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! 19 M O 20 O ST T E E.C LA CE AC NC AN OR ERE CH R F NF O TE SC IS G ETIC RE TH

VOLUME 6/ISSUE 3 - FEBRUARY 2019

®

New Consumer Campaign Launching

MARCH 2019 See inside cover to find out more www.belotero-lips.com

M-BEL-UKI-0463 Date of Preparation January 2019

Anatomy of the Temple CPD

MZ717 Belotero Lips FC Advert for AJ M-BEL-UKI-0463.indd 3

Nurse prescriber Anna Baker looks at anatomical features of the temple

Special Feature: Male Body Contouring Practitioners examine body contouring procedures for men

Male Chin and Jawline Ageing Dr Raul Cetto explores treatment processes for the male lower face

22/01/2019 09:16 Managing Staff Conflict

Staffing specialist Victoria Vilas outlines managing conflict in the workplace


A Natural Look is an EXACT SCIENCE Introducing the new BELOTERO® Lips consumer campaign March 2019 will see the launch of a new BELOTERO® Lips consumer campaign – a first for BELOTERO®. This brand new campaign is based on a recent market research conducted by Merz Aesthetics. Our market research shows that 1 in 5 UK women1 aged 18+ are having or considering lip treatment. Contrary to popular belief the lip filler market is not just about beautification. A substantial number of women 35+ are seeking natural-looking lip rejuvenation. What do we know about women seeking lip rejuvenation?

Women 35+ that have had or are considering treatment told us their biggest fear is an unnatural result1. And when it comes to deciding on

where and who to go to for treatment, established digital platforms are amongst their preferred sources of information. What is the new campaign? It is a multi-channel digital campaign, launching in March 2019. What is the aim of the campaign?

1. Dispel the fear of unnatural results through the science of BELOTERO® 2. Drive consumers who are looking for lip rejuvenation to their nearest BELOTERO® Lips Clinic. Want to be part of the campaign? See below for more Information.

BELOTERO® Lips Contour To create definition in the vermilion border (0.6ml)

BELOTERO® Lips Shape To volumise the body of the lip (0.6ml)

THE ONLY COMBINATION APPROACH TO LIP ENHANCEMENT, SPECIFICALLY DESIGNED TO TARGET THE VERMILLION BORDER AND THE BODY OF THE LIP. To find out more contact Church Pharmacy, Wigmore Medical or your Merz Aesthetics Account Manager In partnership with

®

• Natural integration and movement2,3,4 • Bespoke natural looking results4

www.churchpharmacy.co.uk

www.wigmoremedical.com

• No reported Tyndall effect5,6

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. References 1. Merz Aesthetics Market Research October 2018 2. Micheels P et al; Two Crosslinking Technologies for Superficial Reticular Dermis Injection: A Comparative Ultrasound and Histologic study; J Clin Aesthet Dermatol. 2017;10(1):29–36 3. Micheels P et al; Effect of Different Crosslinking Technologies on Hyaluronic Acid Behaviour. J Drugs Dermatol 2016; 15 (5): 600-606. 4. Sundaram & Fagien 2015 5. Micheels, P., et al. (2012). “Superficial dermal injection of hyaluronic acid soft tissue fillers:comparative ultrasound study.“ Dermatol Surg 38(7 Pt 2): 1162-1169. 6. Micheels P et al; A blanching technique for intradermal injection of the hyaluronic acid Belotero. Plast Reconstr Surg. 2013 Oct;132(4 Suppl 2):59S-68S M-BEL-UKI-0462 Date of Preparation January 2019


Contents • February 2019 06 News The latest product and industry news 14 News Special: Trending on Social Media

