energy transfer. It’s a way to preserve your patient’s endocrinal cell function.” Skincare

Medik8 launches new serum UK skincare manufacturer Medik8 has launched a new retinol alternative peptide-infused serum, Bakuchiol Peptides. The company explains that the product is formulated with 1.25% pure bakuchiol, peptides and cica extract, which together aim to rejuvenate the skin and help with fine lines and wrinkles. Daniel Isaacs, director of research at Medik8, said, “Bakuchiol has been on our radar for some time now as a fantastic retinol alternative. We currently use it in our Calmwise range, but we wanted to create a dedicated bakuchiol product for those who this ingredient is beneficial for. Some people can’t use retinoids including pregnant and nursing mothers, or those with extremely sensitive skin. Bakuchiol Peptides gives these customers an alternative to vitamin A.” Learning

BCAM launches virtual conference The British College of Aesthetic Medicine (BCAM) has launched its first digital conference, which will be held online from September 14-19. The association explains that delegates will be able to access pre-recorded and live sessions, which will cover topics such as: complications, body and wellness, women’s health, skin of colour, mental health and COVID-19. Dr Uliana Gout, BCAM president, commented, “We are proud to steer and lead the UK aesthetic medicine specialty and our Virtual 2020 Conference will be showcasing the latest concepts, trends and regulatory developments within the last year, especially with recent COVID-19 events in mind. We are grateful to all our trustees, members and business partners for all their support in bringing this Virtual Conference together – it has been a fantastic team effort!”

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Threads

Injectables

Novus Medical to distribute APTOS threads Medical aesthetic company Novus Medical has been named as the sole distributor for APTOS threads as the brand launches in the UK. APTOS threads have been used globally in plastic and aesthetic surgery since 1996 and will now be available to doctors, dentists and surgeons in the UK through Novus Medical. The company explains that APTOS offers two types of threads: absorbable threads of L-lactide copolymer with ε-caprolactone that aim to correct visible, fine wrinkles and folds which lasts for two to three years, as well as non-absorbable threads made from polypropylene which last for five years. Like other thread-lifting treatments, practitioners must be practising in a CQC or HIS approved clinic in order to perform the treatment. Director of Novus Medical, Jim Westwood, said, “We’re delighted to be in a position to share this innovation from APTOS with the UK market. We’re committed to offering a significant level of training for our physicians alongside effective marketing support. The expanded range of APTOS products, combined with the latest advances in this field, allows each physician to select an individual solution for their patient and eliminate the problem even in difficult cases through combining methods and threads of different types. It’s a very exciting development for the industry.” Technology

InMode set to launch new hands-free RF device

Intraline launches new dermal filler line Medical aesthetic company Intraline has released three new dermal fillers to its M Series line called the M2 Plus, the M3 Plus and M4 Plus. The company explains that the M2 Plus is designed for fine lines and wrinkles, the M3 Plus for lips and medium to deep wrinkles and the M4 Plus is a subcutaneous filler for facial contouring, nonsurgical rhinoplasty, and treating lips. All fillers from the M Series are formulated using non-animal derived hyaluronic acid (HA), the company states. Lisa Fraser, vice president of Intraline, said, “We are thrilled to launch our new M Series line of dermal fillers. Providing high quality safe and effective products is what we’re all about. The response we have been receiving from practitioners is phenomenal. It’s a very exciting time for our company.” Brand ambassador and aesthetic practitioner, Dr Amrit Thiara, said, “The M Series is at the forefront of filler technology with very little product migration, and very nice, natural, and noticeable results. Patients are finding with the lidocaine it is extremely comfortable at the time of injection. Patients are also reporting that they are getting an overall more attractive appearance, which is also looking so natural.” Education

Medical device manufacturer InMode will launch Evoke, a hands-free radiofrequency (RF) platform for facial remodelling, in the UK by the end of this year. The company explains that the device’s facial applicators deliver bipolar RF energy to the cheeks, neck, and jawline. The RF energy penetrates into the subdermal layer, heating the fibro septal network and remodelling the dermis and subdermal tissue to make facial features more defined. Dr Michael Kreindel, InMode chief technology officer and inventor of Evoke, commented, “The idea of a facial hands-free treatment has been circulating in the market for about eight years. I’m proud that InMode, after years of research and development, is the first company to bring this solution to patients worldwide.” Dr Spero Theodorou, InMode chief medical officer and plastic surgeon, said, “Evoke delivers the ultimate solution in thermal facial procedures. Patients can not only turn back the hands of time but are now also able to achieve long-lasting structural enhancements to their face without excisional surgery.”

Northumbria University removes Master’s in Aesthetics The University of Northumbria will no longer be running its MSc in Aesthetic Medicine, which first launched in 2016. On the decision to stop the course, Andrea Slowly, PR and media manager at Northumbria, said, “Northumbria University worked with professional associations and aesthetic practitioners to develop an innovative three-year Master’s programme for nurses, doctors and dentists undertaking nonsurgical aesthetic interventions. Although student feedback has been positive, the numbers of students have decreased over the years.” She continued, “The course was reviewed during this academic year as part of a broader exercise looking at our nursing, midwifery and health programmes. It was considered no longer viable to run due to small cohort numbers and a decision was made to gradually roll out the programme. We will continue to fully support existing students in their second and third years”. Delegates looking to complete a Master’s in aesthetic medicine in the UK can instead apply to Queen Mary University of London, University of Manchester and University of South Wales.

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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BACN UPDATES A roundup of the latest news and events from the British Association of Cosmetic Nurses

CAREER FRAMEWORK FOR AESTHETIC NURSING In 2013, the BACN produced its first ‘Competency Framework for Nurses in NonSurgical Procedures’, which was updated in 2015. Since the last update, there has been a lot of developmental activity within aesthetics, and the BACN took the decision to re-examine its framework and look at establishing a ‘Career Framework for Aesthetic Nursing’. The framework recognises the specialist and evolving nature of aesthetic nursing and the need to provide clear and consistent guidance for practitioners that will help them to identify and develop competence. In particular, the framework acknowledges that aesthetic nurses require specific, specialist knowledge and skills at different levels of practice. Moreover, the framework advocates the need to establish and maintain appropriate standards of education, training and practice to ensure that aesthetic nurses possess the requisite knowledge, understanding and skills to provide professional and ethical treatment and care to patients, according to their level of competence. The BACN ‘Career Framework for Aesthetic Nursing’ has been delayed by the COVID-19 pandemic but the BACN Education and Training Committee has reconvened and will be looking to complete a first draft of this framework for peer review in the next couple of months. Once the peer review has been completed the BACN will consult its members prior to establishing the framework. During this period, the BACN will also be doing the following: • Consulting and looking to gain support for the framework from key partners including the NMC and the RCN • Identifying and sourcing the expertise to carry out the assessment procedures that will form part of the project moving forward • Reviewing the impact of any proposals on BACN membership categories and fees It is anticipated that it will be 2021 before the framework is introduced in its entirety. This column is written and supported by the BACN

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Business

SkinBrands teams up with Medik8 to support clinics Cosmeceutical company SkinBrands has partnered with skincare manufacturer Medik8 to help produce support packages for aesthetic businesses, which will include free PPE and a 20% discount for Medik8 orders. The company explains that the packages have been designed to help businesses which are struggling to get back on their feet following lockdown. Skinbrands managing director, Amanda Coveney says, “Skinbrands are offering support with free PPE to allow businesses to open safely and a discount that will allow customers to remain competitive. The reality is the online retailers will continue to run discounts so we are giving our customers the opportunity to do the same. We know this has been a very turbulent and unsettling period and we have continued to run free training for our customers but we wanted to provide extra support that allows clinics to renew stock and ease the cash flow burden as the industry eases back into the new normal.” The Support Package will be available until September 30, and SkinBrands will also offer its customers free digital assets to help clinics promote themselves when reopening. Skincare

Nimue launches new range Skincare company Nimue Skin Technology has launched the Dry and Dehydrated skincare range, comprising three new products – Hyaluronic Ultra Filler, Hyaluronic Oil, and Hyaluronic Acid Super Fluid. Nimue states that the products are designed to plump the skin, reduce fine lines and wrinkle depth, and create a better resistance to future wrinkle formation. The company explains that the Hyaluronic Ultra Filler serum and the Hyaluronic Oil can both be included in your patient’s homecare routine, while the Hyaluronic Acid Super Fluid should be used in clinic as part of a professional treatment. Roberta Donovan, head of marketing at Nimue, said, “Consumer research shows that dry and dehydrated skin is the second biggest concern in the professional skincare industry. This need is most prevalent during seasonal climate changes, where the skin can become tight, flaky, itchy, sensitive or dull if we do not take the appropriate measures to treat it effectively.”

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Breast surgery

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Laser

New implant insertion device released Silicone breast implant manufacturer GC Aesthetics Ltd (GCA) has developed a minimal-touch implant insertion device called HydroCone, which will be available in the UK later this year. The company explains that HydroCone is a sterile, single-patientuse device. The inner surface coating is made of hyaluronic acid which, according to GC Aesthetics, becomes extremely slippery when hydrated with sterile saline solution, thus aiming to make the surgery more efficient. Ron Cosmas, chief commercial officer of GC Aesthetics, said, “As a global leader in the women’s health arena, with over 3,000,000 implants sold, it is now more than ever, more critical that GC Aesthetics works closely with our surgeons, educators and innovators to ensure patient safety. The addition of this elegantly simply device is the first of many additions to the GCA portfolio in 2020 and 2021.” HydroCone will first be available in the French, Spanish, German and Italian markets, before being released elsewhere over the next 12 months. Industry

Harpar Grace expands business UK aesthetic product distributor Harpar Grace International has moved into a new warehouse facility in Hampshire and recruited Hayley Couchman as project manager and Mackenzie Collins as operations manager. The company explains that this expansion is to acquire the necessary infrastructure to support e-stores, launch additional support services and improve responsiveness, customer service and quality control. Collins said she is thrilled to work with the company in her new role. “Hayley and I are very excited to be joining Harpar Grace at such an exciting stage of their evolution as a UK and international player within the aesthetics distribution sector. We join at head office in a strategic growth role as part of the operational team and we will enable keystone projects to be implemented in a timely and progressive manner to cement our service offering to our growing client base and fuel onward growth,” she said

ETHEREA MX to launch in the UK Medical aesthetic equipment supplier Harley Technologies Ltd will partner with medical aesthetic equipment company Vydence Medical to launch the ETHEREA MX in the UK and Ireland, having been available worldwide since 2009. Originating in Brazil, the company explains that the laser and light-based multi-platform technology offers multiple applications in one system and can provide more than 70 aesthetic treatments. It features six laser handpieces: the IPL-SQ, for treating darker skin types; the Intense-IR, for skin tightening and skin laxity treatments; the LONGPULSE FDA for treating vascular lesions; and the ProDeep, GoSmooth, DualMode and Acroma-QS for all skin types/conditions. Digital

Mesoestetic launches online training Pharmaceutical company mesoestetic has launched a new online training programme for aesthetic practitioners. The company explains that all of its theory-based learning will now be moved online permanently, including core webinars such as consultation techniques, skin preparation, protocols and homecare solution products. Stephanie Verstraten, marketing executive at mesoestetic, commented, “This year has given us the opportunity to put a major amount of work into adapting to the evolving needs of our customers in the aesthetic field. We feel this new format will allow practitioners more flexibility while learning and have them ready to reopen their clinic feeling confident. Trust that we have put a lot of focus on making these learning experiences interesting and interactive, designed to inspire and impart knowledge. Let us get back into practice stronger and more elevated!” Business

sk:n acquires The MOLE Clinic group Medical skincare clinic group sk:n has acquired The MOLE Clinic group, which has five clinics in London specialising in skin cancer screening, diagnosis and mole removal. Iain Mack, managing director for The MOLE Clinic, said, “We are delighted to join the largest independent aesthetics clinic network in the UK. This is a very exciting opportunity for us to be able to extend our clinic network across the country whilst bringing our experience into a group that is established as the leaders in providing patients with the best experts in medical dermatology.” Darren Grassby, CEO at sk:n, commented, “We are very proud to add The MOLE Clinic into our group. Not only does this acquisition add critical, potentially lifesaving expertise which we plan to make available to patients across the UK, but it also shows confidence in the future of our industry.”

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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On the Scene

Allergan Spark Talks event On July 22, aesthetic support company Allergan Spark held a virtual ‘Spark Talks’ event where aesthetic practitioners gave 15-minute talks from a virtual TV studio. Speakers were chosen after entering a competition, in which they had to share a 30-second pitch about a businessrelated idea or clinical insight that they wanted to share with the wider profession. Speakers included independent nurse prescribers Linda Mather and Nina Prisk, and aesthetic practitioners Dr Ahmed El Houssieny, Dr Emma Sloan, Dr James Olding, Dr Manav Bawa, Dr Abdul Nassimizadeh and Dr Mo Nassimizadeh. Topics covered during the event were: aesthetic photography and the effects of lighting, dealing with a challenging patient, perspectives on the future of the non-surgical aesthetic specialty, how to move from foundation training to creating a successful business, and understanding the patient experience. John Campbell, Allergan Spark sales manager, said, “It was very exciting having the first Spark Talks Live. At Allergan Spark, we want to engage with our community, so it was fantastic for everyone to have the opportunity to submit a topic that they were passionate about, but also allowing the community the decision on the final seven ‘Talks’ they wanted to hear at the event.” Following her presentation, Prisk commented, “I was thrilled to be chosen as a speaker by the aesthetic community to share my passion for my topic ‘Patient Experience’. For me, having a seamless patient experience is essential if you want to be successful in business; it is not just about the treatment you deliver but the whole package. A great patient experience equals happy patients, who become your biggest advocates and a significant contributor to your thriving business.” All talks will be available on-demand in the coming weeks on the Allergan Spark website and another Spark Talks event is planned for 2021. Skincare

Institut Esthederm launches new skincare range Skincare brand Institut Esthederm is launching its new Propolis range, Propolis+, on September 21. The range is made up of three products; the Propolis+ Skin Perfecting Cream, the Propolis+ Concentrate Serum, and the Propolis+ Purifying Mask. The company explains that the range has been formulated for blemishes linked to acne in adult women. According to Institut Esthederm, the Concentrate Serum is designed to reduce blemishes and blackheads using a high content of propolis, salicylic acid and cellular water; the Purifying Mask uses a combination of propolis, cellular water and kaolin in order to remove excess sebum and toxins; and the Skin Perfecting Cream contains propolis, ferulic acid derivative, anti-wrinkle peptide, mattifying powder and cellular water, designed to moisturise the face.

News in Brief Survey indicates consumer distrust in aesthetic practice A survey conducted by Glowday, a marketplace where potential patients can find, review and book medically-qualified practitioners for nonsurgical aesthetic treatments, found that 34% of 2,000 respondents thought that aesthetic treatments were too dangerous. In addition, 47% of people said that they did not know what to look out for when searching for a qualified practitioner. Glowday CEO, Hannah Russell, commented, “Current industry standard allows for almost anyone to be able to inject fillers into someone else without consequence and sadly, the real victims are the individuals, who, may end up with botched procedures.” Intraline hires new business development manager Medical aesthetic company Intraline has appointed Debra Derosa as its new UK business development manager. She has worked in the aesthetics field for five years, having previously been an aesthetic account manager for HA-Derma. Derosa commented, “I am so very excited to be joining the Intraline team and be involved in the launch of the amazing new M Series dermal filler and look forward to working with and supporting our UK clinics following the impact of COVID 19.” Patients feel they look older following COVID-19 lockdown A new survey conducted by aesthetic dentist Dr Yiannis Valilas, owner of the Antiwrinkle Clinic in London, has revealed that almost 70% of participants said that they had seen an increase in lines and wrinkles during lockdown, and more than 50% said they now looked more tired. Despite these outcomes, the survey also highlighted the positive effects of facial aesthetics. Patients said that after getting injectable treatments they felt less stressed, or believed it boosted their self-esteem. BAS launches webinar series The British Association of Sclerotherapists (BAS) will present a series of monthly ‘bite-sized’ skill development webinars for sclerotherapy practitioners, beginning in September. The association explains these webinars will cater for various skill levels, and each one-hour interactive webinar will explore an aspect of the art and science of treating varicose and spider veins, with contributions from a panel of industry professionals. Emma Davies, aesthetic nurse practitioner and a member of the BAS board, said, “After not practising at all during lockdown, practitioners may find a refresher or update before treating patients will be extremely helpful.”

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


Advertorial Facing the World

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Supporting Consultant Trips from the UK Raising funds for Facing the World charity Last month we taught you about Facing the World’s efforts to train medical professionals in how to safely treat children born with facial differences. Each year they send numerous practitioners to Vietnam, as well as hosting Vietnamese doctors in the UK, US and Canada, to learn more about the skills involved. While this is hugely beneficial and has made a significant difference to many children’s lives, it comes with a cost. According to Facing the World, three one-week missions cost £202,550.1 The charity needs funds to not only pay for the operations children with facial differences desperately need, but the cost of travel, visas, accommodation, subsistence, drivers and translators for the team it takes. Figure 2: Trainee medical professionals following a lecture by Facing the World consultants

In addition, the three consultants delivered a two-hour lecture at Hong Ngoc Hospital on the applications of patient-specific planning in maxillofacial surgery, orbital fracture repair complications, and augmentation techniques in facial surgery.

Figure 1: Children affected by facial deformities who were assessed by the UK-based practitioners

Missions from the UK In October 2019, a team of three consultants from the UK – Mr Mehmet Manisali, Ms Sarah Osbourne and Mr Jahrad Haq – representing maxillofacial and oculoplastic surgery, assessed a total of 71 patients, as well as operating on 15 during their stay in Vietnam. Facing the World explains that the mission focused on the delivery and teaching of complex orbital and facial bone surgery for patients with severe congenital facial deformities and post-trauma reconstruction. The charity highlights that, in conjunction with the Vietnamese team they were training, the UK surgeons performed five orbital reconstructions, including the preparation of sockets for eye prostheses, unblockage of tear drainage system and management of a young children with acute orbital trauma (white-eye blow out fracture). 16

The trip was a resounding success, but more donations are needed to offer more in future. Show your support and help fund these missions by donating to Facing the World today.

Facing the World is raising money to fund these missions to Vietnam. Show your support and help our chosen charity by donating today.

To donate to this special charity scan the QR Code using the camera on your phone or visit www.justgiving.com/fundraising/aestheticsmedia

REFERENCES 1. Katrin Kandel, Vietnam Training Program, Facing the World <https://facingtheworld.net>

Aesthetics | September 2020


0208 748 2221 info.uk@venusconcept.com www.venusconcept.com


Advertorial NeoGraft®

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Hair transplants, the new growth industry Exploring the popular new technique for hair transplantation Hair transplants are a popular cosmetic dermatology procedure. Figures show that Europe had the largest growth in the number of surgical hair restoration procedures in 2019, with 106,949 transplants, representing a 35% increase on those carried out in 2016. A popular new technique for hair transplantation is NeoGraft® – a hair transplant technology that is minimally invasive and designed to help patients improve their hairline without the strip scar, discomfort and lengthy recovery of a traditional hair transplant.

What is NeoGraft®? NeoGraft®’s revolutionary automated FUE and implantation technology leaves no linear scar and is minimally invasive with fast patient recovery. It eliminates the inefficiencies of common manual tools and procedures, while enabling physicians to offer hair transplants with consistent clinical outcomes. Other options for hair transplant include the entirely robotic ARTAS iX™ system. NeoGraft® uses a punch and pressure method to suction and extract each hair follicle gently from the scalp without disturbing the surrounding tissue, nerves and blood vessels. This automated method better preserves the hair follicles to ensure more of them successfully survive in the transplanted area. With controlled placement of each follicle, the operator would be able to create a natural looking appearance to the hairline.

FUT vs. FUE There are two tried and true methods for performing hair restoration surgery, the strip excision/follicular unit transplantation (FUT) and follicular unit extraction/excision (FUE). The difference between these two procedures is how the donor hair is harvested from the back of the head. In strip excision, a strip of hair is removed from the back of the

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scalp and the surrounding skin is brought back together by stitches. In FUE, a small circular punch is used to cut around each individual follicular unit. The skin incision dissects the tissue around the hair shaft and root allowing the whole graft to be removed. This process is repeated until the surgeon has achieved the desired number of grafts needed for the procedure.

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NeoGraft® delivers superior clinical efficacy and high patient satisfaction, as evidenced by an average ‘Worth It’ rating of 95% on RealSelf.com. Dr Jack Fisher, a board certified plastic surgeon, explains, “NeoGraft® completely changes the dynamics of introducing hair restoration into your aesthetic practice by providing new advanced technology with the systems and support necessary to create a successful outcome for both the doctor and the patient.”