Aesthetics investigates the consumer craze that puts the spotlight on ageing

16 Explore the Exhibition at ACE 2019 Details of the unique opportunities available to delegates at ACE

CLINICAL PRACTICE

Special Feature Body Contouring in Men Page 19

19 Special Feature: Contouring the Male Body Practitioners discuss their approach to body-contouring procedures for men 27 CPD: Temple Anatomy Cosmetic and dermatology nurse prescriber Anna Baker details the

anatomical features of the temple

31 Male Chin and Jawline Ageing Dr Raul Cetto outlines the ageing process of the male lower face and

possible treatment approaches

35 Infiltration Anaesthesia in the Periorbital Area Dr MJ Rowland-Warmann shares her technique for the use of infiltration

anaesthesia in the eyelids during plasma treatment

41 Erectile Rejuvenation Mr Amr Raheem details the non-surgical options available for treating

erectile dysfunction

45 Correcting a Rhinoplasty Complication Mr Ayad Harb introduces non-surgical rhinoplasty as an alternative for

patients seeking to correct complications of surgery

48 Ingredients for Supplementation Dr Johanna Ward discusses why practitioners need to incorporate nutrition

advice into their consultation

53 Treating Transgender Patients Dr Rekha Tailor discusses the most popular treatment options for

transgender patients

IN PRACTICE 59 Managing Staff Conflict Staffing specialist Victoria Vilas offers tips on how to identify and manage conflict in the aesthetic workplace

63 Changing Website Content for SEO Digital marketing consultant Adam Hampson and marketing content

executive Lottie Staples explain how changing your website benefits your SEO

67 VAT in Aesthetic Practice Chartered accountant Jonathan Bardolph explores common pitfalls

surrounding VAT in aesthetics

71 In Profile: Professor Bob Khanna Professor Bob Khanna reflects on his career of more than 23 years in the

industry and shares advice on what he has learnt

72 The Last Word Mr Ali Juma outlines why he believes all aesthetic practitioners should

undergo training with the use of cadavers

NEXT MONTH IN FOCUS: Growing your Practice • Building your Social Media Following • Fat-dissolving Injections • Treating the Neck

Subscribe Free to Aesthetics

Clinical Contributors Anna Baker is a qualified tutor, cosmetic and dermatology nurse prescriber who has been involved in developing Dalvi Humzah Aesthetic Training with lead tutor, Mr Dalvi Humzah, since 2012. She is the coordinator and a faculty member for this teaching. Dr Raul Cetto specialises in non-surgical facial medical aesthetics. He is medical director of aesthetic training provider Harley Academy and is also a medical board member and international speaker for Swiss aesthetic manufacturer Teoxane. Dr Johanna Ward is a aesthetic practitioner and GP with a special interest in dermatology and minor surgery. She is the medical director of The Skin Clinic Sevenoaks and Brentwood. Dr Ward is also the founder of ZENii – a skincare and vitamin range based on nutritional science. Mr Amr Raheem is a specialist in andrology at the University College London Hospital NHS Foundation Trust and medical director of International Andrology. He has 17 years of experience in complex urogenital surgery.

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

In Practice Managing Staff Conflict Page 59

Mr Ayad Harb is a surgeon specialising in plastic and reconstructive surgery and is the director of The Bicester Clinic and Qosmetic clinics in London, Oxfordshire and the West Midlands. He also practises in the NHS as Senior Clinical Fellow in Plastic Reconstructive Surgery. Dr MJ Rowland-Warmann is a dentist and the founder and lead clinician at Smileworks, a facial aesthetics practice in Liverpool. In 2016 she completed her MSc in Aesthetic Medicine from Queen Mary University of London. Dr Rekha Tailor is the founder and medical director of Health & Aesthetics clinic in Elstead, Surrey. She is a fully accredited general practitioner and aesthetic practitioner. She is a full member of the British College of Aesthetic Medicine and the Royal Collage of General Practitioners.

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Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228


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Editor’s letter February… dull, dismal, cold – unless you’re off skiing or lying on a beach somewhere fun, sunny, hot and not dismal! Wherever you are though, you will need a good read and a catch up on the world of medical aesthetics – so here it is! Men are our focus this month! Our Amanda Cameron Special Feature on p.19 focuses on male body Editor contouring – practitioners discuss what devices work best and how men approach a consultation differently to women. As we know, a strong chin and jawline is often regarded as a sign of masculinity, but what happens when this reduces with age? Dr Raul Cetto details its ageing process and injectable approaches to restore lost definition on p.31. We also have Mr Amr Raheem outlining three methods for erectile rejuvenation, detailing the research that has been done and the treatment options available on p.41, while Dr Rekha Tailor offers advice on consulting with transgender patients on p.53. This is the final month you have to register for ACE, taking place on March 1 and 2. At ACE we try to cater to all aspects of running an