Results with NeoGraft®

Before

After

Before

After

Before

After

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Advertorial NeoGraft®

Advanced technology Typical FUE devices require the physician to punch out each graft then be manually extracted by hand after, whereas the Neograft does this in one step. The NeoGraft®’s harvesting, site-making and implantation functions makes it easier than ever for physicians to address hair loss and provide the hair restoration procedures that patients want. The inefficiencies of manual extractions and implants have been eliminated, and replaced it with advanced technology that provides patients with the benefits of the FUE procedure while also enabling physicians to perform fast, effective, safe hair transplants that yield superior clinical results. OPTIMISED WORKFLOW • Double-jointed arm and enhanced ergonomics ensure faster and more comfortable procedures for both patients and physicians • New contra angle eliminates loss of fluid and protects grafts through vacuum seal • Recipient site creation handpiece delivers more standardised implants • No-touch implanter offers the least amount of bulb trauma • Autoclavable handpieces offer sterilisable and costeffective tools PNEUMATIC MOTOR AND SMART DRIVE TORQUE TECHNOLOGY • Piston-driven motor delivers precise pressure control for both extraction and implantation • Smart Drive Torque Technology delivers 100% torque to the contra angle/punch, for continuous rotation and the smoothest entry • Consistent suction and spin lead to standardised extractions, high quality grafts, and superior patient outcomes INTUITIVE TOUCHSCREEN INTERFACE WITH GRAPHICAL USER INTERFACE • Automatic, real-time extraction and implantation of graft counts eliminates manual counting and paperwork • Graphic user interface (GUI) delivers user friendly, intuitive, interactive experience • Treatment screens allow users to easily switch between two modes – extraction and implantation • User management tools help track and improve performance of treatment providers OPERATIONAL EFFICIENCY WITH IOT TECHNOLOGY AND DEVICE MOBILITY • Advanced internet of things (IoT) technology capabilities enhance business operations by optimising treatment protocols, improving patient results and satisfaction, and maximising operational efficiency and return on investment • Quiet operation and energy-efficient usage

This advertorial was written and supplied by Venus Concept Website: www.venusconcept.com Tel: +44 (0) 208 748 2221 Email: info@venusconcept.com Aesthetics | September 2020

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Special Focus

Aesthetics Diversity aestheticsjournal.com

Voicing the Specialty’s Diversity Concerns In this exclusive Special Focus, we highlight the results from three surveys conducted by the Black Aesthetics Advisory Board on the representation of skin of colour within medical aesthetics In July this year, four award-winning aesthetic practitioners founded the Black Aesthetics Advisory Board (BAAB). The group, comprising aesthetician and founder of the Black Skin Directory Dija Ayodele, Dr Ifeoma Ejikeme, Dr Tijion Esho and Dr Amiee Vyas, aim to investigate the experiences of black practitioners within aesthetics, as well as those of black and minority ethnic patients and consumers. They also plan to provide guidance to brands and professionals to allow them to conduct better training and improve access to aesthetics for black patients.

7 out of 10 “I hope discriminatory practises in the hiring process and lack of knowledge/care for the skin of black patients will not only be addressed but eradicated from the aesthetic field”2 “I’ve attended many conferences where I’ve felt isolated and ignored, with a lack of inclusion in conversations, as well as lack of approach/ demonstrations in exhibitor halls”2

To inform their research, the BAAB created surveys seeking responses from black consumers1 and black practitioners2 to learn about their experiences in medical aesthetics, while also surveying practitioners from all ethnicities to understand their views on the representation and treatment of skin of colour in general.3 Over the next few pages you can gain exclusive insight into the surveys’ results, as well as acquiring valuable advice from the BAAB on actions you can take to improve diversity in aesthetics.

black patients said they had difficulties in finding practitioners confident in treating their skin1

84% 70% of black practitioners said they did not feel well represented when attending aesthetic conferences2

of black practitioners said they did not think they had a fair shot of becoming a Key Opinion Leader2

“It may be difficult to break the culture of being second best but it is possible to break –coming from an ethnic background I will continue to be a voice that supports change”2

86% of black patients think

brands should be more culturally aware1

“When the BLM protests started it was a very confusing and upsetting time… I am remaining positive that together we can all help to teach, support and give guidance in a positive way for a more inclusive industry”2 Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Influence of the Black Lives Matter movement While 70% of practitioners said they felt comfortable with race after recent Black Lives Matter (BLM) events, many admitted it made them think more about what they could to do support the cause.3 Comments included: • “After the BLM movement I felt heartbroken – I want to learn more about how I can treat and attract more people of colour to my clinic” • “I have never considered myself racist, but I am now thinking more about how my lack of actions, may and probably do affect other communities” • “It’s up to us to fight this and make sure that we identify racism when it happens” • “BLM has encouraged me to take responsibility and educate myself on treating darker skin types” • “I believe that in aesthetics we really can change views”

Improving diversity in clinics The majority of respondents (92%) said they felt comfortable approaching diversity in their clinics. Despite this, there were hundreds of comments expressing concerns practitioners have and suggestions of how the representation and treatment of patients with skin of colour can be improved.3 The general consensus was that: • Practitioners were scared to say the wrong thing to patients with skin of colour and worried that people with darker skin wouldn’t trust them or their clinic wouldn’t cater to them • Better training and guidance on what they can do to improve practice is needed • Skincare companies should state what products are suitable for darker skin • Knowledge on how to attract more patients of colour to gain experience would be beneficial • More literature on treating darker skin is needed • Promotional images should better represent skin-of-colour patients • Better training on treating dark skin in medical school and aesthetic courses would help

8 out of 10 black patients

said yes when asked whether they would want to see

a practitioner of the same ethnic background1

“I’ve never experienced direct racism but I have seen BAME colleagues overlooked for promotion”2

“Support your black skincare leaders in the fight for educating and making a difference”2

“I have felt very uncomfortable with the imagery used and the way black skin is described or totally omitted from the conversation… everyone in the industry should be proficient at treating black skin”2

Want to help support diversity in aesthetics? Turn the page for exclusive advice from the Black Aesthetics Advisory Board…

REFERENCES 1. Dija Ayodele, Black Aesthetics Advisory Board Patient & Consumer Survey, 2020, Black Skin Directory, 2020. (164 responses from aesthetic consumers, with 144 identifying as black). 2. Dr Ifeoma Ejikeme, Black Aesthetics Advisory Board: Practitioner Survey, Survey Monkey, 2020. (89 responses from aesthetic practitioners identifying as black). 3. Dr Amiee Vyas, Supporting Diversity in Aesthetics, Google Forms, 2020. (266 responses from

aesthetic practitioners – 210 with less than 50% skin-of-colour patients and 56 with more than 50% skin-of-colour patients). Note: the surveys listed in references 1 and 2 focus exclusively on the experiences of black consumers and practitioners, respectively, while the survey covered by reference 3 asked questions relating to skin of all ethnicities.

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Improving Diversity in Aesthetics The founders of the Black Aesthetics Advisory Board provide practical tips on how the industry can band together to help improve diversity within the field and support both practitioners and patients with skin of colour The latest Black Lives Matter movement has created a conversation. It’s made individuals of all backgrounds reflect on the diversity of their workplace and entire industries are encouraging their communities to think about how they can influence positive change. For the first time, recent surveys conducted by the Black Aesthetics Advisory Board (BAAB) highlight the specific areas that need most attention for progress, which are unique to aesthetics.1-3 Some of the notable results have been highlighted on the previous page4 and now it’s up to every member of the aesthetic community to be a part of this conversation and work together to result in change. This, BAAB founders Dija Ayodele, Dr Ifeoma Ejikeme, Dr Tijion Esho and Dr Amiee Vyas say, will not just be beneficial for black patients and practitioners. They believe it will also benefit those of all backgrounds and will create more business for clinics and companies, as well as aiding the overall progress our ever-evolving field. Dr Vyas explains, “The UK, especially places like London, has a very diverse population and our surveys highlight that the aesthetics field is leaving out a large section of our society, which is concerning.” Dr Vyas continues, “Leaving out this part of the population is an issue because it means patients are not engaging with the field and

practitioners don’t feel welcomed. It’s also a negative for our businesses – we could be expanding our services and tapping into this market if we were all catering to these patients appropriately.” The below advice from the BAAB founders explores how the aesthetic community can make small improvements to implement big changes, thus becoming more inclusive of people from all ethnicities.

Improve education The surveys highlight that although many practitioners want to improve their knowledge, there is a lack of training available to them when it comes to treating darker skin types.1 Ayodele says, “There is a real need for practitioners to undergo more training on how they can better serve the entire population. For example, there is a lack of understanding of how skin concerns present differently in black skin vs. white skin, or what problems skin-of-colour patients commonly face.” Dr Vyas adds that in her experience, often darker skin types are just briefly mentioned by training providers as a risk, without going into much detail. “I had to take it upon myself to do my own research with in-depth literature reviews so I could provide a better service for my patients with skin of colour –

Black Aesthetics Advisory Board founders

Dija Ayodele

Dr Amiee Vyas

Dr Ifeoma Ejikeme

Dr Tijion Esho

in the absence of formal education I really urge my colleagues to do the same. Since doing this, and by voicing my knowledge to my patient base, I now have 50% skin-ofcolour patients and am a trainer for distributor AestheticSource, which offers skin-of-colour education as a priority,” she says. Although Dr Vyas has seen improvements in this area, she and the other BAAB founders believe more needs to be done. This, they say, is the responsibility of aesthetic companies, universities and training providers, as well as practitioners, who need to be active in voicing that they need this education. Dr Ejikeme highlights, “If the aesthetic community has the knowledge, understanding, tools and know-how, then they are going to provide a good service to all their patients. And this is not just the right thing to do, but it can also be profitable for your clinic too.”

Change marketing and branding approaches Have you ever looked at how your clinic appears from the eyes of your patients? What do your website, social media channels and emails say about you and the services you offer? Does it look like you cater to skin-of-colour patients? It might be time for a change, the BAAB founders say. “As a whole, black patients feel underrepresented,”1 says Ayodele, “So, marketing and branding for not only clinics but aesthetic products needs to be a lot more inclusive to patients of all skin types to show that there are treatments available to them. This is not just having a token black women image here and there, but companies should include a wide variety of skin tone imagery from the whitest of white to the darkest of dark.” Dr Ejikeme also believes that aesthetic product companies need to supply clinics with marketing materials that cover wider

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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ethnicities. She adds that the language used needs to be considered carefully. “Think about what keywords you use on your website; do you explicitly say how you can help different skin types and what treatments you have and explain how these can help?” she asks, adding, “If we are not making patients feel welcome via our marketing efforts, then the patient is going to feel that there isn’t a treatment for them.” Ayodele provides an example of how a dermal filler procedure can be adapted to a black audience. “Traditionally, black women already have fuller lips and because it’s often marketed to white women, they think that fillers are all just about making lips look big. However, what many black patients don’t know is that fillers can also be used for definition or hydration, which does appeal to them,” she says.

Conduct more research According to the BAAB founders, there is a lack of clinical research conducted by aesthetic companies on how their products interact with skin of colour. This prevents a comprehensive understanding by practitioners on what treatments can benefit their patients and how to best use these treatments, they say. Dr Ejikeme explains, “When I look at technologies that have never been tested on black skin I am unable to explain to my patients the specific improvement or complications that can occur because the data has only been done on lighter skin types. The manufacturer of every aesthetic device should ask the question: what impact does this have on black skin and how effective is it?” Ayodele says, “Some brands are doing extremely well in ensuring that their clinical and consumer trials are far reaching across all Fitzpatrick skin types, but others aren’t. It is improving, but I think the lack of research is underpinned by the fact that there has always been the misconception that black people don’t spend money on skincare or in the aesthetics arena, so companies are less likely to invest in research.” She adds, “However, from my experience, the brands that invest in the skin-of-colour research and have the clinical trials and imagery to show have done fantastically well with black patients and there is absolutely a market there.” Dr Ejikeme adds, “Companies, black practitioners and those who are experienced in treating skin of colour need to partner together so practitioners can advise on how their devices and technologies can best be utilised for black patients.” She explains

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that practitioners should also actively share their experiences treating black skin by showcasing their case studies in medical journals. Collectively, Dr Ejikeme says this will help to provide treatment protocols for darker skin, which will ensure patient safety, as well as enhance the popularity of treatments within this cohort.

Employ a diverse team and showcase them The majority of black patients think it’s important to have black employees on teams and at senior leadership levels, as well as for brands to be more culturally aware.1 The consumer survey respondents also attached significance to their skincare professional being of the same or similar ethnic background as themselves.1 Ayodele says, “From a business point of view, of course it’s important to have black employees on teams and at senior levels, but actually those that are employed often have a lack of visibility with aesthetics. As such, it’s important that companies not only step up to hire more, but ensure there is a visibility of their black professionals in their teams.” She explains that this is of benefit because it provides an increased ability for businesses to relate to their customers, emphasising, “This will start increasing the cultural awareness of our community and will naturally make it become more inclusive.” As well as employing a more diverse team, black employees need to feel respected in their workplace. Dr Ejikeme says, “I was really shocked that 33% of our survey respondents had experienced racism by a colleague or supervisor specifically in aesthetics – this is way too high. People reported specific circumstances which were very alarming to me. This hasn’t been my personal experience, but black practitioners all come from various backgrounds so people within different groups may have really unique experiences.”2 Dr Ejikeme explains that to tackle this concern in the workplace, businesses should have a zero tolerance policy on racism. “This may

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seem obvious, but for such a high amount of people to have experienced this shows that it needs to be explicitly discussed to all members of staff. I would also encourage diversity education as part of annual training, and for managers to take complaints about discrimination seriously, always following through with an investigation. Try to create a culture which will call out bullying of any kind and ensure appraisal, review and disciplinary roles in the organisation have black individuals as part of the panel.”

Improve black representation for brands and events With 84% of black practitioners stating they do not feel well represented at conferences and 70% saying they don’t feel they have a fair shot at becoming a brand ambassador or KOL, it’s clear there is room for improvement.2 Dr Ejikeme says, “I had 90 black aesthetic practitioners respond to my survey; I was not aware that there were this many in aesthetics because I just haven’t seen them! Where are the black practitioners and why aren’t we as visible?” Dr Vyas adds that whilst she sees diversity in the speakers and KOLs in aesthetics, there is a lack of representation specifically from black practitioners. “If I was a black consumer and not a doctor and went to an aesthetic event I would probably think there’s nothing out there for me in this field,” she says. Dr Ejikeme adds, “You can’t be what you don’t see. If you don’t see black faces you won’t think that you can become a KOL.” Dr Esho also raises concerns in this area. “There are several talented black practitioners in this industry who would thrive within these positions and, if given the chance, those brands would gain an insight from them on how to approach and treat black customers within both marketing and training,” he explains. Firstly, the BAAB founders say aesthetic product companies need to be more active in engaging with black practitioners. “Working with brands can be so important in people’s careers and progression,” Ayodele says, explaining,

“I was really shocked that 33% of our survey respondents had experienced racism by a colleague or supervisor specifically in aesthetics” Dr Ifeoma Ejikeme

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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“Brands need to look at how they can widen their teams. Are they approaching black practitioners to recognise their skills and qualifications, and put them on track to become KOLs or to take senior leadership roles?” Dr Esho also emphasises, “This doesn’t mean giving a position to someone just because they are black,” he says, adding, “No one wants that, but when there are several talented black practitioners in the industry but many faculties and boards where black faces are absent, we really need to sit and discuss why.” Conference organisers also need to do more to showcase the experiences of black practitioners and patients, which will not only make other black practitioners feel represented, but will help to educate practitioners in how to treat skin of colour, they say. “I hope that we not only start to see more black speakers, but that we start to include black patients in all agendas, especially the injectable agendas such as dermal fillers and threads. In my experience, these treatments are very relevant to skin-ofcolour patients, but they just need a different approach. If we can achieve this then I think that would be extremely powerful for our field,” Dr Ejikeme explains. The BAAB is working closely with conferences like CCR and ACE to improve this, but all event organisers should make more of a conscious effort, they say. Alison Willis, director of CCR and Aesthetics Media, as part of Easyfairs, commented, “We want to ensure our conference delegates of all backgrounds feel they are included and wellrepresented when we welcome them to our events. We are active in looking at how we can progress by not only hosting black and skin-of-colour speakers, but also ensuring that the content talks about treating all skin types. We are also working closely with the Association of Event Organisers, which is the trade body representing companies that coordinate events, to improve diversity in the wider events industry across all sectors.” Dr Ejikeme says that non-black practitioners can also play a part in encouraging companies and event organisers to do more. She states, “I think they need to be a champion for change. Be conscious of the lack of black representation and if you’re going to a conference and you see the entire faculty is Caucasian, ask where is the diversity?”

Put yourself out there People of all skin types often find it hard to promote themselves in aesthetics. However,

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the BAAB founders believe that many black practitioners can be doing more to amplify their voice within the community. “Some black practitioners need to put themselves out there a little more. Many don’t think they will be heard if they do, but there are ways to amplify your voice,” Dr Ejikeme explains. “Firstly, be excellent in what you do and then contact people to collaborate with. You will be surprised by the response that you get and you will likely find that you get more positive responses than negative,” she advises, adding, “Network with anybody and everybody of all ethnicities – find allies because they are everywhere, every shade and every age.” Ayodele emphasises that black practitioners do need to be a part of the change. “Have you put yourself forward to be a brand ambassador or KOL? Has a company actually said no you can’t? I think black practitioners need to meet half way. While magazines, conference providers and brands actively need to reach out more and not just feature the few people that they have good relationships with, black practitioners also need to shout that they are here and ready to be heard.” Dr Vyas adds, “Often people think their voice isn’t loud enough, that they won’t get accepted or won’t progress anywhere, so sometimes people don’t try. I always say that if you don’t try, you don’t get. So, promote yourself! Put your experiences especially of treating darker skin out there regardless of what skin colour you have and claim your seat at the table. The first thing is not to feel that your voice isn’t important because, right now, the world is listening and it’s a great thing.”

The future of diversity in aesthetics The BAAB board members are all extremely positive and excited by the future of aesthetics and how the industry will evolve to become more accommodating to people of all ethnicities and backgrounds. Ayodele says, “I hope that the conversations continue. I really think that the lid has been taken off and we need to continue this conversation and progress. I feel very confident that this engagement and future change will be a benefit to the entire aesthetic industry, not just the practitioners but also to patients, who are at the heart of everything we do.” The BAAB members hope to create guidelines for brands to follow to help make their businesses more inclusive, and are currently available to mentor

and consult companies and practitioners who would like to learn more about what changes they can make to cater to a more diverse client base. Dr Vyas says she is also working on producing training events, and would like to thank all survey respondents, especially those who shared their very personal experiences, which have helped identify the specific learning needs of individuals within the aesthetics field. Dr Esho adds, “I think the key message here is that there is a problem. With time and effort of everyone involved we can make it better, but to make it better it has to really matter to everyone involved within this industry.” Dr Ejikeme concludes, “All individuals within the aesthetic field can help in their own little way and if everyone comes together then I believe that the landscape will change very quickly.”

Aesthetics Editor and Content Manager Chloé Gronow says… The team and I are proud to collaborate with the BAAB on this Special Focus on diversity in aesthetics. Representing all ethnicities has always been important to us and, each month, we work hard to ensure we include imagery and articles that consider everyone. Of course, there is always more we can do, so welcome skin-of-colour case study submissions from readers, as well as ideas for articles and CCR/ACE conference sessions that will educate others on treating skin-of-colour safely and effectively. Get in touch via editorial@aestheticsjournal.com. REFERENCES 1. Dija Ayodele, Black Aesthetics Advisory Board Patient & Consumer Survey, 2020, Black Skin Directory, 2020. (164 responses from aesthetic consumers, with 144 identifying as black). 2. Dr Ifeoma Ejikeme, Black Aesthetics Advisory Board: Practitioner Survey, Survey Monkey, 2020. (89 responses from aesthetic practitioners identifying as black). 3. Dr Amiee Vyas, Supporting Diversity in Aesthetics, Google Forms, 2020. (266 responses from aesthetic practitioners – 210 with less than 50% skin-of-colour patients and 56 with more than 50% skin-of-colour patients). 4. Gronow, C, ‘Voicing the Specialty’s Diversity Concerns’, Aesthetics journal, September 2020.

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


Advertorial Merz Aesthetics

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Using BELOTERO® Volume Dr Kim Booysen shares her experience of using the Merz Aesthetics filler for mid-face restoration As an aesthetic physician, having a scientific understanding of every medical device I use to treat patients has always been of paramount importance to me. BELOTERO® Volume is one of the most trusted and frequently used products in my clinic. Its science is robust, accessible and easy to understand. Its safety profile is excellent,1 it is extremely easy and versatile to use, and with a longevity of up to 18 months2 it is ideally suited to my patient cohort.

Where do I use BELOTERO® Volume the most? I believe that treating the deep medial cheek fat can significantly improve the signs of facial ageing in the mid-face itself, as well as improve the jowls, jawline and under eye hollows, so this is often a starting point for facial rejuvenation in my patient treatments.3 My favourite product for mid-face volume restoration is BELOTERO® Volume. Using a cannula, I can access the deep medial cheek fat and improve projection, which will help alleviate the appearance of tired eyes and soften nasolabial folds and early jowl formation. Moving more superficially in the layers, I can also restore mid-face contours by smoothing transitions and supporting lax tissues. BELOTERO® Volume can also be used to treat the temples, chin, cheeks and mandibular angle, once I have addressed any structural mid-face loss. BELOTERO® Volume can be used in combination with other BELOTERO® fillers for comprehensive facial rejuvenation.

Why do I think BELOTERO® Volume is so easy to use? BELOTERO® Volume is a supremely versatile filler, as it can be easily injected at different depths in the facial layers. BELOTERO® Volume is approved for injection in both the subcutaneous and supraperiosteal plane. This allows me to create projection with deeper injections, and then blend and contour by injecting at a more superficial plane, all without changing the type of filler or injectable device. This helps me to minimise bruises, limit injection points and potential infection from compromised sterility. BELOTERO® Volume flows smoothly and is ideal for moulding, so I can inject multiple retrograde threads using a cannula, then I can gently shape the threads into the desired contours.

How is BELOTERO® Volume different from other volumising fillers? Phase 1 Hyaluronic acid in its original form (single chains, random coil structure).

Phase 2 Linearization of individual hyaluronic acid chains: the random coil structure untangles.

Phase 3 First hyaluronic acid cross-linking process with BDDE: a cellular monophasic gel emerges.

Phase 4 Expansion of the gel that was created in the cross-linking process.

Phase 5 Second cross-linking process, supplemented with additional noncross-linked hyaluronic acid.

High Density Zone • Lasting effect of HA • Filling capacity

26

Low Density Zone • Easiest extrusion • Optimal dermal integration

We have all started to move away from the traditional thinking of fillers as being either hard or soft. Other rheological properties, such as viscoelasticity, that impact tissue integration and projection are becoming more important. BELOTERO® Volume is known for having high levels of three important rheological properties that can produce an ideal filler: plasticity, elasticity and cohesivity. Plasticity allows a product to be moulded and shaped, while elasticity allows for recoil after compression and cohesivity ensures the product stays together and doesn’t disperse once Aesthetics | September 2020

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injected. These three qualities are essential for an ideal filler, as they allow a practitioner to sculpt and rejuvenate lost projection, safe in in the knowledge that facial expression won’t distort the new contour and the product won’t migrate over time.

What is the science behind BELOTERO® Volume technology? Merz Aesthetics utilises Cohesive Polydensified Matrix (CPM) and Dynamic Cross-Linking Technology (DCLT) to create their filler range. This technology is different from other filler technology as it includes a second round of cross-linking, which helps create a 3D structure with areas of high density and low density. These different densities allow the product to integrate into the tissues in a more natural way, with even distribution and less clumping of product than some other filler types. The more homogenous the filler integration, the smoother the integration and the more natural the feel for the patient.4 In ultrasound studies, BELOTERO® Volume has been shown to retain more tissue integration than another leading dermal filler due to its increased cohesivity.2 BELOTERO® Volume has also displayed less pro-inflammatory responses than another leading volumising filler, leading to less risk of inflammatory responses.2 Dr Kim Booysen is an independent aesthetic clinic owner in South East London. She holds degrees in medicine, law, international health management and business management. Dr Booysen’s special interests are medico-legal aesthetics and aesthetic education, while her spare time is spent travelling with her husband and working on local environmental causes. REFERENCES 1. Prager W, Agsten K, Kravtsov M, Kerscher PM. Mid-Face Volumization With Hyaluronic Acid: Injection Technique and Safety Aspects from a Controlled, Randomized, Double-Blind Clinical Study. J Drugs Dermatol. 2017;16(4):351-357. 2. Micheels P, Besse S, Sarazin D, et al. Ultrasound and Histologic Examination after Subcutaneous Injection of Two Volumizing Hyaluronic Acid Fillers: A Preliminary Study. Plast Reconstr Surg Glob Open. 2017;5(2):e1222. Published 2017 Feb 24. doi:10.1097/ GOX.0000000000001222. 3. Kerscher M, Agsten K, Kravtsov M, Prager W. Effectiveness evaluation of two volumizing hyaluronic acid dermal fillers in a controlled, randomized, double-blind, split-face clinical study. Clin Cosmet Investig Dermatol. 2017;10:239-247. Published 2017 Jun 29. doi:10.2147/CCID.S135441. 4. Flynn TC, Sarazin D, Bezzola A, Terrani C, Micheels P. Comparative histology of intradermal implantation of mono and biphasic hyaluronic acid fillers. Dermatol Surg. 2011;37(5):637643. doi:10.1111/j.1524-4725.2010.01852.x.

This advertorial was sponsored by Merz Aesthetics. M-BEL-UKI-0818 Date of Preparation August 2020


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Exploring Bone Ageing Mr James Olding details how facial bones change over time and provides considerations for dermal filler treatment Contemporary concepts in facial aesthetics have shifted the focus to rejuvenation through revolumisation and identifying age-related volume loss, with the objective of re-establishing the ideal or previous facial dimensions. The facial skeleton provides the structural support for overlying soft tissues, and changes to facial appearance manifesting as hollowing, folds, creases and rhytids, are usually preceded by bony changes. It is therefore of great importance that any structural deficit is addressed. Facial ageing follows a predictable process, with specific areas of the facial skeleton undergoing resorption, resulting in the appearance of some of the most common stigmata of ageing. The mid-face, the orbit and the mandible are three important areas of the facial skeleton implicated in ageing, and the signs of bony changes in these regions include under-eye hollowing, altered brow position, deepening facial folds, and the appearance of jowls.1,2

The biology of bone remodelling

only two thirds of the amount that women lose over their lifetimes, in addition to reaching peak bone mass later (around aged 30) and having a higher adult peak bone mass.4 In women, in addition to gradual progressive loss of cortical and trabecular bone from the third decade onwards, additional bone loss occurs precipitously within a year of the menopause; a process which is sex hormone linked and attenuated by hormone replacement therapy.9 The idea of selective bone resorption alludes to the site-specific changes in certain areas of the face, while resorption elsewhere is less pronounced or not present at all.1 Despite being regulated by different growth factors, facial bone undergoes a decrease in bone mineral density with age, similar to axial bone.2 In the adult facial skeleton, it has been observed that bone resorption occurs in a predictable manner, commonly affecting the mid-face, orbit and mandible, though each area is not necessarily affected by the same pathophysiological process.2,10 Differences in bone density are well reported between ethnicities and black individuals have been shown to experience less pronounced dimensional changes to the face than white individuals as they age.10 It is not possible to fully assess the reasons underlying these observed differences between ethnicities, though genetics is likely to be central, in conjunction with other factors including body mass, hormones and diet.11

Bone is a living tissue maintained through a delicate balance of osteoid deposition by osteoblasts, and resorption by osteoclasts. Understanding bone biology and its clinical relevance requires an understanding of some important terms; namely, peak bone mass (PBM) and bone mineral density (BMD). Bone mass will depend on bone density and bone size.3,4 Each individual has a bone mass potential which is largely determined by genetics.3 Within this genetic potential, the actual peak bone mass reached as an adult will depend The mid-face on lifestyle, hormonal and environmental factors.5 Research has shown that even within a single area of the face, Differences between sexes are also notable, with the peak bone bone resorption is highly site specific.1,2,12 The bony mid-face mass achieved by males being greater due to increased periosteum consists principally in the maxillary and the zygomatic bones, with a deposition on account of the fact of males having larger and longer predilection for age-related resorption at the maxilla, even in dentate bones in general.6 Sex hormones and the IGF-1 system have been patients.1,2 Maxillary bone resorption leads to reduced anterior 7 implicated in this sexual dimorphism. Bone mineral density is a measure of the inorganic mineral content of bone, and is a surrogate for measuring bone mass and strength. It can be Inferiorlateral measured as a snapshot using a DEXA scan orbital to diagnose conditions such as osteoporosis. It is important to understand that the peak Glabella angle adult bone mass achieved will influence Pyriform angle the risk of sequelae arising from bone loss, Maxilla 6 including osteoporotic fractures, in adulthood. Maxilliary angle Bone responds to mechanical stress, undergoing remodelling, which involves Prejowl suculus resorption followed by deposition, in what is of mandible known as a basic multicellular unit of bone remodelling (BMU).5 The adult skeleton is entirely replaced in this way every 10 years.8 Starting from the middle of the third decade, Figure 1: Areas of the facial skeleton prone to Figure 2: Age-related resorption has been analysed women lose 35% of their cortical bone and age-related bone resorption in longitudinal studies using CT, where the glabella, 4 50% of their trabecular bone. Men lose pyriform, and maxillary angles are measured over time

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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projection, resulting in an undermining of the structural soft tissue support in this region. Geometrical analysis using CT in longitudinal studies have shown that the maxillary angle decreases with age secondary to localised resorption.2,13 The pyriform and glabella angles also decrease, with localised bone loss in these areas contributing to the classical features of mid-facial ageing.2,14 Overlying fat compartments in both the superficial and deep layers are affected by mid-face bone loss.14,15,16 An example of a common process involves a loss of zygomaticomaxillary bone, which undermines the medial and lateral sub-orbicularis oculi fat (SOOF), resulting in infraorbital hollowing and loss of lower lid support.13 A worsening of the palpebromalar sulcus may also be observed. It should be emphasised that maxillary and zygomatic bone resorption has wide-reaching effects, leading to soft tissue descent and lower face ageing, as well as geometrical alterations of the entire face in both vertical and horizontal dimensions.13,14,17

The orbit The orbit has been shown to undergo greatest resorption in two key areas.18 Firstly, selective reabsorption at the inferolateral quadrant of the orbit may occur in middle age, leading to a lengthening of the lid-cheek junction, as well as herniation of the infraorbital fat. These periorbital issues are common reasons for patients seeking aesthetic treatment. Secondly, resorption at the superomedial aspect of the orbit results in a comparative lift of the medial brow, with an associated lower position of the lateral brow. This resorption usually occurs later in life, around the fifth and sixth decades.17,19 Importantly, we must recognise the effect of bone resorption as the primary event here, followed by the appearance of soft tissue changes involving the fat, muscle and skin.19 Progressive enlargement of the orbit occurs with age, however there are important differences between ethnicities. One recent longitudinal study showed that while increased orbital dimensions occur in all black and Caucasian populations, these increases are notably reduced in black females, and do not occur to any significant degree at all in black males.20 Between the sexes, a study using CT imaging found that orbital aperture area and width increased in males and females, with a significant increase between the young (mean age 30 years) and middle-aged (mean age 54 years) female groups.19 This change occurred later and over a more protracted time period in males, with significant increase found between the young (mean age 33 years) and old (mean age 75 years) age groups.

The mandible Previously, the mandible was believed to increase in size with age,2,12,21,22 however, recent longitudinal studies looking at linear measurements have shown that the process is more complex, with concurrent expansion and resorption occurring.23,24 In both males and females, linear measurements of the bigonial width appear to remain relatively constant with age, while mandibular length and height decrease.25 The effect of reduced mandibular anteroposterior and vertical dimensions, coupled with overlying soft tissue changes, will contribute to the progression of jowls, and an exacerbation of the pre-jowl sulcus.25 With areas of isolated concavity such as the pre-jowl sulcus, linear measurements do not permit longitudinal analysis of changes.25 Age-related bone resorption in an anteroposterior dimension, similar to congenital microgenia, may result in mentalis hyperactivity, submental changes, and reduced definition at the mandibular lower

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border.26 A strategy to address jowls must include a geometrical analysis of the patient’s profile, as well as close attention to any mid-face volume deficit. The lower face requires particular attention, in that it can be adversely affected indirectly by mid-face bone changes, as well as directly by lower face bone and dental loss. The squaring out of the face that occurs with age, in conjunction with muscle and skin changes, can have a profound impact on how patients feel about their apperance.25,27 There is clear evidence concerning the impact of tooth loss on alveolar bone resorption of the mandible.27 Alveolar bone and the tooth support each other, and upon tooth loss, resorption can be profound, especially in the mandible, which has the fastest rate of bone turnover in the body.3 In addition to the morphological changes directly resulting from dental issues, the indirect effects of tooth loss must also be considered, where loss of the mandibular bone itself occurs, in conjunction with reduced masticatory functional forces affecting the muscles of mastication, including the masseter.26 Tooth loss can result in reduced vertical occlusal dimension and a reduced lower facial third length, as well as leading to the appearance of perioral concavity and perioral lines.28

Injectable product selection In view of bone loss being the key step in facial ageing, it follows that treatments must aim to revolumise in areas of deficiency. The product used must possess ideal properties to enable preperiosteal placement and to optimise revolumisation after bone loss. Rheological properties, cross-linking, elasticity and cohesivity are important to analyse.29,30 In regard to hyaluronic acid (HA) based products, a higher HA concentration will result in more water uptake and a more volumising effect.31 Cross-linked HA is commonplace, and this affects both the longevity and the cohesivity.32 Cohesivity can be defined as resistance to vertical compression,33 and refers to the ability of a product to be moulded or sculpted to create lift and shape.33,34 Higher cohesivity products are better at creating contours and shapes.33,35 Cohesivity depends on the degree of attraction between cross-linked HA units, through weak, noncovalent forces, and it is a function of both the concentration and cross-linking of the HA. Elasticity refers to the ability to resist shear deformation, and a product with greater elasticity will be better able to maintain its original form after pressure or strain, giving it greater lifting capacity.33 Examples of technologies commonly used in contemporary aesthetics include Vycross and Cohesive Polydensified Matrix (CPM) gels, with others available.34 Vycross technology mixes high amounts of low molecular weight HA chains (promotes crosslinking with reduced need for the crosslinking agent BDDE) with smaller amounts of high molecular weight fibres (promotes cohesivity).34 CPM technology involves a processing step whereby additional HA chains are added after stretching the matrix in the first part of the process. These added chains aid in the crosslinking process, reducing the amount of BDDE that is required.34 Based on our understanding of products and properties, an example of a product that is suitable for use in the mid-face would be Juvéderm Voluma, from the Juvéderm Vycross range, with a HA concentration of 20mg/ml, and relatively high cohesivity and elasticity. An alternative HA product would be Belotero Volume, using CPM technology, which has a similar longevity to Juvéderm Voluma, of around 18 months. Note that there are many other products available that are also suitable. Mid-face treatment strategies should account for any bone loss in the

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Before

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After

Conclusion Bone loss is a key factor in facial ageing, occurring in specific areas and in a predictable pattern. The orbit, maxilla and mandible all undergo age-related resorption, and lifestyle factors, ethnicity and dentition play important roles. Understanding the relationship between the different layers and tissues of the face is fundamental to addressing our patients’ concerns, and bone changes must be considered at the outset of any facial assessment. Knowledge of when, how and which individuals are affected will enable you to pre-empt and treat this crucial initiating step in the process of facial ageing.

anteromedial cheek, the zygomatic eminence, and on the zygomatic arch, and injections are delivered as boluses onto the periosteum.34,36 It is my view that anchoring at the zygomatic arch is the most important step in any mid-face strategy, though exact volumes and areas injected will depend on individual patient assessment and treatment planning. Where new volume or contours are sought, such as in the lower face, in addition to possessing the above properties, the product must have a high level of cohesivity.33 Juvedérm Volux is one example of a suitable product for this purpose, containing 25mg/ml of HA, and the highest cohesivity, elasticity and water-retaining ability of the Juvéderm Vycross range.37 Restylane Volyme is an alternative product for use, with 20mg/ml HA, but others are also available. A strategy to volumise the lower face may involve pre-periosteal bolus injections onto the mandibular angle and at the pre-jowl sulcus. High cohesivity is key to enable the product to resist deformation and to provide the necessary support to overlying soft tissue in the lower face.38 In the periorbital region, greater care must be taken when injecting dermal filler due to the rich periocular arterial anastomoses, which provide a route for an HA embolus to reach the ophthalmic artery and affect the vision. This is in addition to greater risk of bruising due to rich venous plexuses, and special challenges in correctly diagnosing and treating periorbital issues due to the complex anatomy involving superficial and deep fat, as well as issues affecting the muscle, skin and bone.35 Pre-periosteal placement on the inferior orbital rim must be carried out using a product with low HA concentration to confer low waterretentive ability, and low elasticity to promote better flow properties and more homogenous tissue integration.39 Under correction is also important to prevent hydrophilic HA fillers causing unwanted swelling which can affect aesthetics and lymphatics.40 Injecting in this area may form part of a strategy to address a tear trough deformity, however it is important to assess the maxilla and zygoma, and to treat these areas before moving to the infraorbital region itself, in that zygomaticomaxillary bone loss precipitates and propagates loss of lower lid support, anterior cheek flattening and descent of the SOOF.12 As such, bone loss must be treated directly (at the orbit) and indirectly (at the mid-face).

TO VIEW THE REFERENCES GO ONLINE AT WWW.AESTHETICSJOURNAL.COM

Test your knowledge! Question Selective bone resorption affects which part of the orbit first?

Peak bone mass attained by an individual is not dependent on which of the following?

Possible answer A. Superolateral B. Superomedial C. Inferomedial D. Inferolateral A. Eye colour B. Genetics C. Diet D. Hormonal factors

Mandibular tooth loss has no effect on which of the following?

A. Reduced vertical occlusal dimension B. Maxillary alveolar bone C. Masticatory function D. Mandibular alveolar bone

In respect to hyaluronic acid-based products, which of the following is false regarding cohesivity?

A. It is related to the degree of HA cross-linking B. It refers to the ability to resist shear deformation C. It refers to the ability to resist vertical compression forces D. It is related to the HA concentration

Through bone remodelling, the adult skeleton is replaced in its entirety how frequently?

A. Every 2 years B. Every 5 years C. Every 10 years D. Every 20 years

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020

Answers: D, A, B, B, C

Figure 3: Mid and lower face revolumisation in a 52-year-old female patient. Zygomaticomaxillary and alveolar bone loss predominated here. Revolumisation was carried out with Juvedérm Voluma to the mid-face, Juvedérm Volbella to the infraorbital region and Juvéderm Volux to the lower face. Onabotulinumtoxin A to the upper face carried out at same time as dermal filler treatments – the positive effect on brow form and position can be seen.

Mr James Olding is an aesthetic doctor and injectables trainer. He is also training in oral and maxillofacial surgery in the NHS. Mr Olding studied medicine at the University of Bristol, is a member of the Royal College of Surgeons, and is in his final year of studying dentistry (DPMG course) at King’s College London. Qual: MBChB (Hons), BSc (Hons), MRCS (England)


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There are many different factors believed to be associated with this muscular activity.12 An increasing amount of evidence suggests a relationship between sleep bruxism and other disorders or systemic diseases, including reflux disease, sleep breathing disorders, uncontrolled limb movements during sleep and neurological disorders.13

Understanding Bruxism Dr Heather Muir details the classifications and treatment options for teeth clenching and grinding Bruxism is a movement disorder of the masticatory muscles associated with tightening or grinding of the teeth. An expert group defined bruxism as a repetitive jaw muscle activity, characterised by clenching or grinding of the teeth and/ or by bracing or thrusting of the mandible.1 Bruxism is a common condition with an adult prevalence ranging between 8-31% within the general population.2 It is clinically relevant owing to its association with tooth abrasions and mobility, fracture of dental restorations and teeth, hypertrophy of the masseter muscle and myalgia or arthralgia characteristic of temporomandibular disorders (TMD).3-5 TMD are the second most common causes of orofacial pain, with dental pain as the first, recognised by pain in the temporomandibular joint region and in the facial muscles. As well as pain, patients may experience other signs and symptoms, such as clicking of the joint and trismus (restricted mouth-opening). The prevalence of the population who have TMD symptoms to some degree is 5-12%, which varies by age group and gender.6 Bruxism is a disorder of multifactorial origin and may require several treatments to alleviate the symptoms and manage the disorder. Aesthetic practitioners are in an ideal position to treat this with the use of

botulinum toxin or make a diagnosis and/or refer. The clinician needs an understanding of the condition, the treatments available to offer, and the approaches for successful treatment.

Classifications Bruxism can be subclassified into primary or secondary types. Primary bruxism is not related to any other medical condition, whereas secondary bruxism is associated with either neurological disorders or an adverse effect of medication. It may have two distinct manifestations: sleep bruxism, which is also known as nocturnal bruxism, or awake bruxism, also known as diurnal or wakeful bruxism.7 Sleep bruxism Sleep bruxism is a masticatory muscle activity during sleep that is characterised as rhythmic (phasic) or non-rhythmic (tonic) and is neither a movement disorder nor a sleep disorder in otherwise healthy individuals.1 Sleep bruxism does not show gender prevalence.8 It is estimated globally that sleep bruxism affects 16% of the population,9 however the prevalence of sleep bruxism among children and adolescents is often higher and can be from 3-49%.10 The exact aetiopathogenesis of sleep bruxism is not fully understood.11

Awake bruxism Awake bruxism is a masticatory muscle activity during wakefulness that is characterised by repetitive or sustained tooth contact and/or by bracing or thrusting of the mandible. It is not a classed as movement disorder in otherwise healthy individuals.1 Awake bruxism is more prevalent in females than males8 and affects 24% of the adult population.9

Aetiology In general the aetiology and pathophysiology of bruxism are not fully understood. Several factors have been proposed, such as emotional stress, neurological disorders, certain drugs and occlusal interferences.14,15 It seems to have a multifactorial origin mediated by the central and autonomous nervous systems.16,17 The aetiology of bruxism can be divided into three groups; psychosocial factors (stress, anxiety and depression), peripheral factors (such as occlusal discrepancies and anatomy of the bony structures of the orofacial) and pathophysiological factors (such as sleep arousal response).7

Impact on the patient A study by Lal and Weber included a good summary outlining the indications for the treatment of bruxism as follows:7 • Tenderness and stiffness in jaw muscles • Increased wear of tooth resulting in loss of occlusal morphology and flattening of the occlusal tooth surface • Tooth fractures and recurrent fracture of restorations such as class I and class II restorations, fracture of crowns and fixed partial prosthesis • Unpleasant loud noise during sleep, which causes disturbances and can awaken the partner • Limited mouth opening • Pain in the preauricular region • Clicking and tenderness of the temporomandibular joint • Headaches occur as a result of muscle tenderness associated with the temporalis muscle

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• Cosmetic appearance of hypertrophic masseter muscle and/or hypertrophic temporalis muscle are dissatisfactory for the patient The management of bruxism relies on the recognition of the potential causative factors associated with its development. Awake bruxism may be confounded by stress and other psychosocial parameters. This form of bruxism can be managed by considering interventions such as habit modification, relaxation therapy and biofeedback. Awake bruxism can often be effectively eliminated via intervention, however recurrence of the condition is common.7 In patients with sleep bruxism (which does not appear to be impacted by psychological or psychosocial factors), appropriate intervention might include appliance therapy and medication. The healthcare provider managing bruxism must understand that nocturnal or sleep bruxism is not usually cured by intervention, however the behaviour is likely to diminish with age.18 In patients with medication or drug-induced bruxism, medication withdrawal or a change of type of medication to a less likely cause of bruxism should be considered. Other factors to consider would be dietary, when there is an excessive consumption of caffeine, or tobacco use.