aesthetic business and are confident we have done it well this year! You will see sessions suitable for clinic managers and staff, as well as clinical workshops for qualified practitioners, so literally something for everyone! Access restrictions will apply for certain medical sessions; however the Exhibition Floor and business agenda is open to everyone and free to attend. Back this year is the Elite Training Experience, after huge success last year. These experiences are the only paid-for sessions taking place at ACE (you still have 29 free clinical and 19 free business talks!), but at just £195 +VAT for three hours of jam-packed learning with injection techniques, anatomy overviews, live demos and so much more, the Elite Training Experience is fantastic value for money! You can attend just one or book all four – check out the agenda online to work out what fits best with your development requirements. Don’t forget, you will earn 1 CPD point for every hour of education you complete – so make the most of two days filled with learning opportunities! The team and I are looking forward to catching up with everyone at ACE, so if you haven’t already, register today via www.aestheticsconference.com

Editorial advisory board

We are honoured that a number of leading figures from the medical aesthetic community have joined the Aesthetics journal’s editorial advisory board to help steer the direction of our educational, clinical and business content Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with over 20 years’ experience. He is an international presenter, as well as the medical director and lead tutor of Medicos Rx. Mr Humzah also runs the multi-award winning Dalvi Humzah Aesthetic Training courses. He is a founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow.

Dr Raj Acquilla is a cosmetic dermatologist with more than 12 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 in the cosmetic use of 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 non-surgical medical standards. She is a registered university mentor in cosmetic medicine and currently a second year student on the Northumbria University Masters course in non-surgical cosmetic interventions. Bennett has been developing her practice in aesthetics for 25 years.

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 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine and ensures that along with day-to-day clinic work he also attends and speaks at numerous conferences.

Mr Adrian Richards is a plastic and cosmetic surgeon with 12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of the British Association of Plastic and Reconstructive Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards and has written a best-selling textbook.

Dr Maria Gonzalez has worked in the field of dermatology for the past 22 years, dividing her time between academic work at Cardiff University and clinical work at the University Hospital of Wales. Dr Gonzalez’s areas of special interest include acne, dermatologic and laser surgery, pigmentary disorders and the treatment of skin cancers.

Jackie Partridge is an aesthetic nurse prescriber with a BSc in Professional Practice (Dermatology). She is currently undertaking her Masters 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 Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multiaward 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. Dr Williams is also author of Amazon-No-1 Bestseller ‘Look great, not done’.

Dr Christopher Rowland Payne is a consultant dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies.

Dr 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 Samizadeh frequently presents at international conferences and is passionate about raising industry standards.

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Patient safety

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #AlwaysLearning London Professional Aesthetics @londonprofessionalaesthetics Always Learning. Always Growing. Always Improving. London Professional Aesthetics Clinical Director Elizabeth Rimmer was a proud participant of The Aesthetic Entrepreneurs GSD Day in Brighton led by Richard Crawford Small. Learning from peers, developing new professional skills and improving our service to our clients is part of our vision to continue to grow to be our very best. #HormoneReplenishment Dr Stefanie Williams @DrStefanieW In Utah at the moment to find out about the newest developments in hormone replenishment practice. #HRT #AestheticTraining Professor Bob Khanna @bob_khanna Excellent start to the week with some great delegates from around the world #ClinicalExcellence #FacialAesthetics #PreventativeAgeing Dr Jane Leonard @drjaneleonard Almost every day I get asked how can I “antiage” my skin and stay looking young? Simple answer; stop wrinkles forming in the first place #PreventativeBotox

#Marketing Justin Richards @justinjrichards Hologic Global Marketing Summit, all divisions knowledge sharing, learning. #hologic #marketing #medicalaesthetics #cynosure #Charity British Foundation for International Reconstructive Surgery and Training @BFIRSTraining An update from our #BFIRST heroes, @bjemec and @RobearPierre on our latest project in Dhaka, #Bangladesh – enjoying the great hospitality and food before the hard work begins! #ReconstructiveSurgery #Charity #Overseas #MotivationMonday