Treatment Various treatments have been investigated, however none have been shown to be completely effective. This may be owing to the fact that they are mainly managing the signs and symptoms and to limit damage to the dentition, rather than the cause. Multifactorial treatments may be a better approach involving occlusal correction, behavioural changes and a pharmacological approach such as occlusal splints, cognitive behavioural therapy and benzodiazepines.19,20

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Case study A patient was complaining of severe pain around the masseter and temporal regions and was experiencing headaches and sleepless nights. Their general dental practitioner ruled out all odontogenic causes of pain and urgently referred them to the dental hospital for chronic temporomandibular joint disorder with acute episode of pain. The general medical practitioner prescribed sleeping tablets and diazepam, however the patient was still not sleeping and had suicidal thoughts stating that she “Couldn’t go another night with the pain and sleeplessness.” The dental hospital were unable to see the patient immediately as the waiting list was very long, so her general dentist suggested botulinum toxin in adjunct to the diazepam and her current splint therapy. The patient was referred to me by the dentist. I prescribed botulinum toxin to the masseter muscles and suggested to call at any time. I injected a dose of 50 speywood units per masseter muscle into three sites with a 20mm needle. The patient’s doctor was informed of the treatment plan and of the concerns we had about their mental health and wellbeing at this time. The patient was encouraged to persevere with the diazepam and splint use. On review four weeks later, the patient had some, but not full relief from the pain. However, it was enough to enable the patient to sleep and she was delighted with the outcome.

Splints Night guards, occlusal splints, removable appliances or interocclusal orthopedic appliances, as well as customised appliances can be used for the treatment of bruxism. Occlusal splints are generally to prevent tooth wear and tooth injury, while reducing clenching. Removable splints are worn at night to guide the movement to reduce periodontal damage. Splint use should result in a reduction in increased muscle tone. Appliances vary in appearance and features and can be constructed in the dental surgery or a laboratory, and fabricated from hard or soft material. Appliances typically, but not always, cover either all of the maxillary or mandibular teeth.21 Riley et al.’s systematic review concluded that there is no evidence to support the use of oral splints for either bruxism or TMD, based on the results found. Furthermore the type of splint, diagnostic criteria or outcome factors did not change this outcome.22 The efficacy of splints may be in doubt, however there is data which supports their effectiveness as an adjunct for pain management as patients’ perception

The management of bruxism relies on the recognition of the potential causative factors associated with its development

of their effectiveness is generally positive.23 Their use should be limited to prevent dental damage and to manage the habit. Occlusal adjustments Premature contacts or occlusal interferences can be corrected by coronoplasty – where some enamel is removed from the tooth surface. Before occlusal adjustment, muscles should be brought back to their relaxed position for the jaw to resume its normal physiologic movements. This is carried out by biannual manipulation of the temporomandibular joints to return the occlusion to its centric relation.24,25 Psychotherapy If the cause of the bruxism is thought to be stress, then psychotherapy can be used to aid calmness. Patient counselling, mindfulness, relaxation techniques and cognitive behavioural therapy can lead to a decrease in tension and also create awareness of the habit, thereby reducing symptoms. This results in an increase in the voluntary control and thus can aid in reducing parafunctional movements. However, there is a need for further good quality large scale studies in this area and referral pathways for this treatment type.26,27 Physical therapy Physical therapy is recommended if bruxism is associated with muscle pain and stiffness. Manipulation can be carried out by a chiropractor or physiotherapist to reduce tension in the muscles around the head and neck area. This can be both preventative and to alleviate the symptoms of bruxism.28

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Pharmacological Pharmacological management includes antianxiolytic drugs, tranquillisers, sedatives and muscle relaxants (both injectable and oral). For example, diazepam can be prescribed for a few days to alter the sleep arousal and anxiety, while low doses of tricyclic antidepressants may be used to inhibit the amount of REM sleep.29 Patients and practitioners often prefer pharmacological treatment to be as short as possible and to treat the acute symptoms of the condition. The other treatments are used more for long-term solutions. Biofeedback Biofeedback consists of electronics mounted in a headband with feedback given via an earphone worn by the patient. The patient can view an electromyography (EMG) monitor while the mandible is postured with a minimum of activity. The headband picks up EMG voltage signals indicative of bruxism. Positive feedback is then used to enable the patient to learn tension reduction. Positive results have been described, however larger scale studies are required.30 Electrical method Electrogalvanic stimulation can be used for muscle relaxation.31 Somatoemotional release (SER) therapy aims to release emotional issues or memories within its tissues.32 Pulsed electromagnetic field (PEMF) therapy has a dual effect on muscle and produces heating and molecular resonance (vibration) with resultant muscle lengthening and reduction of ischemia.33 Equilibration therapy Bruxism may be due to malocclusion – teeth misalignment. The malocclusion can be corrected using orthodontic treatment. Acupuncture Acupuncture has been used to treat awake and sleep bruxism. Research has shown improvements, however as with other treatments further long-term studies are required.34 Botulinum toxin Kumar et al. proposed that botulinum toxin represents a possible option for the management of sleep bruxism. Botulinum toxin was shown to reduce the frequency of bruxism episodes, masticatory force, muscle mass and decreased pain.35 Fernandez-Nunez et al.’s systematic review consisting of 188 patients concluded the

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use of botulinum toxin is a safe and effective treatment for patients with bruxism. They also concluded that it showed better clinical results than occlusal splints, drugs or cognitive-behavioural therapy and that its use would be justified in clinical practice.36 Note that the studies in the review were not directly comparable. There are few studies which describe the use of botulinum toxin for the use of awake bruxism, however its use would be identical for both in reducing the contraction of the masseter muscle.37 In my practice, botulinum toxin is a treatment which I commonly provide for bruxism, with patients often being referred from my dental colleagues (see case study as example).

Conclusion Bruxism is a condition generally of multifactorial origin which can be treated with various treatment modalities. Kumar et al. concluded that bruxism may be better treated with botulinum toxin than splints which is more often than not a dentist’s first treatment modality of choice for bruxism.31 It is for this reason that aesthetic practitioners with an understanding of bruxism should be able to offer this treatment to patients. As it is a disorder of multifactorial origin it may not be the only treatment which should be used and therefore the clinician needs an understanding of the other treatments available to offer or refer. Dr Heather Muir is a dentist with more than 17 years’ experience in facial aesthetic treatments. She currently teaches facial aesthetic techniques to dentists, doctors and nurses and is the owner of Your Face Aesthetics in Uddington, Scotland. Qual: BDS, MSC (UCLAN) REFERENCES 1. F. Lobbezoo J. et al.,‘Bruxism defined and graded: an international consensus’, (2012). 2. Manfredini D, et al., ‘Epidemiology of bruxism in adults: a systematic review of the literature’, Journal of Orofacial Pain, (2013) 27: 99-110. 3. Koyano K, et al., ‘Assessment of bruxism in the clinic’, J Oral Rehabil. 2008; 35 :495-508. 4. Bader G, et al., ‘Body movement during sleep in subjects with long-standing bruxing behavior’, Int J Prosthodont, (2000); 13:327-33. 5. Manfredini D, Lobbezoo F., ‘Relationship between bruxism and temporomandibular disorders: A systematic review of literature from 1998 to 2008’, Oral Surg Oral Med Oral Pathol Oral Radiol Endod. (2010);109:e25-50. 6. National Institute of Dental and Craniofacial Research (NIDCR). Prevalence of TMJD and its Signs and Symptoms. 2014. <https:// www.nidcr.nih.gov/datastatistics/finddatabytopic/facialpain/ prevalencetmjd.html> 7. Sona J. Lal; Kurt K. Weber, Bruxism Management <https:// europepmc.org/article/med/29494073> 8. Shilpa S, et al., ‘Bruxism: A Literature Review’, The Journal of Indian Prosthodontic Society, (2010);10:141-148. 9. Lobbezoo F, et al., ‘Are bruxism and the bite causally related?’ Journal of Oral Rehabilitation., (2012); 39: 489-501. 10. Melo, G, et al. ‘Bruxism: An umbrella review of systematic reviews’, J. Oral Rehabil. 2019, 46, 666-690.

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11. Klasser, G.D., et al, ‘Sleep bruxism etiology: The evolution of a changing paradigm’, J. Can. Dent. Assoc. 2015, 81, f2. 12. Kuhn, M.; Türp, J.C., ‘Risk factors for bruxism’, Swiss Dent. J. (2018), 128, 118-124. 13. Beddis, H.; Pemberton, M.; Davies, S., ‘Sleep bruxism: An overview for clinicians’, Br. Dent. J. (2018), 225, 497-501. 14. Pierce CJ, Chrisman K, Bennett ME, Close JM., ‘Stress, anticipatory stress, and psychologic measures related to sleep bruxism’, J Orofac Pain. (1995) ;9:51-6. 15. Rugh JD, Barghi N, Drago CJ., ‘Experimental occlusal discrepancies and nocturnal bruxism’, J Prosthet Dent. (1984) ;51:548-53. 16. Lobbezoo F, Naeije M., ‘Bruxism is mainly regulated centrally, not peripherally’, J Oral Rehabil. (2001);28:1085-91. 17. Klasser GD, Rei N, Lavigne GJ., ‘Sleep bruxism etiology: The evolution of a changing paradigm’, J Can Dent Assoc. (2015);81:f2. 18. Godoy de Oliveira PT, et al., ‘Aesthetic Rehabilitation in Teeth with Wear from Bruxism and Acid Erosion’, Open Dent J. (2018);12:486-493. 19. Okeson JP., ‘The effects of hard and soft occlusal splints on nocturnal bruxism’, J Am Dent Assoc. (1987);114:788-91. 20. Saletu A, et al., ‘On the pharmacotherapy of sleep bruxism: Placebo-controlled polysomnographic and psychometric studies with clonazepam’, Neuropsychobiology, (2005);51:21425. 21. Aggarwal V R, et al., ‘Dentists’ preferences for diagnosis, management and referral of chronic oro-facial pain: Results from a national survey’, Health Educ Journal, (2012); 71: 662-669. 22. Riley, P., et al., ‘Oral splints for temporomandibular disorder or bruxism: a systematic review’, Br Dent J. (2020);228:191-197. 23. T.T. Dao, GJ Lavigne, ‘Oral Splints: the Crutches for Temporomandibular Disorders and Bruxism?’, Critical Reviews in Oral Biology & Medicine, July 1, 1998. 24. Nakayama R, Nishiyama A, Shimada M., ‘Bruxism-Related Signs and Periodontal Disease: A Preliminary Study’, Open Dent J. (2018);12:400-405. 25. Gouw S, de Wijer A, Kalaykova SI, Creugers NHJ., ‘Masticatory muscle stretching for the management of sleep bruxism: A randomised controlled trial’, J Oral Rehabil. (2018) Oct;45(10):770-776. 26. Machado E, Machado P, Cunali PA, Dal Fabbro., ‘Sleep bruxism: Therapeutic possibilities based in evidences’, Dental Press J Orthod. (2011); 16(2): 58-64. 27. Dobson D, Dobson KS., ‘Evidence-based practice of cognitivebehavioral therapy’, New York/London: The Guilford Press; 2009. 28. Fernández-de-las-Peñas C., Bensen K., (2019) ‘Adjunctive Therapies for Temporomandibular Disorders. In: Connelly S., Tartaglia G., Silva R. (eds) Contemporary Management of Temporomandibular Disorders’, Springer, Cham. 29. E Machado, P Machado, PA Cunali., ‘Sleep bruxism: Therapeutic possibilities based in evidences’, Dental Press J. 2011. 30. Wang, L., Long, H., Deng, M. et al., ‘Biofeedback treatment for sleep bruxism: a systematic review’, Sleep Breath. (2014);18: 235-242. 31. Daniel M. Laskin, Sanford Block. ‘Diagnosis and treatment of myofacial pain-dysfunction (MPD) syndrome’, Journal of prosthetic dentistry, July (1986); 56(1): 75-84. 32. Rivera, Floribeth, Reconnecting the Mind and Body: Using Bodywork to Help Improve Mental Health, (2016). Loma Linda University Electronic Theses, Dissertations & Projects.326.http:// scholarsrepository.llu.edu/etd/326 33. Atef Abd el hameed Fouda et al., Low Level Laser Therapy Versus Pulsed Electromagnetic Field For Inactivation Of Myofascial Trigger Points, American Journal of Research Communication, 2013. 34. B Sebregts, The Treatment of Bruxism with Acupuncture, Journal of Chinese Medicine, 2020. 35. Kumar A., Spivakovsky S. ‘Bruxism- is botulinum toxin an effective treatment?’, Evid Based Dent. (2018) Jun;19(2):59. 36. Tania Fernández-Núñez,1 Sara Amghar-Maach,2 and Cosme Gay-Escoda., ‘Efficacy of botulinum toxin in the treatment of bruxism: Systematic review’, Patol Oral Cir Bucal. (2019) Jul; 24(4): e416–e424. 37. Ågren M, Sahin C, Pettersson M, The effect of botulinum toxin injections on bruxism: A systematic review, Journal of Oral Rehabilitation 47 (3), 2020, 395-402.

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include a variety of conditions affecting the skin such as ichthyosis, chronic dermatitis, burns and skin tumours.5 In specialised oculoplastic aesthetic practice there is a significant number of patients with postblepharoplasty retraction, a complication as prevalent as up 20% in some studies.6 Thyroid eye disease and other forms of Consultant oculoplastic surgeon Mr Daniel Ezra inflammatory orbital conditions can also details his approach to treating ‘almond eyes’ cause this. Lower lid skin shortage can also be congenital, in the form of euryblepharon.7 1 Appearance has enormous influence on psychosocial functioning The majority of patients with constitutional lower lid sag are typically and the eyes in particular play an important role in perceived seen in context of myopia (short sightedness). Myopic eyes have a attractiveness and communication.2 larger diameter and tend to protrude forward in what is described as There is a wide range of physiological and constitutional variability in a ‘negative vector’ eye configuration. In these settings, the lower lids the contours of the eyelids. The spectrum of different eye shapes are have less support and often appear to be sagging. If also associated only partly due to the nature of the eyelids themselves. Eye shapes with a canthal dystopia (drooping outer corner of the eye), this can are often determined by the morphology of the mid-face, the depth give rise to a lethargic or sad appearance.8 of the eye sockets and importantly, the size of the globes (eyeballs). Treatments of pathological lower lid elevation generally require spacer There have been many morphometric studies demonstrating the grafts to be placed within the lower lid. Treatments like this date back importance of eye shapes in different ethnic groups, establishing to the 1940s, when cartilage grafts and other similar spacers have this as an important indicator of attractiveness.3 A more reductionist been used to elevate the lower lid, but due to their thickness give an analysis has identified several parameters as being important, such as unsightly appearance.9 eyelid length and ‘canthal tilt’, describing the angle formed between There are only sparse reports in the literature of lower lid contour the inner/outer corners of the eye and the horizontal meridien.4 reshaping in healthy individuals undertaken for aesthetic reasons. Lower lid sag is a common feature in many individuals and this can This article reports on the experience of a patient undergoing almond give a tired and drawn appearance. This article describes ‘almond eye surgery to address lower lid droop and canthal dystopia using a eye’ surgery, which is a technique using novel biocompatible implants mucograft as a novel spacer implant. Mucograft is normally used for to address this particular feature. Conventional blepharoplasty is soft tissue augmentation in dental reconstructions.10 effective at reducing excess tissue, but is not able to correct changes in the shape of the lid contours. Many patients are seeking specialist aesthetic treatments focusing on shape change, rather than reduction of skin and bags. This is particularly the case for younger patients. There are a variety of eyelid shape parameters that can be changed using established treatments such as: ptosis correction, to raise the upper lid position; canthoplasty, to lengthen the eyelid in selected cases; and levator recession to lower the upper lid and reduce the palpebral fissure height. However, one of the most difficult features to treat is lower lid sag, which often requires lower lid elevation and change in canthal tilt. There are many causes for lower lid sag and retraction which can either be pathological of physiological (constitutional). The pathological causes of lower lid retraction are beyond the scope of this article, but

Case Study: Contouring the Lower Eyelid

Many patients are seeking specialist aesthetic treatments focusing on shape change, rather than reduction of skin and bags Patient background

Posterior lamella

Anterior lamella

Orbital septum

Middle lamella

Figure 1: The multiple layers of the lower lid. The anterior lamella is made up of skin and muscle.

A 27-year-old gentleman presented to clinic to seek advice regarding improving lower lid sag which had been present as a constitutional feature since childhood (Figure 2). The lower lids were retracted, causing the white of the eye to show between the cornea and the lower lid. The feature is referred to as ‘scleral show’, meaning that there is white of the eye showing between the lower lid and the iris. He felt that this gave a somewhat tired appearance and droopy look to the eyes and he was keen to explore treatments to improve the lower lid position and eliminate the scleral show. The patient was clear that he did not want a significant change in his overall appearance, but rather wanted only to reduce the scleral show and improve the canthal tilt. We discussed the possibility of performing almond eye surgery. The risks were discussed and would include chronic chemosis, failure of the procedure to elevate the eyelid, eye discomfort and asymmetry. These risks were all very low and the patient opted to proceed with the treatment.

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Post-surgical recovery is usually between two to three weeks, although chemosis (conjunctival oedema) can take longer to settle, particularly in myopic patients. Until the mucograft epithelialised and integrates into the lower lid tissues, it maintains a hard and roughened surface. Bandage contact lenses are used in the meantime to allow for comfort, along with prophylactic antibiotics. Figure 2: Demonstrating 3mm reduction in scleral show (white below the cornea). There is also an associated reversal of canthal tilt, making the eyes look less droopy. Please note that the lump on the outer part of the lower lid in the postoperative image is a coincidental chalazion and was not related to the surgery.

Figure 3: A different patient with a very similar set of issues demonstrating 3mm of lower lid elevation at six months. There is also an accentuation in canthal tilt postoperatively.

Patient selection considerations When counselling a patient for this surgery, a meticulous examination of the eyelids and eyes is required. The almond eye procedure will not work for all patients. This individual had several factors in his favour for a positive outcome: • The patient was, somewhat unusually, not myopic, with a positive vector eye configuration. In my experience, patients with a negative vector eye configuration are less likely to maintain the post-surgical elevation due to limitation in lateral support of the new eyelid position. • The eyelid is a complex multi-layered structure (Figure 1). The almond eye procedure is undertaken through internal incisions to recess the middle and posterior (orbital septum and retractors) layers of the eyelid. However, if skin and muscle shortage (anterior lamella) is the critical factor mediating the retraction, this procedure is less likely to work. Raising the lower lid in the context of skin shortage is more complex, requiring mid-face elevation and is generally not recommended as a primary aesthetic procedure. A careful examination of this patient suggested that there was enough skin to allow for the elevation created by the almond eye procedure. • No signs of dry eye. In my experience, patients with existing ocular surface disease, particularly blepharitis or dry eye, can have significant long-term discomfort after this surgery. The patient had no such ophthalmic issues.

Treatment The patient underwent a combined lower lid septo-retractor recession, with mucograft implantation and lateral canthoplasty. The precise details of the surgery are beyond the scope of this article but, essentially, the surgery is performed through the inside of the eyelid leaving no discernible scars. Through the conjunctival incision, the natural retractor bands within the eyelid itself are released, and then the spacer graft is sutured in to elevate the eyelid and prevent retractor re-attachment. A canthoplasty procedure resets the lateral canthal position, to provide further support for the eyelid and ensure that the canthal tilt (angle between medial and lateral canthi) is improved. Mucograft is an animal-derived acellular collagen matrix commonly used in dental reconstruction. Mucograft is a highly versatile component allowing for epithelialisation of the compacted part and full integration into the inner eyelid.11 This lower eyelid procedure represents a novel application for this material.

Outcomes and satisfaction

The primary outcome measured was elevation of the lower lid. The elevation of the lateral and central parts was 2.5mm after six months. Although this seems like a small amount, the normal palpebral aperture is between 8-9mm, so this change represents a dramatic improvement. The patient reported significant satisfaction with the outcome of the procedure with no residual discomfort reported (Figure 2).