Regulatory bodies sign agreement with JCCP The Joint Council for Cosmetic Practitioners (JCCP) has signed a memorandum of understanding with a number of regulating bodies, which aims to work towards an improvement in public safety within aesthetics. A memorandum of understanding is a document describing the general principles of an agreement between two or more companies or organisations, often indicating a common line of interest. According to the JCCP, these agreements aim to set out the arrangements for working on matters of common interest including the design and development of qualifications and the promotion of best practise in the aesthetics specialty. The JCCP met with a number of bodies including: the Nursing and Midwifery Council (NMC); the General Dental Council (GDC); the General Pharmaceutical Council (GPhC); the Royal Pharmaceutical Society (RPS); the Hair and Beauty Industry Authority (HABIA) and the Scottish Qualifications Authority (SQA). These add to the existing agreements with the General Medical Council (GMC), Ofqual and the Advertising Standards Authority (ASA). Professor David Sines, chair of the JCCP commented, “The agreements cement our shared commitment to ensuring high standards and supporting better, safer care, while giving a clear framework for communication where there are concerns about the practice of individuals.” Nurses

BACN announces new management committee

The British Association of Cosmetic Nurses (BACN) has confirmed a new management committee. The BACN recently said farewell to longstanding BACN board members Frances Turner Traill and BACN Vice Chair Andrew Rankin and has since welcomed Clare Amrani, Michelle McLean and Corrine Hussain. Amrani, McLean and Hussain will be working alongside existing board members Sharron Brown (secretary), Anna Baker, Mel Recchia, Lisa Niemier, chair Sharon Bennett and Sharon King, who has been newly elected as vice chair. Chartered accountant Jonathan Bardolph will continue to act as the BACN treasurer. BACN chair, Sharon Bennett said, “Andrew and Frances have been instrumental in positive developments for nurses working in aesthetics. They will be sorely missed. I am very excited to welcome our new management committee members and I look forward to further progressing the BACN and the aesthetic nurses that we support.”

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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Conference

Dermalux LED confirmed as ACE 2019 headline sponsor The headline sponsor of the awardwinning Aesthetics Conference and Exhibition (ACE) 2019 taking place on March 1 and 2 in London is Dermalux LED, manufactured by Aesthetic Technology Ltd. Director of Dermalux LED, Louise Taylor said, “We are delighted to be the headline sponsor for ACE 2019 as this really is the leading aesthetics conference of the year. We are also hosting an Expert Clinic session as we want to advance the education of LED in the industry, which will be co-hosted by Dr Simon Ravichandran and our managing director Dale Needham. In addition, we are excited to announce the launch of new developments at the show! It’s going to be a fantastic year!”

Vital Statistics A report in 2018 showed that 24% of patients that have cosmetic surgery do not check their surgeons’ credentials (BAPRAS, 2018)

71% of UK adults believe that patients should be psychologically assessed prior to having cosmetic surgery (Mintel, 2018)

Medical devices

New treatment for cellulite and skin laxity launches Aesthetic device company Lumenis has launched the NuEra Tight, a non-surgical radiofrequency system designed to improve the appearance of cellulite and skin laxity. According to Lumenis, the NuEra Tight uses a technology called automatic power and impedance control (APIC), designed to control the temperature of the skin to ensure safety and efficacy. It works with one resistive bipolar handpiece and two monopolar handpieces with coated capacitive energy transfer (CCET) electrodes in a wide variety of capacitor head sizes. The system emits radiofrequency waves at 470kHZ with 250W power, aiming to heat the skin’s surface superficially or reach deeper tissue levels. The company states that the treatment can be used on the abdomen, flanks, buttocks, inner and outer thighs, upper arms, bra and back fat, as well as around the eyes, mouth, cheeks and neck.

Facebook remains the market social media leader with more than 2.2 billion monthly users (Statista, 2018)

Sensitive skin is claimed to affect 50% of women and 30% of men in Europe (British Journal of Dermatology, 2018)

57% of British women aged under 25 admit the reason they don’t adopt healthy lifestyle habits is because of a lack of motivation (Mintel, 2018)

Training

John Bannon Pharmacy skin rejuvenation courses Medical aesthetic supplier John Bannon Pharmacy has confirmed a new partnership with aesthetic equipment and training provider CosmoPRO. John Bannon Pharmacy says CosmoPRO will now offer training on plasma skin rejuvenation, microneedling and chemical peels in its training locations. Suzanne Bannon, director of John Bannon Pharmacy, said, “We are looking forward to showcasing the CosmoPRO range in both Ireland and the UK.” CosmoPRO managing director, Rachael Turner-Percy added, “We look forward to helping to provide further professional development for John Bannon’s clients.” In addition, CosmoPRO has launched a microneedling pen, called Derma Pro, which aims to be an affordable alternative to methods such as laser treatments. Derma Pro is a cordless device with seven speeds, an LED display and a lightweight design.

A survey in 2018 showed that 62% of patients found their practitioner through social media (Save Face, 2018)

Research shows that 48% of women are unhappy with the appearance of their waistline, in comparison to 24% of men (Mintel, 2018)

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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Events diary 1st – 2nd March 2019 The Aesthetics Conference and Exhibition, London www.aestheticsconference.com

1st-5th March 2019 American Academy of Dermatology Annual Meeting, Washington, D.C. www.aad.org

4th-6th April 2019 Aesthetic & Anti-aging Medicine World Congress, Monte Carlo www.euromedicom.com

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Conference

New clinical sessions announced for ACE 2019 The clinical programme for the Aesthetics Conference and Exhibition (ACE) 2019 is quickly filling up, with new sponsors announced for a range of sessions within the free Expert Clinic and Masterclass agendas. The CPD-certified clinical agendas at ACE 2019 on March 1 and 2 will be presented by expert speakers on a range of topics including skincare, devices and injectables. Not only this, but delegates will be able to watch live demonstrations and make the most of the show offers available across the two days. New sponsors confirmed for the one-hour Masterclass sessions are BeamWave Technologies, SkinCeuticals, BTL Aesthetics, Lumenis, and AestheticSource. Meanwhile, Dermalux LED, AestheticSource, Invasix and Naturastudios Ltd will all lead a 30-minute Expert Clinic session. To attend these exciting clinical workshops, delegates are invited to register for their free ACE 2019 pass today to learn from some of the leading companies within the aesthetics specialty. Also newly announced is the WiFi and Floorplan sponsor for ACE 2019, Healthxchange. Visit aestheticsconference.com to make sure you don’t miss out. Chemical peels

8th-10th May 2019 37th Annual Conference of the British Medical Laser Association, London www.bmla.co.uk/bmla-conference-2019

14th May 2019 British Association of Sclerotherapists Annual Conference, Windsor www.bassclerotherapy.com Cellulite

MAG to supply anti-cellulite clothing range Aesthetic product supplier Medical Aesthetic Group (MAG) is now supplying the CRYSTALSMOOTH range of anti-cellulite clothing by compression garment company Macom Medical. The range aims to improve skin elasticity and leave skin looking healthier and smoother. The company explains that the garments are made from emana fibre, a fabric that is woven with bioactive crystals that absorb body heat and return in the form of far infrared rays. These rays aim to stimulate blood microcirculation, cellular metabolism and lymphatic drainage. Macom Medical claims the CRYSTALSMOOTH range also enhances the results of professional cellulite and firming treatments, including radiofrequency devices, mesotherapy injections, ultrasound technologies, infrared, laser and cavitation therapies.

iS Clinical introduces Post Peel Kit Skincare company iS Clinical has launched a kit for patients to take care of their skin during the downtime of a chemical peel, called the Post Peel Kit. Targeting specific areas to aid the skin recovery process of delicate skin following the treatment, the kit contains a combination of pharmaceutical grade botanical formulations to protect, hydrate and treat the skin after a peel procedure, according to iS Clinical. The kit includes the Cleansing Complex, Sheald Recovery Balm, Extreme SPF 30 and a guidance card for the patient. Alana Chalmers, founder of Harpar Grace International, the exclusive UK distributor of iS Clinical, said, “The Post Peel Kit has been created with a clinically-proven combination of products to enhance the experience and outcome of post-ablative procedures. We recognise the need for a comprehensive yet affordable kit to be used after any chemical peel offered within the UK market and, as such, we are opening the access of this kit to all non iS Clinical accounts when purchasing 10 kits at a time. They will be available at £60. The kits are available to our iS Clinical accounts at their normal margin and through our distributing partner Med-fx.” Implants