Conclusion Blepharoplasty alone is an effective procedure to reduce excess tissue and tighten skin, but is not able to change the shape and contour of lids. Treatment trends mean that patients are increasingly looking to consider reshaping of the eyelid contours, in terms of lengthening, changing angles and raising or lowering the curvatures of the lids. These are complex procedures with very narrow margins of error and require meticulous planning and examination of the eyes themselves. As with all eyelid surgery, this procedure requires a detailed biomicroscopic assessment of the ocular surface before proceeding. This type of procedure should only be performed by an oculoplastic surgeon with training in ophthalmology and an appropriate subspecialist fellowship training. Almond eye surgery represents another step in the ongoing evolution of aesthetic eyelid surgery, with this report demonstrating that it can be carried out effectively and safely. Mr Daniel Ezra is a consultant oculoplastic surgeon at Moorfields Eye Hospital and honorary associate professor at the UCL Institute of Ophthalmology in central London. He is also the head of department and service director of Oculoplastic Surgery. Mr Ezra has published widely on eyelid movement disorders and runs a busy private practice based on Harley Street and at Moorfields, focusing on aesthetic eye and facial treatments. He also has a special interest in revision surgery and managing filler complications. Qual: MA (Cantab), MMedEd, MD (Cantab), FRCS (G) FRCOphth, FHEA REFERENCES 1. T. Pruzinsky, ‘Psychological factors in cosmetic plastic surgery: recent developments in patient care’, Plas Surg Nurs, 13 (1993), pp.64-69. 2. A. Clarke, N. Rumsey, J.R.O. Collin, et al. ‘Psychosocial distress associated with disfiguring eye conditions’, Eye, 17 (2003), pp.35-40. 3. Rhee SC, Woo KS, Kwon B., ‘Biometric study of eyelid shape and dimensions of different races with references to beauty’, Aesthetic Plast Surg, 2012 Oct;36(5):1236-45. 4. Bashour M1, Geist C., ‘Is medial canthal tilt a powerful cue for facial attractiveness?’ Ophthalmic Plast Reconstr Surg. 2007 Jan-Feb;23(1):52-6. 5. Samuel Hahn, Shaun C Desai , ‘Lower Lid Malposition: Causes and Correction’, Facial Plast Surg Clin North Am, 2016 May;24(2):163-71. 6. D.B. Rosenberg, J. Lattman and A.R. Shah, ‘Prevention of lower eyelid malposition after blepharoplasty:anatomic and technical considerations of the inside-out blepharoplasty’ Arch Facial Plast Surg, 9 (6) (2007), pp. 434-438. 7. J A Keipert, ‘Euryblepharon’, Br J Ophthalmol. (197)5 Jan;59(1):57-8. 8. NHS, Short Sightedness <https://www.nhs.uk/conditions/short-sightedness/> 9. Park E, MD; Lewis K, BA; and Mohammed S. Alghoul M, MD, ‘Comparison of Efficacy and Complications Among Various Spacer Grafts in the Treatment of Lower Eyelid Retraction: A Systematic Review’, Aesthet Surg J (2017) pp.743-754. 10. Geistlich Pharma, Geistlich Mucograft <https://www.geistlich.co.uk/en/dental/matrices/mucograft/ product-range/> 11. Roberto Rotundo, Giovanpaolo Pini-Prato, ‘Use of a New Collagen Matrix (Mucograft) for the Treatment of Multiple Gingival Recessions: Case Reports’., Int J Periodontics Restorative Dent, 2012 Aug;32(4):413-9.

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Advertorial Thermage FLX®

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Treating Cosmetic ‘Tech-Neck’ for Patients Post-lockdown with Thermage FLX® With the world working from home, healthcare professionals are now seeing more patients than ever with an interest in their neck and jawline “The dermis, whose main components are mainly collagen fibres, is very thin, making it more prone to ageing than other parts of the body,” says cosmetic surgeon Dr Angelica Kavouni.1 And, while cumulative sun exposure over a lifetime has always been the main culprit of premature ageing on the neck, Dr Kavouni has seen a significant increase in patients asking for treatments to tighten the jawline and combat the symptoms of what she terms ‘Tech-Neck – cosmetic’ after a prolonged period of working from home.

New and improved Thermage FLX® is the brainchild of Solta Medical®, one of the world’s most notable names in medical aesthetics and the company that introduced leading noninvasive antiageing treatment Thermage® over 13 years ago. Today, the new generation, Thermage FLX®, promises even faster results.* Before

After

Thermage FLX® treatment uses radiofrequency technology to heat the deeper, collagen rich layers of the skin, while the tip vibrates and cools the surface to help aid in patient comfort.2

All aided by the new ‘Total Tip 4.0’ that offers faster treatment up to 25%* and an even heat distributed over the entire skin area, allowing a multidimensional tightening effect. “The result is an immediate skin tightening3 and well-defined three dimensional skin contour, all in a single treatment with little to no downtime. The patient’s skin continues to improve for the next six months,4 with results lasting up to 12 months,”** says Dr Kavouni.

Proven track record What is the ‘Tech Neck’ – cosmetic? “The changes to the neck and jawline definition that we see as a result of looking down at a screen for a prolonged period include creases, folds, fine lines and wrinkles caused by laxity of muscular support and the cumulative effects of photodamage and gravity. These contribute to the loss of definition of the cervicomental angle, submental sagging and redundancy of the skin, along with an increase in platysmal band visibility,” explains Dr Kavouni. “As a result, the lower facial third may appear loosened and untoned, which can diminish the ‘heart-shaped’ facial shape that is so widely associated with a youthful and desired appearance. The delicate skin of our neck may develop deep etched horizontal and vertical lines. Thermage FLX® offers a great treatment option for patients as it aims to tighten the lower face and neck, as well as tone and improve skin elasticity in the long term,” she adds.

Before and after Thermage FLX®. Courtesy of Carolyn I Jacob, MD FAAD (Dermatologist, USA)

Featuring innovative AccuREP™ technology, the new Thermage FLX® provides personalised skin tightening by employing the new treatment algorithm that optimises and tailors the radiofrequency energy output to each skin type, for precise and gentle heating. As well as this, the Comfort Pulse Technology, which intersperses cooling bursts, works with the multidirectional tip vibration to ensure comfort2 throughout the session.

How it works Targeting the skin’s dermis layer where collagen fibres are found, Thermage FLX® uses patented monopolar radiofrequency that delivers a uniform heating effect that penetrates deep into the collagen-rich layers of the skin. This gentle heating causes existing collagen tissue to tighten, stimulates the production of new collagen, and helps to define contours. Thermage FLX® integrates the Comfort Pulse Technology with the latest AccuREP™ technology that auto-tunes each pulse of energy for an even more precise and consistent treatment. Each treatment takes about 45 minutes for the face and up to 90 minutes for the body depending on the area to be treated.

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Aesthetics | September 2020

A pioneer in non-invasive skin tightening, CE mark approved and FDA-cleared, Thermage FLX® is known for its ability to reduce the appearance of fine lines, wrinkles and sagging skin and is recognised for its good safety profile, demonstrated in more than 50 published clinical studies. Thermage® has been the go-to choice for many patients concerned with signs of ageing on their face, neck, arms and even buttocks and knees. Over 2 million Thermage® treatments have been performed worldwide, and it’s the only FDA-cleared non-invasive eye skin tightening treatment. * All comparisons are made with Thermage CPT® and its components. **Recommended by physicians as part of an annual skin rejuvenation maintenance programme.

REFERENCES 1. www.ionkavounilondon.com 2. Solta Medical, 2009. Report on Gazelle Clinical Study 09-100GA-T ‘Validation of the Thermage 3.0 cm2 STC and DC Frame Tips, Comfort Software and Vibration Handpiece on the Face and Thighs’ (#09-019ER). Bothell. 3. B. D Zelickson, et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based non-ablative dermal remodelling device: a pilot study. Arch Dermatol. 2004 Feb;140(2):204-9. 4. R. Fitzpatrick et al. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med. 2003;33(4):232-42.

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A summary of the latest clinical studies Title: Breast Augmentation for Transfeminine Patients: Methods, Complications, and Outcomes Authors: Bekeny, et al. Published: Gland Surgery, August 2020 Keywords: Transgender, breast augmentation, chest surgery Abstract: Although there are many techniques for genderaffirming care, surgical breast augmentation, or “top surgery,” is often cited as the most important-and sometimes onlyprocedure sought by transfeminine patients. Unfortunately, years of individual and systemic prejudice placed barriers between transgender patients and the healthcare providers needed to affirm gender identity. Policy has recently begun to change as research proving the safety, need, and outcomes of breast augmentation in transfeminine patients dismantles long-established systemic inequalities. With this change, more patients are seeking knowledgeable and respectful providers who can address their unique gender-affirming needs. The most common method of augmentation relies on breast implants, since removable prostheses, exogenous hormones, and fat grafting alone often produce unsatisfactory results. Special attention needs to be directed towards anatomic differences in transgender versus cisgender patients in order to achieve optimal size and position of the breast and nipple-areolar complex. The aim of this review is to give providers the technical knowledge concerning breast augmentation options, pre-surgical evaluation, post-surgical care, and special considerations in transfeminine patients so that provider and patient can have a successful, respectful partnership in reaching gender-affirming goals. Title: Enhanced Pulsed Dye Laser for Facial Rejuvenation Authors: Ross, et al. Published: Lasers and in Surgery and Medicine, August 2020 Keywords: Pulsed dye laser, telangiectasia, rosacea, pigment Abstract: Thirteen patients were enrolled in the study. Nine patients were female, four were male. All patients presented with either facial telangiectasia, rosacea, pigment, or a combination thereof. At the initial evaluation, test spots were performed to determine the subject’s response to selected treatment parameters. In the study, the enhanced 595 nm PDL deployed a spot size range of 5-12 mm with fluences ranging from 8 to 18 J/cm2. Pulse duration was 10 milliseconds. Enhancements in this device included the option for contact or cryogen spray cooling, increased maximum pulse energy, increased repetition rate, option for addition of radiofrequency (RF), an option for a 15 mm spot size, and longer dye life. Determinations of improvement were made by evaluation of photographs with standard settings using polarized and nonpolarized images. Up to three treatments were performed approximately 1 month apart with follow-up visits 1 and 3 months after the final treatment. Evaluation by a panel of blind observers determined a mean clearance of at least 50% in all lesions, while 77% of lesions had 50-75% clearance, and 23% of lesions had 76-100% clearance. Pain was approximately 4/10. Subjective lesion improvement and satisfaction rates were 3 out of 4 and 3.6 out 4, respectively.

An enhanced PDL is effective in one pass treatments for facial rejuvenation with considerably less operative time than previous commercially available systems. A second pass applied to focal challenging lesions results in even more improvement, in a single treatment session. Title: Ultrasound Assessment of Tissue Integration of The Crosslinked Hyaluronic Acid Filler VYC-25L in Facial LowerThird Aesthetic Treatment: A Prospective Multicenter Study Authors: Urdiales-Gálvez, et al. Published: Journal of Cosmetic Dermatology, August 2020 Keywords: Biointegration, hyaluronic acid, lowerface Abstract: Prospective, noncomparative, open-label, and multicenter study conducted on healthy subjects, with age comprised between 30 and 60 years old, who attended the clinic to perform a facial rejuvenation treatment of the lower third of the face. VYC-25L was injected using a 27G needle (supraperiosteal bolus, from 0.2 to 0.3 mL per bolus) in the chin and with canula (retrograde threads, from 0.4 to 0.6 mL) in the jaw. Ultrasound examinations (UE) were performed at each study center by the same experienced observer at baseline, immediately after injection, 48 hours, and 30 days after treatment. Thirty patients (10 per center) were included in the study. At baseline, UE found a characteristic heterogeneous pattern of subcutaneous cellular tissue, with alternation of soft anechoic and hyperechoic images. The UE, performed immediately after treatment, showed a poorly defined globular ultrasound pattern, with anechoic images indicative of liquid content. Forty-eight hours after treatment, UE are still showing a globular pattern, with well-defined anechoic areas. Thirty days after treatment, a thickening of the subcutaneous cellular tissue was observed in all the evaluated zones, with a total integration of the HA into the tissue. Title: A Case Report of Episcleral Artery Embolism Caused by Hyaluronic Acid Injection Into the Malar Area Authors: Akoglu, et al. Published: Journal of Cosmetic Dermatology, August 2020 Keywords: Arterial embolism, episcleral artery, hyaluronic acid, malar area, vascular occlusion Abstract: Dermal fillers are one of the most commonly used minimally invasive cosmetic procedures. In recent years, malar filler injections have become increasingly more popular among women to have more prominent cheekbones for attractiveness and facial beauty. To provide a more comprehensive structure for restoring malar eminences, the depth of injection points are recommended to be positioned supraperiostally. Owing to supraperiosteal planes, apart from the zygomaticofacial pedicle, are called as major artery-free areas malar filler injections are usually considered to be relatively safe in terms of vascular complications. Herein, we describe a case of episcleral artery embolism following malar filler injection procedure with hyaluronic acid (HA) and discuss the possible embolism mechanisms.

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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So how did the idea actually come about, what was required to turn the idea into reality, and, most importantly, how do patients respond to a theme of this extent?

Turning a concept into reality

Spotlight On: Smileworks An insight into the unique aesthetic practice with the UK’s most elaborate theme From the moment you step into Smileworks Liverpool, you feel more like you are bound for a holiday, rather than a medical procedure. The reception desk is a cleverly crafted repurposed air brake from a Tornado F3 aircraft, the waiting room consists of seats from a real Boeing 747, and porthole windows are placed on the side of the walls, as well as a realistic cockpit mural at the front. Yes, Dr MJ Rowland-Warmann owns an aviation-themed dental and aesthetic practice, with elements of the theme everywhere. Dr MJ Rowland-Warmann If you were to meet Dr Rowland-Warmann, you wouldn’t be surprised that she chose a unique theme for her practice; her own wedding was medieval themed after all. However, when you learn the details behind the practice’s inception, it’s more than just a theme. “You really do get the very best customer service at 34,000 feet,” Dr MJ Rowland-Warmann says, “And I believe customer service is one of the most important determining factors for a long-lasting business so our theme really does transpire across everything that we strive for.” Dr Rowland-Warmann adds that medical aesthetics and dentistry are very much like air travel. “You can pay cheap, and you will get that kind of experience. You can pay premium and you can get luxury and first-class service. We think of ourselves much like Virgin Atlantic, where you can always guarantee high-quality, good service with great value and people who really look after you. The theme is also just fun; having fun whilst delivering fantastic customer services is one of our core values,” she says.

“It all started with an aeroplane drinks trolley,” Dr Rowland-Warmann remembers, I was on a flight to the US and looked in the catalogue and saw a drinks trolley and thought how fun and useful it would be to have one in the practice. Now, the airline theme has woven into the fabric of everything!” she laughs, explaining that it’s all in the details. They decided they wanted a desk made of aeroplane parts, so found on eBay what she describes as a 2m long, old, tired and heavy piece of metal that she didn’t know what to do with. “We posted an advert on Gumtree to find someone to make us a desk out of the part, and we didn’t have very high hopes to be honest. However, someone got in touch who made floats for the Olympic Games closing ceremony. This piece of metal came back as a beautiful, amazing, practice desk that was mirror polished. It was down to the millimetre perfect and I remember thinking it was like the ring in the Lord of the Rings! It was honestly the most impressive thing I had ever seen, and I think this desk is the secret of Smileworks’ power, it just has this magical quality,” she says. Dr Rowland-Warmann also commissioned bespoke uniforms for her staff, which grew from a team of just three in 2013 to 40 after several practice expansions. She explains, “We got in touch with a fashion design student in London to create bespoke themed uniforms, and a local lady in Liverpool who made us our hats. I didn’t want to be wearing a generic uniform as I didn’t want to be the same as other practices. All the uniforms have rank stripes

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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I think we probably have the most photographed waiting room in the UK! on the shoulder; the support staff get one, the associates get two, Ed, my husband, is our first officer and director of marketing so has three, and I have four as the director and clinical lead – or our captain!” Dr Rowland-Warmann highlights that she takes pride in ensuring her staff feel comfortable and good about themselves in what they wear, as she believes it helps them deliver a better service to patients. The theme is probably most evident in the waiting room; the real aeroplane seats, plane windows and cockpit mural is so realistic you really do feel like you are flying through the skies. “I think we probably have the most photographed waiting room in the UK,” Dr Rowland-Warmann laughs, adding, “So many patients take pictures and tag

everything,” she says. Dr Rowland-Warmann explains that the theme actually helps to attract the types of patients she is looking for. “Having a practice with a theme like this makes it clear that we don’t take ourselves too seriously; we of course take our work very seriously, but we are all humans and like to have fun. We tend to attract the type of patients who are mostly happy, light hearted, genuine and love what we are trying to do. The overall patient experience, which is reinforced with our theme, really does leave a lasting impression on patients, which makes them remember you and come back,” she says. When you look at Smileworks’ online reviews, it’s clear that Dr Rowland-Warmann is doing something right. “We have more

us on social media and we have people who play jokes on their significant others pretending they have gone away!”

than 550 Google reviews with a rating of 4.9 and they say for every one person who writes it, 100 people think it so we are extremely delighted about our positive feedback,” she says proudly.

The patient experience Of course, the theme is not for everyone, Dr Rowland-Warmann admits. “We do get the occasional grumpy person who says they don’t like dentists and they don’t like flying, and I just think, well, what are you doing here? Patients do have a choice of where they go, and I am not worried if a few people are not enthusiastic about our theme and ethos. You cannot appeal to everyone and that’s a really important message for other practices to remember. I think some practices struggle and believe they have to appeal to everyone and

Advice for creating a themed practice For those thinking about opening a new practice or rebranding with a theme, Dr Rowland-Warmann advises to always consider your core values in everything that you do. “A theme is an attraction for the eye, but also an essential pillar of your values. Don’t just pick a theme that doesn’t align to anything you strive for – just because you like sailing doesn’t mean you should have a

nautical-themed practice, for example.” Your staff are also important, Dr RowlandWarmann confirms. “We put extra emphasis on hiring the right people who will fit with our core values and overall theme. Growing our own talent is really important and we hire on attitude, rather than ability, because I believe technical skills can be taught, whereas attitude can’t,” she says, adding that it’s important to her that staff are nice, have great customer service and are very enthusiastic. “We have a relatively young team and I think you always need to maintain a fun vibe and a working environment where you build meaningful relationships with the patient – this is the most important thing,” she explains. Dr Rowland-Warmann is excited for the future of Smileworks, which is currently undergoing another expansion. She says this will see the premises housing seven aesthetic treatment rooms, seven dental surgeries and an aesthetic training academy. Dr Rowland-Warmann hopes to have a team of around 50 once open. “The theme won’t be as obvious in our extension as it will have more of a focus on training,

but it will still have the Smileworks feel; the staff will all still be wearing the same uniforms for example,” she notes. When reflecting on how the theme has helped her practice grow, she concludes, “Some of the details might seem a bit ‘kookie’ to some, but I think they really do reconfirm what we are trying to achieve. It’s all about being good to your patients and making them feel valued and cared for. As a customer, I believe the experience is what sets something apart and I will happily part with money if I know my experience is going to be positive and that people care. That is what underpins everything that we do – and we have fun doing it!”

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Considerations for Redundancy Employment associate Catherine Hawkes provides advice for business owners considering staff redundancies following COVID-19 and explores the typical pitfalls often made by employers Despite the Government’s best efforts to financially support businesses throughout the pandemic, the reality is that a number of employers are struggling with the impact of COVID-19 and may have to consider making redundancies. With the furlough scheme coming to an end in October 20201 this may be a potential consideration for many aesthetic businesses. If this is the case for your clinic, it is important to start planning now, as the consequences of getting the process wrong can be costly. Employees with more than two years’ service have the right not to be unfairly dismissed.2 If an employer is faced with a genuine redundancy situation, redundancy is a potentially fair reason to dismiss an employee.3 However, a fair procedure will need to be followed. This will typically consist of: • Identifying the correct ‘pool for selection’ of employees at risk of redundancy • Engaging in meaningful consultations with affected employees before any decisions are made • Considering suitable alternative employment

For employees with less than two years’ service, a comprehensive process may not always be required and should be considered on a case by case basis. In this article, I will consider the top tips employers should remember when considering and undertaking an individual consultation redundancy process (where less than 20 employees are to be made redundant from one establishment within a 90-day period). Principles governing procedural fairness in redundancy cases in the UK are those established by case law. To ensure that the correct protocol is followed, businesses should consider the following factors when going through the redundancy process.

Assess your reasoning In order for a dismissal to be fair, there needs to be a genuine redundancy situation which satisfies the statutory definition under section 139 of the Employment Rights Act 1996.4 Typical redundancy situations will occur where there is a reduced requirement for work of a particular kind; for instance, where a business is closing entirely or the demand for the work has reduced, or the place where the work is undertaken is changing, meaning

that there is no longer a need for the work to be done in that particular location. Therefore, before commencing a redundancy process, always ensure that redundancy is the real reason for the dismissal. If redundancy is used to disguise the true reason for dismissal, which may be poor performance for example, then any termination of employment for redundancy is likely to be considered unfair which would entitle an employee to bring a claim for unfair dismissal. Some employers may want to consider offering voluntary redundancy in advance of starting a compulsory redundancy consultation process, to enable them to short-circuit the process. However, in order to incentivise employees to apply, the amount offered should be over and above the statutory and contractual minimum payments that the individual would receive if they were made compulsorily redundant. A settlement agreement would also need to be signed by both parties.5 This may be feasible for some employers, but for financial reasons it may not be for others.

Keep a paper trail Employers should consult with employees on the business reasons behind the need for redundancies, and it should be made clear that no decisions have been made until the end of the process. It is therefore important that employers keep a clear paper trail to reflect the fact that no final decisions have been made, for example, through internal emails and file notes. Further, each step of the process should be clearly documented, which will typically mean keeping notes of consultation meetings, as well as written invitation letters and outcome letters which should be provided to employees. If an employee subsequently sought to challenge the fairness of the process, documentation will be vital in disproving this.