Breast implants removed from European market Breast implants that have been linked to a rare form of atypical lymphoma, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), have now been removed from the European market. The recall of the Microcell and Biocell implants, which are manufactured by global pharmaceutical company Allergan, came about after the French national agency for the safety of medicine and health products (ANSM) said it was suspending the CE mark for these specific products. The implants can no longer be manufactured or sold in Europe and those held at clinics are being recalled. Mr Paul Harris, president of the British Association of Aesthetic Plastic Surgeons (BAAPS) and consultant plastic surgeon said, “This news will be a cause for understandable concern for many patients, particularly those who have implants currently in place. It is important, however, to recognise that this is a precautionary step taken by the regulators whilst the link between breast implant surface and BIA-ALCL is investigated.”

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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LED

Celluma product line expands Light emitting diode (LED) device manufacturer BioPhotas has announced a major product line extension to the company’s Celluma light therapy devices. New versions of Celluma have been added to the company’s product offering; Celluma SKIN; Celluma FACE, Celluma CLEAR and Celluma SPORT. According to the company, the Celluma SKIN is a device for treating skin, wound healing and pain conditions. The more compact Celluma FACE treats the same conditions as the Celluma SKIN and is ideal for at-home use. The Celluma CLEAR is a single mode device for treating acne and preventing breakouts, while the Celluma SPORT is designed to address ageing and injury-related pain issues, states the company. Patrick Johnson, president and CEO of BioPhotas, the creator of the Celluma series, said, “We understand that our customers are sometimes very focused in their practices, wanting products that are specifically tailored to a particular clinical specialty or condition. This product line expansion is intended to address this desire for condition specific device applications.”

COUNTDOWN TO ACE 2019 ONE MONTH TO GO! We can’t wait to see you on March 1 and 2! Whether you just pop in for a couple of hours or spend the whole Friday and Saturday exploring the conference and exhibition, you’re sure to take home fantastic pieces of advice, new skills and maybe a new product or two!

Industry

Dr Lori Nigro becomes mesoestetic KOL Pharmaceutical and skincare manufacturer, mesoestetic, has appointed aesthetic physician Dr Lori Nigro as its UK medical advisor and key opinion leader. Dr Nigro qualified from WITS medical school in Johannesburg in 2003 and started her career in aesthetics in 2010. Adam Birtwistle, managing director of distributor Wellness Trading, commented, “It is a huge honour to us that Dr Nigro has chosen mesoestetic as the brand she is happy to represent and we are looking forward to working with her to further develop mesoestetic in the UK.” mesoestetic has also appointed Agnes Kuzniak as trainer in aesthetic dermatology to provide training and support in the south of England. Birtwistle said, “Kuzniak is a highly qualified educator and skin fanatic who cannot wait to start helping our customers and sharing her knowledge.”

WHAT CAN YOU EXPECT? • • • • • • •

29 in-depth clinical sessions 19 comprehensive business workshops More than 80 leading exhibitors Exclusive offers and giveaways Networking opportunities CPD points And so much more!

WHAT DELEGATES SAY

“Good variety of exhibitors, valuable demonstrations” Aesthetic doctor, Surrey

Marketing

SkinMed introduces clinic marketing service Dermatological research and distribution company SkinMed has introduced an updated marketing programme, called the Clinical Marketing Suite, for its clients. Clinics are eligible for this service if they fulfil certain product protocols and have a leading account with SkinMed. The clinics will be allocated a campaign manager who will design and create a bespoke multi-channel campaign. SkinMed says eligible clinics can also gain access to bespoke posters, leaflets, flyers, video and text, as well as protocol guide booklets, designed to help guide patients through the treatment journey. In addition, SkinMed will provide campaign support to promote clinic open days, including online advertising, tailored emails, social media promotion and materials to use in clinic. Peter Roberts, managing director and head trainer at SkinMed, said, “We believe this tailored service will really help our clients to communicate the benefits of the products to their patients.”