Ensure the correct ‘pool’ for redundancies Before the consultation process commences, employers should identify an appropriate pool from which to select potential redundant employees which is fundamental for ensuring fairness.6 When identifying a pool, a good starting point is to consider the specific roles at risk, including any positions which are interchangeable with those roles such as administrative or secretarial duties. It is important that the focus is on roles as opposed to individuals, as this may be seen as predetermining any selection process.

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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If it can be justified however, employers may have a pool of only one employee; for example, because the work is reducing and unique to the business with only one individual who undertakes that particular role.

Always ensure that redundancy is the real reason for the dismissal

Selection criteria Employers can determine their own selection criteria provided that it is objective and measurable, and does not rely on the opinion of the person applying the criteria.7 Standard criteria will typically include performance, skills or qualification, length of service, and disciplinary or attendance records. Employees should be fairly scored against the relevant criteria and this should be recorded. It is commonly recommended by employment lawyers that two managers separately undertake the scoring exercise for each employee to reduce any risk of subjectivity if this is practical, taking into account the size and administrative resources of the clinic. Otherwise, one manager will suffice.

Avoid discrimination All employees, regardless of their length of service, have the right not to be discriminated against.8 Therefore, selection criteria should never be discriminatory. If using attendance as a criterion, any absence for pregnancyrelated illness, disability-related absence, maternity or other family-related leave should be discounted – otherwise selection because of a high absence record could be considered discriminatory.9 Reasonable adjustments should also be made for disabled employees to ensure that they are not placed at a disadvantage because of their disability, such as making alternative arrangements for consultation meetings or allowing them to bring a companion to a meeting.

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Where an employee on maternity leave is selected for redundancy, they are afforded enhanced protection under section 10 of the Maternity and Parental Leave Regulations 1999.10 This means that they are entitled to be offered any suitable alternative role available ahead of other employees. For example, if an employer is reducing five similar roles to three, a woman on maternity leave who currently occupies one of those roles must be given one of the three remaining roles.

Consider alternatives Where appropriate, employers should undertake a search within the business for suitable alternative employment and, if available, should notify the employees at risk of redundancy. Where there are a few employees at risk of redundancy who are interested in the same alternative role, they should each be invited to apply and then a standard interview process should be undertaken. If an employer has given no consideration to suitable alternative employment available within the business, this may amount to an unfair dismissal, particularly if an employee can point to alternative roles that should have been offered and were not.11

Ensure correct payments are made It is important to check the employee’s contractual rights under their employment contract and staff handbook, specifically in relation to notice provisions, holiday entitlement, benefits and bonus entitlements. If the employee has more than two years’ service, they will be entitled to statutory redundancy pay.12 For employees with less than two years’ service, they will not be entitled to statutory redundancy pay but are entitled to any payments as set out within their contract of employment. If applicable, employees may be entitled to company-enhanced payments in accordance with any redundancy policy and/or custom and practice. Employers should ensure that they treat all employees consistently if an enhanced redundancy package is offered.

Settlement agreements To afford an employer protection from any potential employment claims, some employers offer an ex-gratia payment to employees (in addition to their contractual and statutory rights) and require them to enter into a settlement agreement as a condition of receiving additional payment.5 The effect of the settlement agreement is that the

employee waives their rights to bring any legal claims against their employer arising from the termination of their employment. It is not necessary in all circumstances, but it is worth giving consideration to after carrying out a risk/benefit analysis, especially if voluntary redundancy is offered.

Conclusion A redundancy process must be genuine and fair. Fairness relates to the quality of the employee consultation – that is, ensuring that a meaningful consultation is undertaken. It also relates to ensuring that the selection criteria used is objective and the application of those criteria is applied fairly and specifically, ensuring that employees are not dismissed for unfair or discriminatory reasons. Employers should review individual contracts as well as staff handbooks and any company redundancy policy to ensure they do not fall foul of their own policies and expose the business to possible contractual claims. Furthermore, employee engagement will be crucial to businesses during this time to ensure a smooth process and employee morale. If this can be achieved, this will ultimately assist in minimising any potential employment claims. Catherine Hawkes is an associate at Royds Withy King LLP, specialising in employment and HR law. Hawkes qualified in September 2015 and her experience includes advising on a variety of employment law related issues including unfair dismissal, discrimination, redundancy/restructure and whistleblowing. She has extensive experience in employment tribunal litigation and has particular expertise in the handling of senior executive exits and advising on the enforceability of restrictive covenants. REFERENCES 1. Treasury, H. (2020, May 12). Chancellor extends furlough scheme until October . Retrieved May 12, 2020, from Gov.UK. <https://www.gov.uk/government/news/chancellor-extendsfurlough-scheme-until-october> 2. Section 108(1) Employment Rights Act 1996. <https://www. legislation.gov.uk/ukpga/1996/18/section/108> 3. Section 98 Employment Rights Act 1996. <https://www. legislation.gov.uk/ukpga/1996/18/section/108> 4. Section 139 Employment Rights Act 1996. <https://www. legislation.gov.uk/ukpga/1996/18/section/139> 5. ACAS Guidance: Settlement Agreements. <https://archive. acas.org.uk/media/3736/Settlement-Agreements-A-guide/pdf/ Settlement_agreements_Dec_18.pdf> 6. Polkey v A E Dayton Services Ltd [1987] IRLR 503. Accessed via Thomson Reuters Practical Law. 7. Williams v Compair Maxam UKEAT/372/81. Accessed via Thomson Reuters Practical Law. 8. Part 2, Equality Act 2010. 9. ACAS Manage Staff Redundancies. <https://www.acas.org.uk/ manage-staff-redundancies/select-employees-for-redundancy> 10. The Maternity and Parental Leave Regulations 1999. <https:// www.legislation.gov.uk/uksi/1999/3312/contents/made> 11. Vokes Limited v Bear [1973] IRLR 363. Accessed via Thomson Reuters Practical Law. 12. Gov.UK Redundancy: Your Rights. <https://www.gov.uk/ redundancy-your-rights/redundancy-pay>

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Getting Started in Aesthetics Dr Sadequr Rahman shares his ‘ABC toolkit for aesthetic medicine’ and details the qualities he believes are necessary for a successful career There are a lot of things I hadn’t been told when I first considered a career in medical aesthetics, and so many things I wish I knew before embarking on this journey. Having said that, the lessons I have learnt along the way mean I wouldn’t change a thing. In this article I will share what I call ‘the ABC toolkit of aesthetic medicine’. I believe these eight qualities form the basis of a truly successful career as an injector in aesthetics. You don’t need to have mastered them all before you can start building your aesthetic career, but there has to be a plan for how you will achieve them.

A is for ability It goes without saying that to be a top-level injector, you need ability. Our patients put a lot of trust in us, which should never be taken for granted and we owe it to them to perform to our best ability. Our abilities improve when we seek knowledge and apply it over and over again. To gain knowledge and ability, you must choose a reputable training provider, read textbooks, medical journals and magazines, follow practical webinars, and listen to lectures from experts at industry events. You should also seek good advice from experienced professionals. There’s nothing wrong with asking questions, even ones that seems basic or ‘silly’. You can’t build knowledge without asking questions. You then need to use this knowledge. Of course, early in your career, it is unlikely that you will have a ready supply of willing candidates to practice your new skills on; thus, the conundrum. How to improve skills without patients, and how to gain patients when in the early stages of a career and with only rudimentary skills? I would suggest that there are three options: • Slowly and patiently build a presence by word of mouth and online marketing. This is the most ethical self-made approach, but can be expensive and take many months to develop a reputation. • Flood the market with offers of ‘cheap’ treatments and introductory offers. This can help you build a list quickly, but your patients will be bargain-hunters. And when you want to raise your prices to ‘normal’ levels, they will disappear in a flash. Not the most ethical approach. • Attach yourself to an established clinic. This has the benefit of using someone else’s name and reputation, and they will likely have an established patient base. Of course your profit share will be reduced and you will be an employee. This may not suit everyone. Attaining ability will require patience, absorbing knowledge, and treating as many patients as you can, as often as you can. There are no short cuts.

B is for belief Over the years I’ve met a lot of practitioners early on in their medical aesthetics training and noticed that many struggle to really believe in themselves, despite being committed and competent injectors. Make no mistake; aesthetics is no easy-option career. There should be no assumption that having mastered any other branch of medicine, aesthetics will be a straightforward step. At the same time, you have to believe in yourself that this is something that you can grasp. The basis for this should be the desire to help your patients, and the willingness to risk that there may be mistakes made along the way. Once you have scratched the surface of the ‘foundation’ courses, it becomes evident that there are so many things to master. There are numerous types of product. Every lecturer and demonstrator you meet has their own unique way of doing things within the context of the basic principles. People who have taught me, and whom I have taught, have used different approaches to achieve their results. It is quite daunting, not to mention confusing, when you hear on one course to ‘do this’ when you’ve heard others

say ‘never do that’. If you look like a rabbit in headlights holding a needle, this will not inspire confidence in your patients. Sooner or later you have to approach with confidence. I could write a great deal on self-confidence and motivation, but for now I will say this: when you learned to walk as a baby, you didn’t just give up on walking because you fell over many times. Neither did your parents berate you for not being able to walk – instead they encouraged you at every step and celebrated your success when you did. If you intend to succeed, you have to: • Believe you will succeed • Have a strong reason to want to • Be prepared to fall many times • Have people around you cheering you on

C is for collaborative spirit Something I learnt years ago is that success is a team game. Most aesthetic clinicians set themselves up initially as a ‘one-man band’. This is fine and to be expected early in your career, but the limitations soon become obvious. A few things you will need to do beyond just being an injector are: marketing, bookkeeping, stock taking, attending courses, keeping track of regulations and arranging the calendar. All of this has to be done whether you have 10, 100, or 1,000 patients a month. Can you really see yourself doing all that by yourself? The point should be clear; you need some form of team, whether they are employed in house or outsourced. You therefore need to consider, are you the sort of person willing to share a piece of your pie, in return for a potentially bigger pie? When I talk about collaborations, I also mean using colleagues to help build your skill base. When I started out, I talked to other clinic owners in my area, as well as through conferences and courses. Sometimes I just rang them up directly – you’d be surprised at how many of your ‘competitors’ are interested in helping. It turns out that the best in the business aren’t worried about the ‘competition’ in that respect. In fact, they know that having more and better practitioners in this industry improves the reputation of medical aesthetics. The more the public recognise that there are reputable and caring injectors, the more they would like to try (and continue trying) treatments, and the more the industry grows. That helps everyone. So don’t be afraid to approach your peers. You may even end up working with them or referring between each other if you have specific, complementary skillsets.

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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D is for drive If you’ve got this far, you’re clearly a driven person, and that’s good. In my talks I refer to your BIG VISION. What I mean is, what is the end goal? Is it having a clinic in a particular location? Having a certain number of patients? Winning an award? Running a business is incredibly rewarding but incredibly challenging, and there are lots of small, humdrum tasks that have to be carried out day to day. Taking out the bins, phoning the plumber, writing copy for a new advert to run on social media – these are tasks that by themselves are often boring, repetitive and uninspiring. But, of course, they still have to be done! Do you have that big vision in mind all the time? There has to be an inspiring goal, something that makes you get up in the morning and face the challenges, because there will be many. In my opinion, if you have a significant goal in mind, the setbacks are just obstacles in the road. Obstacles can be overcome with persistence and help. So, building your vision and making it clear in your mind is a critical component in building a successful business. That’s how you find the motivation to tick off the little steps in your todo list that take you to the top of the mountain.

E is for continued education To take a career in aesthetics seriously and to maintain a high standard of practice, you need to arm yourself with as much information and knowledge as possible and continue to do this over your career. A one-day course alone will not be sufficient. An education plan for the long term needs to be created, developed, re-written as necessary and adhered to if any kind of success is to be achieved. It is worth considering whether you have such a plan in place and, if not, what the likely long term success of your business is likely to be. You should regularly attend conferences and webinars, as well as reading journals where the latest techniques and equipment are discussed. Aesthetics is a rapidly moving field, and those that don’t keep up will not last long. The ‘experts’ are the ones who understand that we never stop learning.

F is for financial sense You may already be a business owner, or have experience in the private sector. However, most who venture into aesthetics will come from the NHS and, therefore, will have had little training in setting up a business and entirely new skills are needed to succeed. There are many business skills you will need to develop, but, in my opinion, one of the most important and easily forgotten concepts in business is if there is more money going out than coming in, your business will fail. Most medical students leave university under a cloud of debt right from the start of their working life, so it becomes normal for your finances to be out of control. In my opinion, instead of just managing your debt, you need to master elimination and prevention of debt. To keep things very simple, I suggest to go through all your monthly outgoings on your bank statement. Use a chart to categorise your spending. Be honest about where your money is going. This column has to total less than your income. If that exercise was time consuming and stressful, it’s nothing compared to squaring the accounts of your business. Doing so may be the defining moment in your deciding whether you’re cut out to run a business. If need be, get some expert advice on financial planning.

G is for guidance It is common knowledge that when receiving support, a person makes much more rapid progress than alone. One of the biggest factors that took me to the next level was the decision to have both clinical and

business mentors during my career. When you choose a mentor, you’re putting your trust into someone of greater experience, wisdom and success than yourself. For experienced medical professionals, it can be hard to accept that someone is better than you and even harder to hear someone tell you that you need to improve. But this is exactly what you need if you want to make your business a success and outlast your competitors. By taking on board the wisdom and guidance of someone with many more years of experience, you can see your practice leap forward, whereas before you could only take small steps. A mentor can also help you see the long-term view, whereas you may be only trying to get through the month. Mentors can also open up opportunities for development and qualifications that may never have occurred to you. Finding a good mentor takes time. Not everyone will ‘gel’ with your personality and some will have quite different career goals than you. Be willing to pay someone for their time and expertise if that is what is needed to accelerate your career. The most successful value their time, as you should also do. Ask locally who offers the opportunity to ‘shadow’, and even treat their patients. Ask if they are able to discuss cases with you either in person or remotely and if they will be willing to help if you’re stuck. You may seek out different guidance for different skillset, for example for financial education, business skills, and even communication skills. Every learning moment is valuable, even if you only learned how not to do something. Being a member of an industry association can also help, as they often provide mentorship opportunities.

H is for humility One of my mentors told me that one of the best skills I could develop and perfect is the skill of knowing that I will never know everything. Having a modest opinion of yourself means that you have the selfawareness to understand that you don’t know everything and you cannot be right all the time. That means you will get things wrong and you may have complaints levelled against you. You need to be able to deal with such events in a way that allows you to conduct business ethically and empathically. Over-confidence has no place in this industry. You need to know your limitations and work within them until you have gained the extra competence required. Of course, you need a level of confidence to operate, however you have to also be able to take constructive criticism. If you are unable or unwilling to cultivate a sense of humility, you should not be working in aesthetics.

Summary This article has covered the ABCs (or the A-H, if you will) of the skills required to be a successful practitioner in the field of aesthetics. It represents a ‘wish-list’ of what I wish I had known at the start of my career. Hopefully it gives a taste of what is needed to not only be competent, but to thrive in an industry where there remains a lot of mediocrity. Most businesses fail within 12 months. Be one of the few who will outlast their competitors. Disclosure: Dr Sadequr Rahman offers paid-for mentorship opportunities. Dr Sadequr Rahman is a GP and aesthetic practitioner with clinics in Harley Street, London and Newport, South Wales. He has appeared on ITV and Channel 5 discussing aesthetic procedures, as well as written about stress and burnout in his book ‘Superdoc’. Dr Rahman regularly offers mentorship to new practitioners. Qual: MRCGP, MBBS, BSc (Hons)

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Establishing credibility, authenticity and connections

Creating Aesthetic Podcasts Audio production specialist Ben Anderson explores how to create podcasts to establish credibility for your clinic Driven by the change in the way people consume television programmes, which has seen a significant shift to on-demand services like Netflix, Amazon Prime and BBC iPlayer, the country’s listening habits are being transformed. Until the recent stay-at-home warnings, the number of people listening to live radio had been dropping, particularly amongst youth audiences, and this trend is expected to continue once the coronavirus crisis has passed.1 Meanwhile, those choosing to listen to podcasts is on the rise,2 with the latest Radio Joint Audience Research data reporting almost a quarter of 15 to 34-yearolds now listen regularly to podcasts.3 A podcast is a set of digital audio files that are made available on the internet for people to listen to immediately or download for later use. Users can subscribe to specific podcasts on the relevant platform to ensure they receive it as soon as a new one is uploaded. The biggest brands in the world, like

Jaguar Land Rover, Nike and Microsoft understand the power of branded podcasts and are releasing their own frequently but, regardless of the size of a business, podcasts are a great way to communicate your value proposition to an engaged and captive audience. Businesses now use podcasts for a variety of purposes, including sharing information about new products, company news or general information related to the sector in which they operate and even information aimed only for the ears of their employees. In a survey conducted with 300,000 podcast listeners in the US, around 63% of respondents indicated they had bought what the host had been promoting, which demonstrates the power of podcasts to positively influence the buying decisions of the audience.4 This on-demand format reflects the growing trend amongst the public, offering your clinic an opportunity to share insights and expertise with an engaged and captive audience.

As an aesthetic clinic, patients are trusting you to carry out procedures safely and deliver the desired results without adverse effects, so there can be no room for error. Short, engaging, and insightful podcasts, where experts are talking passionately about the services they provide or discussing them with colleagues and even patients, can be a great way to establish credibility and authority within the field, offering insights and advice that will assure new patients they are in safe hands. Listening to you explain in person helps the audience better understand your values and the way you run the business. You become a companion voice, a source for interesting news to be listened to whilst they undertake other tasks; unlike video or reading, which requires their undivided attention. Not only will it help potential customers understand the personality and authenticity of your clinic and the people that work there, but they will feel much more comfortable and more likely to use your services if they can hear you have in-depth knowledge of the industry. This trust was supported in Edison Research’s 2017 survey of 28,964 podcast listeners, in which 33% of respondents said they viewed podcasts as ‘very trustworthy’ and 49% described them as ‘somewhat trustworthy’.5 Your podcast is the opportunity for you to demonstrate, then share your experience and expertise to listeners. Previously, you may have relied on the written word through blogs and social media, but podcasts are a different way to show your enthusiasm for what you do that will make you stand out from your competitors. Podcasts offering information, opinion and new ideas for discussion also helps establish you and your business as a leading authority, as people come to you for regular advice. The insights you offer could also be relevant and beneficial for other practitioners, boosting your reputation in the eyes of fellow professionals and even competitors. Hearing people present sector news or discussing topics creates a strong connection with the audience. Regular listeners will recognise your voice and presentation style, hopefully finding it a pleasant experience and want to listen to more. If you’re good, there is the added benefit of your podcast being recommended to others who may be

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Aesthetic podcasts available There are many podcasts available that aim to educate the public about aesthetic treatments, which might be good to listen to before you produce your own. Some that are currently releasing regular episodes on Apple Podcasts and/or Spotify include the UK Beauty Decoded podcast with Allergan KOLs, the US podcast Aesthetic Express with nurse practitioner Dr Kyle Farr, the US podcast by nurse Rachel Thompson called Understanding Aesthetics with The Derm Diary, US podcast ask Dr. Ben with Dr Ben Johnson, and Australian podcast Inside Aesthetics with Dr Jake Sloane and David Segal. Aesthetics Clinical Advisory Board member and consultant plastic surgeon Mr Adrian Richards has also recently launched a podcast titled Plastic Fantastic, alongside copresenter and nurse prescriber Alison Telfer. As well as podcasts targeted to patients, there are also podcasts available that aim to educate practitioners. If this is your target audience, or if you are looking to educate your peers rather than your patients, have a listen to Skin Viva Training’s Aesthetics Mastery podcast, the US Aesthetic Success Podcast, or What Would Larry Do by the Clearskin Institute of Laser Aesthetics.

interested in what you have to say and offer. An additional benefit of a podcast is that you can engage with your audience while they are doing other things; one survey suggested that 94% of 2,000 respondents tune in to podcasts while multitasking, including doing chores, driving, exercising and running errands.6

Creating a memorable podcast Technically speaking, a podcast is relatively easy to produce, requiring just a good microphone connected to your computer to make the recording and a way of editing the finished sound files. In terms of your equipment, you do not need to blow the budget on the latest and greatest products, especially if you are unsure of your long-term commitment to producing the podcasts. Start with the affordable options whilst you are learning the ropes – if the sound quality is good then that’s all that matters. If you are looking for a reliable brand, then I find that Rode Microphones offer a range of highquality equipment at various price points, but there are various other brands available. Like your microphone, the recording software doesn’t need to be overly sophisticated and it does not require a large budget to start recording clear and insightful episodes. If you have a Microsoft Office subscription, then that comes with sound recording software, which is more than enough to get started. Alternatively, services like Zencastr can be used, which costs $20 per month for the professional package, offering unlimited guests and recordings, as well as access to a live editing soundboard. More important than the equipment itself is how you go about producing the podcasts,

as there are important techniques that can help improve the quality of your episode. If you don’t have the luxury of a quiet and distraction-free room that improves the acoustics of your voice, then broadcasting under blankets or sheets can help block out any unwanted background noise. It goes without saying that all equipment should be tested before recording starts, as this will eliminate any post-production issues. Content is key A podcast may be easy enough to produce, but the content is critical to the success and longevity of your activity. As an aesthetic clinic, patients, and perhaps even fellow practitioners, will be looking to you for expert guidance and in-depth analysis of industry issues, so it’s good to have a rough idea of the topics you’re planning to discuss before getting started, with a plan that stretches for the first three to four episodes at least. It’s not all about well-edited scripts or

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carefully crafted questions, but about researching the topics carefully, agreeing what’s to be covered, and then talking as though you are friends having a coffee, not colleagues in the boardroom – this is where the authenticity comes from. Inviting similar respected individuals from within your business or from across your sector to help create the podcasts, will only add to your credibility, and generate further trust from the audience, whilst expanding the number of likely listeners. The content can cover topics such as current events, changes in the sector, news specific to your business, a discussion around sector-specific topics, trends or legislation, but it must be interesting to the target audience and delivered in short sections. To begin the podcast, a short ‘sting’ is always a good idea as this will notify listeners that the episode is about to begin, before the host spends the first few minutes introducing the upcoming topics and talking points. This short introduction will give listeners the information they need to decide whether this episode is relevant to them. Meanwhile, products like the Rodemaster Pro offer an all-in-one console for podcast production, allowing creators to add professional sound effects throughout.7 Whilst the structure of your podcast is unique to your business, it’s best practice to follow a radio style template, where you raise the issue and then take time exploring it with your guests. This means slowly navigating your way through the episode, taking short breaks to allow listeners to digest the information.8 Although the average podcast length is around 43 minutes, this length of time on a single topic might bore the average listener, so it’s a good idea to break the topic up into smaller pieces and deliver several

One survey suggested that 94% of 2,000 respondents tune in to podcasts while multitasking, including doing chores, driving, exercising and running errands

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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The recording software doesn’t need to be overly sophisticated and it does not require a large budget to start recording clear and insightful episodes podcasts that revisit the subject.9 It is useful to have a person to host or moderate the podcast. This could be the experienced clinic owner, practitioner or manager, who will feature in each podcast and may interview and interact with guest speakers. You don’t have to be funny or try hard to entertain. You just need to use your experience and imagination to deliver short bursts of interesting chat or discussion, in a professional manner, with the content tailored to your audience. And the more you do, the easier it will become. Remember to include a call to action in your podcast, usually it’s a good idea to do this at the end. You can point listeners to your website if you have more detail on a topic, like a guide or catalogue they can download, or even to enquire to make a booking. Depending on how you want your listeners to engage with you, perhaps you might want to tell then to follow your social media channels. Whatever your call to action is, try to make it consistent in each podcast.

Publishing Once you have finished recording and editing your podcast, you will need to make the podcasts available on a variety of distribution channels, such as Spotify and Apple podcasts, both of which are free to use. By publishing your episodes on different platforms, you aren’t limiting your podcast to certain audiences, as everyone has their own preference as to where they choose to access podcasts. Spotify and Apple are the most popular platforms due to their large userbase, but other services like Soundcloud can provide a suitable alternative if you find it easier. It is crucial that episodes are published either weekly, fortnightly or monthly depending on your commitment, as you need your podcast

to build momentum and follow up each instalment quickly, so that subscribers do not lose interest or forget there are more coming. Once it’s published you can start promoting it to increase its exposure to a larger audience via your social media channels, website blog, e-newsletter and even send a press release to local press. If you want to talk in detail about sensitive information only for your employees, perhaps explaining strategic decisions, or current policies, a private podcast can be created, and a link emailed to specific recipients – it can be password protected if necessary.

Seeking a producer Whilst it is possible to produce a podcast on your own, professional producers will enhance the quality of the output considerably. A podcast producer will help you from the creation to the publishing of the podcast and will be able to advise you on the best channels to choose to publish your podcast. The producer is also helpful for handling the transition between different speakers on the podcast, asking questions, requesting clarification of unclear points or jargon, and ultimately editing the hours of chat into a professional and efficient podcast. Remember, if you don’t have the budget to pay for an external producer, then appointing a member of your team to fulfil this role is also fine. When it comes to finding a suitable producer, it’s always best practice to review their previous work, ensuring they have the relevant experience for your project. Producers will often have show reels of their past work, so take a closer look and see what other podcasts they have helped deliver. Each producer will have their own rate depending on their experience and demand, so it’s important to consider all the options before making a final investment and hiring

someone. If you need assistance in finding a suitable candidate, then it may be worth asking your communication or marketing agency, if you have one, to do the research on your behalf. Once you are happy with your choice of producer, it’s wise to give them some general background information on your clinic and the work it does, as this will help them gain a better understanding of your business before recording begins.

Podcasts add business value Podcasts can be a uniquely spontaneous, informal and intimate medium, perfect for delivering important insight with emotion, warmth and passion for a topic. Ultimately, the podcast must be an additional means for your clinic to assure potential patients that they are in safe hands and that you have experience needed to deliver results they are looking for, which is where the personable nature of podcasts can offer added value. Disclosure: Ben Anderson is the founder and managing director of Sound Rebel, which produces and promotes podcasts specifically for businesses. Ben Anderson is the founder and managing director of Sound Rebel, having worked in the commercial radio industry for the last decade. He has been a breakfast show producer for Capital FM and Free Radio in Birmingham and managing editor for Capital FM in Liverpool and North Wales. He specialises in producing audio and podcasts specifically for businesses to help them inform, engage and entertain their audiences. REFERENCES 1. Sweney, M, Is streaming killing the radio star?, The Guardian, 2019, <https://www.theguardian.com/media/2019/feb/08/isstreaming-killing-the-radio-star> 2. Podcast Insights, 2020 Podcast Stats & Facts (New Research From Apr 2020), <https://www.podcastinsights.com/podcast-statistics/> 3. Press Gazette, RAJARs: BBC Radio 4 loses 300,000 listeners as podcast uptake increases, 2019, <https://www.pressgazette. co.uk/rajars-bbc-radio-4-loses-300000-listeners-as-podcastuptake-increases/> 4. Small Business Trends, Six reasons why your business should use podcasting, 2017, <https://smallbiztrends.com/2017/01/ benefits-of-podcasting.html> 5. Medium, Understanding public media’s most engaged podcast users, 2017, <https://medium.com/informed-and-engaged/understandingpublic-medias-most-engaged-podcast-users-bb592cd7e03e> 6. Sutton, K, Research finds branded podcasts are 22% better than TV at engaging consumers who avoid ads, Ad Week, <https://www.adweek.com/tv-video/research-finds-brandedpodcasts-are-22-better-than-tv-at-engaging-consumers-whoavoid-ads/#> 7. Where to find sound effects and music for your podcast. <https://www.rode.com/blog/all/where-to-find-sound-effectsand-music-for-your-podcast> 8. Planning your podcast – free podcast scripts and formats. <https://www.voices.com/blog/planning-your-podcast/> 9. Duran, O, Five basic tips on how to podcast, Cision, 2019. <https://www.cision.com/us/2019/08/5-basic-tips-on-how-topodcast/>

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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– a study cited by Cialdini saw individuals asked to make a series of difficult economic decisions while hooked up to brain scanning equipment.2 When they made their own choices, the scanner picked up activity in the areas of the brain we know are used to evaluate options. But the scanner did not pick up activity when the study participants received expert advice from a distinguished university economist – suggesting they not only followed his advice but did so without actually evaluating the pros and cons of the decision he was suggesting.

Using your authority ethically

Building Trust by Establishing Authority Business consultant Alan S. Adams discusses how authority can impact customer decisions and shares some practical suggestions for clinic owners Building trust is essential in most businesses, but even more so in the aesthetics sector which provides a service not a product: procedures cannot be simply be returned or refunded. Trust is even more vital when you consider the potentially serious negative outcome if the proper practices aren’t upheld. Patients are putting their health, wellbeing and appearance in the hands of practitioners – and they simply must trust a clinic or they won’t hand over their money, and they definitely won’t become repeat customers. Trust not only engenders loyalty, but the majority of customers will also recommend you to others, as well as spending more money, if they trust you and your clinic.1 There are many ways to build trust, some of which can take a fair amount of time. But, foremost, psychology and marketing professional Dr Robert Cialdini (among many others) suggests there’s a simple shortcut you can take: establish your authority and people will trust the information you give them. When considering how businesses can ethically persuade a customer to make a decision, he states that sometimes information is only persuasive because its source has authority (think of all the facts you believe to be true because a teacher told you them, or the societal norms you follow because your parents encouraged abiding by the rules when you were a small child). This authority-based belief system is especially true at times when the recipient is unsure what to do.2 This is especially pertinent for clinic owners with potential customers who are new to the world of aesthetics, have been displeased with treatments received from other clinics, or may be keen to try a new treatment but have reservations based on something untrue they’ve read or heard elsewhere. Being an authority is also incredibly useful when dealing with customers who are uncertain

Of course, from a professional, legal and ethical viewpoint it’s imperative that authority is used with utmost caution – for example, persuading a potential patient to use your clinic rather than a competitor’s by establishing your authority would be fine, but encouraging a teenager to have an antiageing treatment they clearly don’t need would be a violation of the ‘power’ you have by virtue of being the authoritative figure in the exchange between yourself and the teenager. Questions have since been raised around the ethics of an experiment on obedience to authority figures, which most people have heard about, conducted in the 70s by American social psychologist Stanley Milgram. Participants thought they were giving their peers electric shocks of increasing intensity, guided by a person dressed in a lab coat.3 Of the 40 participants, two thirds continued to give the highest level of 450 volts, while all administered 300 volts; potentially fatal levels had they been real. While the ethics might be disputed, the Milgram Shock Experiment shows the impact of an authority figure on the behaviour of the general public.

Clothing In the Milgram study, authority was established through the use of a lab coat; this shows how something as simple as clothing can make a huge impact on the way you are perceived. Similarly, pedestrians are far more likely to comply with a stranger’s request about picking up something or moving to a different position in the street if they are dressed in a security guard uniform than they are in ordinary clothes.4 In Texas, where crossing the road in the wrong place or at the wrong time is against the law, researchers looked at how many

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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blogs and social media sites; publishing or contributing towards a book about your specific expertise; or what about creating your own news by pioneering a new treatment, speaking out about a relevant and important topic or winning awards?

It takes seconds for a reader to form an impression of you and your clinic, so make those seconds count

people would choose to follow a man across the street illegally depending on what he was wearing. More than three times the number of pedestrians would do so when the man was wearing a suit and tie compared to when he was wearing a shirt and trousers.5 It’s no coincidence that many beauty and aesthetic businesses choose to model their uniforms loosely on medical attire – and indeed it may even be appropriate for your team to wear medical uniforms if they are suitably qualified and the treatments that they are providing necessitate this.

Qualifications and accreditation Another very simple way of establishing your authority is ensuring potential patients can’t miss what makes you experienced and qualified enough to be their aesthetic clinic of choice. Think of the organisations you’re a member of and who you’re accredited by – are their logos clearly displayed on your website? Are your qualifications hidden away in a dusty cupboard somewhere or are they proudly framed and on show in the reception area of your clinic? Your level of experience is hugely important, and can actually be the reason that makes a patient choose your clinic. In one study which looked at the views of 150 plastic surgery patients, more than a third (35.6%) said the experience of the surgeon was the most important factor when choosing a clinic. Online presentation (9.7%) also had an impact.6

Website We live in the digital era, and you’ll already know that your website is one of your biggest marketing tools. The website

enables you to effectively advertise to all of your target customers – but once you’ve got over the hurdle of driving internet users to your site, you need to ensure that your authority and experience is right there in their face. It takes seconds for a reader to form an impression of you and your clinic, so make those seconds count. Yes, the layout of the website needs to be user-friendly (on both web and mobile versions); the content needs to be checked for typos, grammatical mistakes and formatting errors, the font needs to be readable and professional, and the colour scheme needs to reflect the vibe of your clinic. But you also need to treat the website as your CV; while you don’t need to list your grades, is there a prominent mention of your credentials? Are you wearing a clinic uniform in your picture or every-day clothes? Do you instantly inform readers of your length and calibre of experience?

Thought leadership As well as physically within your clinic, on your website and social media, think about the other places potential patients may see you. If you establish yourself as a thought leader within a niche area of aesthetics, you immediately have authority in the minds of those who are exposed to your knowledge. This is a slightly longer process than some of the adjustments already mentioned, but it’s perfectly doable provided you adopt the right approach. This can see you developing relationships with relevant media titles and asking to write opinion-led articles or provide quotes for industry-related news; putting yourself forward to speak at events; producing regular content for your own and other people’s

Summary Establishing authority can go hand-in-hand with creating trust between a clinic and a patient. Of course, you then need to work on their loyalty to ensure future visits and recommendations to others – but authority can be a hurdle which is hugely beneficial to overcome. And it needn’t be a lengthy process: display your qualifications online and within the clinic, wear appropriate clothing, ensure your website is professional, and share your expert opinion. Essentially, it comes down to one question, ‘Have I explicitly told customers why they should trust me, by sharing what makes me an authority in the aesthetics specialty?’ Alan S. Adams is an awardwinning business coach, professional speaker, and bestselling author. The publication of his third book, The Beautiful Business: Secrets to Sculpting Your Ultimate Clinic focuses on the medical, cosmetic and aesthetic clinic sector. He was a finalist in The Association of Professional Coaches, Trainers and Consultants’ Coach of the Year Awards, and has been recognised by Enterprise Nation as a Top 50 Advisor in the UK. REFERENCES 1. Finch L, Managing the Customer Trust Crisis: New Research Insights (San Fransisco: SalesForce, 2018) <https://www. salesforce.com/blog/2018/09/trends-customer-trust-researchtransparency.html> 2. Cialdini R, Pre-suasion: A Revolutionary Way to Influence and Persuade (New York: Simon & Schuster, 2016), p. 164. 3. Milgram S, ‘Behavioural Study of Obedience’, The Journal of Abnormal and Social Psychology, 67(4) (1963) p. 371-378. <https://doi.org/10.1037/h0040525> 4. Bickman L, ‘The Social Power of a Uniform’, 1974 <https://doi. org/10.1111/j.1559-1816.1974.tb02599.x> 5. Cialdini R, Influence: Science and Practice (Fifth Edition) (USA: Pearson Education Inc, 2009), p. 189. 6. Marsidi N, Maurice van den Bergh, Roland W. Luijendijk, ‘The Best Marketing Strategy in Aesthetic Plastic Surgery’, Plastic and Reconstructive Surgery, 133 (2014), p. 52-57.

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Opening a New Clinic Dr Anna Hemming shares her experience and advice on establishing your own aesthetic premises In 2019 I decided to develop my clinical practice and find premises of my own. For the past 11 years I had been working from CQC-registered medical practices, but my dream was to open my own clinic. The project was eventually started after returning from living in the US and having my children, who were one and four-years-old.

One of the benefits of having a good business plan was the ability to use it to project the size of the premises I would need. It became apparent that we would outgrow a two to three room clinic within a 10-year lease, so we instead starting looking for a building with space for five or more rooms.

Location Creating a business plan The first thing I did was write our business plan with the help of my husband, who is the managing director of a large multinational company. We calculated the cash flow forecast, income statement, projected revenue and cost of goods for the next two years. We also estimated the cost of staff, introducing them when most appropriate, facilities, marketing and equipment lease. The plan took into account the renovation and set-up costs, although we had a separate renovation cost tracker to monitor carefully. Through speaking to others who had done a renovation before, as well as visiting other colleagues’ clinics, we gained a good insight into the cost of setting up a clinic from an empty shell. While working as a GP for my regular income, I had been saving all of my aesthetic profits for the last 10 years to finance the project. I chose to invest a £160,000 director’s loan, while also taking earnings from the business from July 2019. Of course other methods of financing are available through such things as external investments and bank loans.

Purchasing in London was not really an option, so I decided to rent my first premises. I hope to one day purchase the building, but I am taking small steps!

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Finding a suitable property took six to eight months. First I chose my area; after exploring central London and local towns, I eventually settled on Twickenham, which is much closer to home. Working in this area would allow me to see all of my current patients, drawing in from the different locations I practised in which included Richmond, Teddington and Wimbledon. One really useful step I took and something I’d recommend other practitioners do is I employed a local planning consultant to review the premises I saw. He investigated the likelihood that I would be able to change the use of a building in various locations to a D1 medical lease with the council.1 I felt this was important as I wanted to create a medical clinic, and not convert a retail space. The advice was valuable and helped me to change track on one of the first sites I found. Several sites later, after visiting a previous bank and prime retail shops, I revisited an office tucked away in a mews building in Twickenham. I fell in love with the building for a number of reasons. The location was ideal – just a five-minute walk from two stations, near a large car park, but with three spaces of its own outside. It also had the scope to make five rooms and have some staff space. The building is also just off the high street; central yet tucked away, has a private entrance and great light – ideal and an important consideration for welcoming and treating aesthetic patients. The challenge was that it needed total refurbishment. We had to build walls to create new rooms, put in new electrics, plumbing

Before

After

Before

After

Clinic entrance and reception before and after renovation

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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My top 10 tips for opening a new clinic 1. Research everything in detail before you go ahead 2. Apply for change of use with the council for a D1 property1 3. Call the Valuation Office Agency to challenge rates if you change use of the building – we are doing this at the moment – there’s no guarantee, but it could help2 4. Reach out to others and visit their new clinics 5. Have a clear goal of what your clinic will be like, envisaging the patient flow and how you want to deliver your services 6. Understand your market, who is your patient, what services you are going to provide 7. Understand the devices and machines for specific higher energy circuits that need to go into the design early 8. Ask friends/colleagues for contacts and help with contractors 9. Apply for trade accounts for everything 10. You do not need to go with a project managed service if you can do it yourself

and clinical cabinetry. We also decided to put in a floating floor for sound proofing, in order to allow for patient confidentiality, which is of course an important point to consider when opening a medical clinic. We decided to take on the project management ourselves, which meant more work, but allowed us to get the clinic to exactly how we wanted it. I have found having a clinic outside of central London invaluable. There are many patients in the area who used to travel into central London for treatment who are now finding me, especially in the current climate when people are working from home and need general medical advice. When the time comes I have a list of new patients for our non-medical aesthetic services.

the bridge in the A we created in ‘THAMES’ (Figure 1), further representing the river. I also started getting quotes for the website build. I had created the last three websites I’ve used but wanted a different feel and a bespoke site. If you’re not in a position to make it completely bespoke just yet, I would recommend using website builders such as Wordpress or Wix, which I have used in the past and allow for a good level of personalisation. I also knew that I would be working really hard with the day job, refurbishment and preparing our own home renovation, so outsourcing was the best option for me.

Branding I had to set up a limited company with the new clinic’s name. Before deciding, I had a shortlist of potential names. Upon research, however, we found that many aesthetic clinics sounded similar to others. I wanted to make it personable, yet allow for brand growth so, after much consideration, eventually chose Thames Skin Clinic. With a love of water from rowing and living close to the river, it seemed like a good option and has the flexibility to grow a brand with multiple locations. I would recommend others bear clinic growth and name similarities in mind before making a decision! Next was designing my wordmark and logo. I worked with some branding professionals on this, with the aim for it to be an evolving part of my clinic’s story since starting in medical aesthetics in 2008. We created mood boards, with our target patients in mind. We eventually chose a navy blue and white colour scheme, which fits with the clinic name, and I love

Figure 1: The Thames Skin Clinic logo, demonstrating the bridge in A linking to the clinic name

Design Designing the clinic was a great experience. With such an iconic building, it became very clear how we should use it. It has been developed into five clinic rooms, a patient lounge separate from the reception and a staff kitchen, meeting room, patient restroom and staff restroom with shower. We invested in clinic flooring and bespoke cabinets with inbuilt sinks, which give a very professional finish. If you’re not sure where to start I would highly recommend using Pinterest for layout and décor ideas, which really helps you envisage how things should look. There I built

boards for clinic rooms and furniture, which really helped. I also spent a lot of time visiting furniture shops and taking pictures of things I liked to further build mood boards. You will soon start noticing themes and your ideas will come together! I set up trade accounts everywhere I could, including BoConcept for the patient lounge, clinic chairs, shelves and lights. Trade accounts vary in that for some you will need to spend a certain amount to get a good discount (on average 30%), while for others you’ll only get a 5% discount but, of course, every little bit helps! The medical couches were designed by Avalon in Wiltshire, where I visited with textile samples to choose the right couches and fabrics. I worked with Sussex Signs to design the internal and external clinic signs. These needed to be eye catching but very subtle at the same time. Our clinic music is powered by Sonos which can be controlled in every room from our tablets, as can our door entry system and CCTV cameras.