“Speakers very knowledgeable about their subjects” Aesthetic doctor, Liverpool

“This is the best aesthetic conference in the UK!” Aesthetic nurse, Essex

REGISTER FREE TODAY

AESTHETICSCONFERENCE.COM ACE HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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

BACN REGIONAL MEETINGS The Regional Group meeting dates have now been set for 2019 and are available to book via the BACN website under the events page. If you need any information regarding the meetings, contact Tara Glover, BACN Events Manager at tglover@bacn.org.uk. Wales, Cardiff: Monday April 8 Northern Ireland, Belfast: Thursday April 11 Scotland, Glasgow: Tuesday April 16 Yorkshire, Leeds: Wednesday May 1 North East, Newcastle: Thursday May 2 South East and London, London: Tuesday May 7 North West, Manchester: Friday May 10 South West, Bristol: Wednesday May 15 Central, Birmingham: Wednesday May 22

BACN EDUCATION AND TRAINING COMMITTEE The BACN Education and Training Committee met on January 14 in London to discuss a number of projects that the BACN are taking on in 2019. Led by Board Members Anna Baker and Melanie Recchia, these included updating the BACN Competency Framework that was last reviewed in 2015, and to prioritise the development of a new career framework for the category of ‘Specialist Aesthetic Nurse’ based around an agreed set of standards, competencies and assessment criteria. The committee oversees the strategic direction of the project, agrees deadlines and outputs, reports back to the BACN Management Committee on progress, and agrees proposals for consulting with members.

BACN RENEWALS The BACN Membership year runs from April to the end of March, so members are reminded to prepare for the renewal period that begins at the end of February and will run throughout March. Renewal reminders will begin to be sent out towards the end of the month, and the BACN has implemented a quick-step process this year to make it as simple as possible to do so. This column is written and supported by the BACN

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Skin rejuvenation

Venus Concept launches new rejuvenation device Manufacturer of non-invasive aesthetic devices, Venus Concept, has launched a new product that aims to provide deep and lasting hydration for the skin; the Venus Glow. According to Venus Concept, the device works with one lightweight applicator, while the adjustable vacuum and spiralised treatment tip gently removes impurities from the stratum corneum without irritation. The vacuum micro-massages the skin, aiming to increase the speed of nutrients released from the bloodstream. The Venus Glow aims to brighten dull skin, reduce uneven skin tone, improve elasticity, moisturise skin, remove blackheads and whiteheads, control sebum secretion and enhance effectiveness of post-treatment products. Jade Shelden, clinical trainer at Venus Concept said, “The Venus Glow uses two high-powered rotating water injectors, the diameter of a hair strand to penetrate the hair follicle, to exfoliate, clean and hydrate the skin from within. This is combined with a light suction to aid lymphatic drainage and increased blood circulation.” Equipment

The Baldan Group launches wellness devices

Italian aesthetic manufacturer and distributor, The Baldan Group, has launched two new devices. The first is the InfraBaldan 3.0, a device which the company states is designed to trigger aerobic metabolic exercise and weight loss. The InfraBaldan 3.0 combines moderate, constant physical activity with infrared radiation at precise wavelengths. According to the company, the system uses a heartbeat monitor, in which the sensor is attached to the patient’s earlobe, to regulate their pulse, whilst the machine exposes the body to infrared wavelengths. Each treatment lasts around 40 minutes and it is recommended that patients have two to three treatments per week. A further two to three treatments per month are then advised to maintain results. The second launch is the Iridium Eyes Pressotherapy; a lymphatic drainage treatment that massages the eye area and aims to promote deeper penetration of product into the skin. The treatment uses air pressure and the massaging effects help the congested lymph to disperse throughout the body to relieve swelling and restore radiance and texture to the skin, the company claims. The Baldan Group states that the Iridium Eyes Pressotherapy device relieves tension in the forehead and eye contour area, improves blood circulation around the eye, provides a relief to dry eyes and reduces stress through the use of heat. As well as this, the built-in meditation music aims to create a relaxed atmosphere for the patient. The treatment lasts 10 minutes and each device is fitted with disposable woven bandages to ensure good levels of hygiene between patients.