Summary We were lucky to have a lot of personal renovating experience and detailed technological insight into certain aspects such as sound proofing, so the project overall was not as daunting as it might have been. It was, however, a huge task, especially with the fact my husband changed jobs two months in and was away from home all week, meaning I juggled the project with working and looking after two small children. For anyone considering opening a new clinic, I would advise that speaking to other people is key. I spoke to friends in all kinds of related spaces, from commercial conveyancing to recruitment and talent. Their insight and advice was invaluable. Over the months, everything pulled together and I moved into the building earlier this year. It is a tranquil medical space with natural softness and a calm, relaxing spa feel. Dr Anna Hemming has more than 12 years’ experience in medical aesthetics. She is the owner and medical director of Thames Skin Clinic in Twickenham and associate doctor at Cranley Clinic on Harley Street. Dr Hemming is a GP who has worked at Buckingham Palace and spent five years as an army doctor. Qual: MBChB, BSc, DFFP, MRCGP REFERENCES 1. Gov.uk, The Town and Country Planning (Use Classes) Order 1987 <http://www.legislation.gov.uk/uksi/1987/764/schedule/ made> 2. Gov.uk, Valuation Office Agency <https://www.gov.uk/ government/organisations/valuation-office-agency>

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Applying Skills from Dentistry to Aesthetics Dr Caroline McAuley explains how the clinical skills learnt from dental training relate to aesthetic medicine and provides tips for a successful transition Aesthetic medicine is a specialty with ever increasing popularity, requiring an underpinning medical knowledge to provide safe and effective treatments, as well as extensive training and investment in continued professional development and learning. Soft skills, as well as academic knowledge, are essential in aesthetic medicine to achieve excellence as a practitioner in a competitive market. Beginning my training in aesthetic medicine after completing a Diploma in Restorative Dentistry and a Certificate in Aesthetic and Restorative Dentistry, I was naturally anxious at the thought of carrying out injectable procedures such as dermal fillers and botulinum toxin. Although dentistry was my comfort zone and it wasn’t easy to be a beginner again, I quickly found that facial aesthetics was, in many ways, like dentistry. As an undergraduate I had studied head and neck anatomy in depth and as I learnt the basics of aesthetic medicine, I realised I had been honing my skills to become an aesthetic medical practitioner since day one of dental school. This article will reassure dental professionals of their place in aesthetic medicine, as well as provide some useful tips for a successful transition.

Consulting patients Consultation skills are similar in both aesthetics and dentistry, as briefly outlined in Figure 1. Dental postgraduate training has a strong focus on information gathering in a methodical way. Dental students are taught to take a full history, carry out a thorough examination and formulate a diagnosis and treatment plan before they can perform the treatment. Aesthetic medicine is no different, especially in complex cases where the need for a methodical approach is paramount. This begins with taking a thorough history including previous aesthetic treatments, current skincare regimes, and the patient’s hopes and expectations. Then we must carry out an examination – it’s common practice in both dentistry and aesthetics to work in a methodical fashion when carrying this out. For example, in dentistry we assess the extraoral skeletal form and then, intraorally, the teeth and soft tissues. In aesthetics we should be equally as methodical, assessing horizontal thirds from the upper to the lower face and in the vertical plane from the outside in. This process can be time consuming, however ensures that just like in dentistry, we do not miss key information. If we take the time in both disciplines to discuss diagnoses and treatment options with our patients, we are allowing our patients time to understand the options, acting in their best interests and allowing them to consent to any treatments in a meaningful way. Practising in an ethical manner is of the utmost importance in both fields. The General Dental Council (GDC) is the UK regulatory body which all UK dentists must be registered with. It lists non-surgical cosmetic procedures as an extended duty of dentistry, and therefore it is essential to follow the guidance set out by the GDC in its Standards for the Dental Team1 document when treating aesthetic patients. This document emphasises the need to practise the core principles outlined above; putting patients’ interests first, communicating effectively with them and obtaining valid consent.

our clinic with digital marketing, patient referrals and the like, keep returning for their treatments. Building good relations with patients makes day-to-day work more enjoyable and is advantageous if there is ever an undesirable outcome following a treatment. Patients are far more likely to be forgiving should this occur if you have invested in building a relationship with them. A piece of advice that has stuck with me was given to me on a postgraduate aesthetic dentistry course. This was to look in the mirror and practise saying, “The cost of that treatment will be £2,000.” This was said rather flippantly but the sentiment holds true. Talking about money is an essential part of the general dental practice business model and I have taken this into my aesthetic practice with ease. Many medical professionals who transition into aesthetic medicine are not used to money changing hands or discussing costs with their patients, and can find the subject difficult to broach. However, talking about the cost of treatments without embarrassment is an essential skill to master. In my experience, patients have already researched the prices of your clinic and are prepared to pay for aesthetic treatments, far more so than in dentistry as usually it is treatments they ‘want’ rather than ‘need’.

Anatomical knowledge In undergraduate training, medical, dental and nursing students spend a significant portion of their degree studying head and neck anatomy – the blood vessels, the nerve innervations, the facial musculature and skeletal development. This knowledge is invaluable to help assess a patient’s facial shape and bone structure to understand if there is any deviation from the normal pattern Before

After

Communication In our various medical roles, we learn early on the importance of developing our ‘soft skills’. They enable us to communicate effectively with our patients, to make them feel at ease and trust in our ability to look after their needs. Traditionally, dentistry can be anxiety inducing for patients and one of my goals as a dentist is to dispel that fear and anxiety. I have always taken time to build rapport with my patients, striking a balance between friendly and approachable, yet maintaining a professional and knowledgeable approach. It is as important in aesthetic medicine to build a business that ensures that the patients we work so hard to get into

Figure 2: Gummy smile treated using four units of Bocouture used to relax the lip elevator muscles

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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History taking

Medical / social / previous treatments / wishes and aspirations

Examination

Methodical approach – upper third to lower third/ skeletal pattern / skin / photodamage / volumetric changes / asymmetries

Information gathering

Clinical photos – full face / 90 degrees / 45 degrees Lips – full smile / half smile

Treatment planning

Treatment planning / options discussion – having a full set of clinical photos can allow you to treatment plan with your mentor Treatment can be phased depending on patient’s budget Estimates signed / emailed to patient

skeletal pattern can result in functional jaw issues and a displeasing appearance. Having the knowledge to assess the skeletal form can enable the aesthetic practitioner to use dermal filler to correct and enhance a patient’s skeletal profile. In this case, dermal filler was used to enhance the appearance of her chin and jawline, camouflaging the appearance of her retrognathic mandible.

Tips for future success

For me, my success moving from dentistry to aesthetic medicine has come down to continued support. I am fortunate to work in Consent forms Discussed / signed and emailed to patient a clinic that is run by two fantastic aesthetic Table 1: Patient consultation factors that are similar to both aesthetics and dentistry medical practitioners who are always there to answer my questions and give advice. Having and, if so, how we could potentially correct and camouflage this using the support of like-minded colleagues has made the transition easier dermal fillers. While aesthetics may focus on reversing the signs of as I always have someone to go to for help and advice and it has ageing, environmental damage or enhancing a patient’s features, allowed me to expand my field of practice and grow in confidence in it can also be valuable in offering a non-surgical alternative for exploring new treatments. skeletal or muscular deviations from normal. In-depth knowledge Finding a mentor, whether it be a colleague who is more of the blood and nerve supply of the face is incredibly important experienced in aesthetic treatments or a teacher on an aesthetic to allow practitioners to undertake aesthetic treatments safely and course you have subscribed to, can help answer questions, avoid complications. troubleshoot problems and lend an ear to any issues you may be experiencing. Just as I have in my dental career, furthering your Transferrable treatments education with webinars, advancing skills courses and conferences There are many treatments performed by aesthetic professionals is essential to keep up to advance your knowledge and skills in the which are related to dentistry. The knowledge gained about facial rapidly progressing world of aesthetic medicine. muscles during undergraduate dental training is there, ready to Another tip for transitioning into aesthetics is one that was given to tap into to achieve desired results for our patients’ treatments and me when I graduated as a dentist – don’t try to be too fast. Focus on practise safely. doing an excellent job and over time your speed will pick up naturally. During my time in dental practice I have had numerous cases where Trying to work quickly to improve profit margins will only allow mistakes a patient presents complaining of a ‘gummy smile’, referring to an to creep in, whereas taking your time will allow you to build a portfolio of excess amount of gum on show. Before moving into aesthetics, I treatment photographs, reduce stress, and fewer mistakes will be made. treated this problem with crown lengthening surgery. However, a contributing factor to a gummy smile is a hyperactivity of the muscles The next stage of your career which elevate the upper lip. A small amount of botulinum toxin can For dentists entering the field of aesthetic medicine, as well as nurses relax these muscles while also achieving an aesthetically pleasing and doctors, I appreciate it can be overwhelming. Like me, you may outcome for the patient (Figure 2).2,3 In my experience this is a far less feel anxious at the thought of being a beginner again. However, if invasive treatment and could potentially avoid the need for a complex you take a step back, you will realise that many of the skills required dental procedure, so it can be a good alternative. to become a successful practitioner are already there from your undergraduate and postgraduate training, as well as work experience. Before After Figure 3 shows a It takes time and dedication to learn this new skill, but through seeking patient who attended the right mentors and drawing on your previous experience, you will our clinic as she find success in your new endeavour. was unhappy with Dr Caroline McAuley qualified as a dental surgeon from the appearance the University of Glasgow in 2007. She has spent her time of her chin and working primarily in private dental practice, developing a keen eye for carrying out aesthetic treatments. She has jaw. The treatment completed extensive training in facial aesthetics at the that had been Aesthetic Training Academy and joined Clinetix in 2019, currently suggested prior to splitting her time between there and general dental practice. Figure 3: 18-year-old female with retrognathic her presenting at our Qual: BDS, MJDF, Dip Rest Dent RCSEng mandible camouflaged using 2ml of Belotero Volume and 1ml Belotero Intense clinic was to undergo REFERENCES orthognathic surgery, 1. Standards for the Dental Team. General Dental Council, September 2013. 2. Polo, M. 2008. Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival in order to reposition her lower jaw forward into a ‘correct’ alignment. display on smiling ( gummy smile), American Journal of Orthodontics and Dentofacial Orthopedics However, this patient had no functional issues and her concern was 133: 195-203. 3. Ravichandran, S Ravichandran, E ( 2017) Essential Summary of Medical Injectable Techniques, solely cosmetic, meaning she wanted a less invasive approach. Spotlight Editorial. Dentists will routinely carry out an extraoral examination of a patient’s skeletal form as part of a full examination. Deviation from a ‘normal’ Estimates / budget

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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“I believe if you really set your mind to something, you can do it” Aesthetic nurse Anna Gunning shares her journey from a hospital nurse to a three-clinic owner in Ireland Growing up in a family of nurses, Anna Gunning was encouraged to follow in their footsteps from a young age. Due to a lack of training places in Ireland at the time however, it was a difficult field to get into. She reflects, “To be considered for a spot at one of the hospitals you had to go through a rigorous interview process and complete exams and essays – because of this a lot of people from Ireland went to the UK for their training instead.” Gunning was thrilled that she did manage to pass this challenging entry process though, and went on to complete her training at the Mater Misericordiae University Hospital in Dublin, graduating in 1994. She says, “It was very strict there because it was run by nuns. Everything had to be perfect – even down to what colour tights we wore. Although, we were given a lot of responsibility from the outset – they would leave us alone to watch over the wards by ourselves. That’s something most people probably don’t even get to do in their third year of university. I think that allowed me to become capable from a younger age and when I started working elsewhere I really noticed the difference.” After 10 years working in nursing across London and the Middle East, Gunning realised that she wanted to try something different. She comments, “I signed up to a recruitment agency and was put in contact with The Harley Medical Group, London. I’d always had acne when I was younger so I liked the idea of getting into aesthetics and being able to help people like myself. I went for an interview and ended up working for them for two years as a cosmetic nurse.” While working in aesthetics, Gunning noticed a gap in the market and decided to open her own practice in her hometown, Mullingar. Despite having no business background or expertise, she bought what she describes as “a derelict building” and in 2005 transformed it into what’s now known as The Laser and Skin Clinic. Gunning explains that starting a new business proved difficult at first. “I remember when I’d first opened and I was sat there with my friend wondering why the phone wasn’t ringing and people weren’t booking appointments – and she told me it was because nobody even knew I was there! I had to learn how to market myself,” she reflects, adding, “Of course, it was very different from how you would now as there was no social media. It was also tough because back then aesthetics wasn’t as big or as known – people didn’t really understand what it was I was doing. To promote the clinic I relied heavily on leaflet dropping and local newspaper adverts. Eventually I built up a good patient base and from then on I got new leads through word of mouth.” Now the owner of three clinics across Ireland – Dublin, Mullingar and Athlone – Gunning states that the highlight of her career was being able to expand her business and run them all successfully. She is also proud that her clinic has been recognised at the Aesthetics Awards; wining Best Clinic in Ireland in 2015 and Best Clinic Group UK & Ireland (3 clinics or more) in 2016 and 2018. On what advice she

would give to other practitioners opening clinics, Gunning says it’s important to maintain a strong business mind and keep sight of your end goal. “I believe if you really set your mind to something, you can do it,” she says, adding, “I’ve always had a strong drive to succeed in my career. I didn’t know anything about business when I started out, but I didn’t let that stop me and I learnt on the way!” Expanding and updating your treatment offering is also something Gunning sees as integral to maintaining a successful clinic. “When I first started The Laser and Skin Clinic, I only had two treatments – the Cynosure Elite Laser system and a medical microdermabrasion system. I kept researching and investing in new products and devices, making sure I could offer the best possible service to my patients. My Christmas present was always a new laser for my clinic! I now provide a variety of skin, laser and injectable treatments. Just because a practitioner becomes successful doesn’t mean they can stop looking for new things – it should be a constant process,” she advises. As well as being a clinic owner, Gunning is also one of the founding members of the Dermatology and Aesthetic Nurses Association of Ireland (DANAI), runs her own online store for skincare, and has her own aesthetic training company, Cosmed. She says, “I decided to start Cosmed two years ago because I wanted to share everything I had learnt over the last 15 years in aesthetics, as well as 25 years in nursing, and I felt like I had reached the right place in my career to do this. The aim is to help people who are just entering the industry as I know it can be daunting for new practitioners.” Through Cosmed she has worked in conjunction with pharmaceutical companies such as Merz Aesthetics, distributor MedFx and skincare brand SkinCeuticals. When asked about the future of her career and clinics, Gunning notes that she’s happy with what she has achieved. She smiles, “All the employees at my clinics are like a family – everyone supports each other. I don’t think I’d open any more clinics or spread myself too thin, as I wouldn’t want to risk losing that closeness. I hope to keep developing my training programme and contribute to furthering the profession as a whole.”

My favourite treatment to perform… Cheek filler – it makes the face look much more alive!

My top advice for new practitioners… Get patient reviews and before and after images to use in marketing by keeping in contact with them following treatment – also keep a record of them! People will trust you more.

Something most people don’t know about me… My age! People always think I’m younger than I am.

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Using before and after images in marketing

The Last Word Nurse prescriber Natalie Haswell explains why she no longer uses before and after photos for marketing The Advertising Standards Authority (ASA) and the Committee of Advertising Practice (CAP) has always reminded practitioners that it is prohibited to use before and after images for prescriptiononly medicines (POMs) like botulinum toxin or ‘Botox’ in marketing. In fact, as we know, it’s prohibited in the UK to market POMs to the public at all, including vitamin and hay fever injections for example, unlike in the US.1 In January, this was reinforced after the CAP and the Medicines and Healthcare products Regulatory Agency (MHRA) issued an Enforcement Notice to the beauty and cosmetic service industry due to minimal compliance from injectors.2,3 This reminder prompted me to revise my own marketing efforts, not just for toxin, but every message I was sending my patients. What I realised was that some of my own social media posts (notably the before and after images) did not actually give the right or appropriate messages that I believe in: safe, bespoke treatments. So, I decided to delete all my previous

before and after posts on my social media and website and not use ANY (including for filler and skin treatments) in future. This article will discuss the relevance, reliability and significance of before and after images in marketing for not only the consumer, but other injectors and the aesthetics industry as a whole.

Personally, I have great concerns for the younger and vulnerable generation with regards to what message before and after photos are actually giving. Often, pictures are promoting certain products and specific individual results, which is not educational for the consumer. Importantly, the same results cannot be achieved for every patient; 1ml of product, three chemical peels or medical-grade skincare will not give the same results to everyone, and not every patient is suitable for every treatment. So how are one person’s before and after photos of these treatments beneficial to anyone but the patient in question? Mentioning certain products when sharing good before and after photos can also influence consumers to ask for them specifically, when they might not actually be suitable for them. This could be filler, skincare or skin treatments – in fact I once had a patient that said they wouldn’t come to me unless I used a certain product! In my experience, often the only thing patients can tell me about the product/ treatment they think they want is the name, not actually what they need to know for their own health and safety and if it’s actually of benefit to them. This is concerning, and as medical professionals I feel it is our duty of care to educate the public that not one treatment, amount, product or procedure fits all. Ensuring patients are aware that it’s not just about price, photos and results – but that their safety comes first – is paramount. It has been reported by Save Face that the public predominantly choose practitioners based on social media following and

I have great concerns for the younger and vulnerable generation with regards to what message before and after photos are actually giving

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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Possible positives

Possible concerns

Shows skill of a good treatment result.

The practitioner’s training, skills and accountability to the patient are not evidenced in a photo. Was the practitioner reassuring and knowledgeable? How is this measured in a photo? Do they have official accredited training? Are they their photos?

Can help guide expectations and show what outcome might be expected.

Photos usually only show treatment straight after at optimum results or after several weeks. Rarely they show or explain the downtime stages of treatment (such as bruising, & swelling). No evidence of pre-care given, a consultation completed, or aftercare advice supplied verbally and in written form. No explanation of consent process, cooling-off period, risks. Every patient is different and no two results will be the same.

Allows for product and clinic/business promotion; before and after photos are very eye catching and noticeable to the consumer. Demonstrates and advertises what treatments you perform.

Same as above. In addition, they may not be the injector’s photos and could have been sourced from another practitioner’s work.

Products

Adds to scientific evidence for product manufacturers. Great for auditing, reports and statistics.

Photos of healing stages or final results months after treatment are rarely used to show the product quality and longevity. However this is individual and different for every patient.

Reviews

Shows a positive outcome. Comments on the before and after image may show the popularity of the practitioner and other’s thoughts and feelings about them.

Missing review of the patient’s actual experience. Did they experience common or rare side effects or complications? Did they experience pain? Did the patient like their results?

If accompanied by explanation in the correct context with all information, can be educational for the consumer and other injectors of what can be achieved.

Educational content comes in many forms and we need to be careful not to give unqualified practitioners or patients the information they feel is enough to practice unsafely without official training and qualifications or go and self-inject.

Shows patients a guide to the practitioner’s clinical practice/ethos such as natural vs. accentuated/overfilled approach.

Depends on the clientele they treat, where they live and trends patients want to follow. Ethnicity is very important here; as are facial profiles, proportions and planes.

Social proof the practitioner is actively treating.

Could be sourced from someone else’s marketing and copied. Could be edited digitally and not genuine. Could be old photos, not new or returning patients.

Training

Patient expectations

Promotion

Education

Ethos

Authenticity

Insurance/legal

Poor photo quality, lighting and angles can be shared, or they could be edited so that they do not show the full result, which could be misleading. Provides evidence and proof of results, which are essential for insurance purposes and malpractice claims. Good practice for medical records, to reflect, review and improve practice.

Table 1: Potential pros and cons/concerns of using before and after images

pictures of aesthetic treatments.4 The same report also suggests that the majority of the complaints received by Save Face came from patients who sought an aesthetician or injector on social media for their images and predominantly nothing else. So, actually, how reliable and safe is this kind of marketing? It’s my opinion that as medical professionals we should focus on educating the public to source well trained, educated and experienced professionals with appropriate knowledge, qualifications and word-of-mouth reputation, not just simply posting a before and after photo. Encourage patients to find someone who can assess and consult them according to their holistic needs/ desires, not to simply administer the treatment they demand. The possible concerns I have with the marketing of before and after photos are outlined in Table 1, as are the potential positives/benefits. I do feel that there are some positives of before and after imagery, however I feel they are dependent on the honesty of the practitioner. I also believe that the benefits are more valuable to the market and the injector, not really the patient. In my practice, the way I use before and after images is through the consultation to show

potential patients some of my treatment results (with consent as per GDPR of course).

The solution We know that patients like seeing before and after images. However, I believe practitioners should be actively promoting the consultation, assessment and the knowledge and expertise of the practitioner; not the drug, amount, brand, product or treatment. This, I believe, is more beneficial for the patient. I am not saying we should stop taking before and after images or ban them; they do absolutely have their place for tracking a patient’s unique treatment journey, for insurance and legal purposes and for the further education of colleagues. But I do think we need to be more responsible in how we use them in marketing for the mental health of our current and future patients. Official guidance focuses specifically on POMs and advertising, and I believe a universal framework or guidelines on all aesthetic marketing would be useful for all to follow to ensure patient safety and continuity. Alternatively, looking at other ways to show aesthetic results digitally would be beneficial for patients and aesthetic injectors. Patients should be encouraged to research a practitioner for their skill, visible

real-life results from friends and family, reputation, word of mouth, ethics, legal responsibility and accountability, safety and qualifications, not just their before and after images. Natalie Haswell has been a registered general nurse since 2005. She started practising in aesthetics in 2017 while working as a prescribing matron in the NHS. Haswell completed her Level 7 qualification at Harley Academy, where she now teaches as a clinical mentor two days per week. She practises at her clinic Haswell Aesthetics in Colchester, Essex. Qual: INP, RGN REFERENCES 1. ASA, CAP Code: 12 Medicines, medical devices, health-related products and beauty products, <https://www.asa.org.uk/type/ non_broadcast/code_section/12.html> 2. Enforcement Notice: Advertising Botox and other botulinum toxin injections on social media, 9 Jan 2020. <https://www.asa. org.uk/resource/enforcement-notice-botox-social-media.html> 3. Regulators Tighten Rules on Toxin Advertising, 2020. <https:// aestheticsjournal.com/feature/regulators-tighten-rules-on-toxin-advertising?authed> 4. Save Face complaints report 2018-2019. <https://www.saveface. co.uk/complaints-report/>

Reproduced from Aesthetics | Volume 7/Issue 10 - September 2020


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