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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Skincare

New skin brightening serum released Private label cosmeceutical supplier, 5 Squirrels, has added a new day serum to the Your Signature Range of own-brand products, aimed at targeting pigmentation. The serum is called Illuminate, and contains azelaic acid that aims to calm inflammation, alpha-arbutin and glutathione to inhibit melanin synthesis, which is the main cause of pigmentation, as well as vitamins E and C, glycolic acid and glycyrrhiza. Gary Conroy, co-founder of 5 Squirrels Ltd, said, “We have been working closely and extensively with our 200 international brand owners to further develop new formulations to meet their patient’s skincare needs, whilst protecting their service proposition and rewarding customer loyalty. Illuminate has been extensively tested in clinic and is delivering great results, so will be in high demand.”

News in Brief PM addresses aesthetic regulation issues Prime Minister Theresa May has addressed concerns regarding patient safety and regulation in the non-surgical cosmetic sector in the House of Commons on January 23. A question was put forward in Prime Minister’s Questions by Conservative MP, Alberto Costa of the South Leicestershire constituent. May responded, “We recognise that this growth in non-surgical treatments does increase the need for consumer protection. We are currently working with stakeholders to strengthen the regulation and we are committed to increasing the safety of these procedures in a number of ways. For example, better training, robust qualifications for practitioners and clear information where people can make an informed decision about their care.”

Education

Bookings open for RSM conference The 11th annual Aesthetics Conference hosted by the Royal Society of Medicine will be taking place on Friday February 22 in London. The conference will cover topics such as thread lifting, preventing and managing complications, cannula techniques and best practice in key areas of aesthetics – both surgical and non-surgical. There will be lectures from international speakers such as Professor Bob Khanna, Dr Albina Kajaia and associate professor Ivor Lim. The conference will also include live demonstrations, as well as two workshops that will take place during the day. In order for delegates to take part in the workshops they must have an active GMC, NMC or GDC licence. Following the conference there is an RSM Aesthetic Gala Dinner taking place in the evening. The dinner will feature three speakers discussing their work for African Humanitarianism – they key theme for the Gala Dinner. Skincare

Medik8 releases new vitamin A night cream Global skincare brand Medik8 has released the r-Retinoate Intense, a night cream that combines retinyl retinoate and crystal-stabilised retinaldehyde. According to the company, both ingredients have not been combined before and by doing so it is designed to re-energise and rejuvenate skin, increase firmness, reduce fine lines and wrinkles, stimulate the skin’s defence mechanisms to repair itself and provide a more hydrated and brighter complexion. The product contains polymer-encapsulated retinyl retinoate that aims to stimulate collagen synthesis, crystalencapsulated retinaldehyde, which has antibacterial properties, hyaluronic acid, vitamin E, ceramide complex, copper peptide and organic carrot seed oil. Medik8 advises usage twice weekly for the first fortnight, every other night for the next two weeks and then every night. Daniel Isaacs, head of research and development for Medik8 stated, “I am excited to launch r-Retinoate Intense as it’s our best ever vitamin A product. The combination of retinyl retinoate and retinaldehyde creates what I believe to be the most effective vitamin A product in the world.”

AAFRPS stats indicate rise in younger patients The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) has released its annual member’s survey for 2018. It indicates that out of 110 respondents, 72% of facial plastic surgeons saw an increase in cosmetic surgery or injectables in patients under the age of 30; a 24% uplift from 2013. Surgeon Mr Phillip Langsdon, AAFPRS president, said, “This points to the larger ‘prerejuvenation’ trend with more patients wanting to remain youthful rather than turn back the clock on signs of ageing later. Our younger patients are controlling the ageing process and taking prevention seriously.” New marketing coordinator for Dermalux LED Aesthetic Technology Ltd, manufacturers of the Dermalux LED systems, has recruited Lucy Cade as its new marketing coordinator. Cade will be working across a variety of channels to develop the Dermalux brand by managing social media platforms and email marketing campaigns. Cade said, “I’ll be drawing on my previous experience to create effective email marketing campaigns. I’m excited to challenge myself and help this company to reach new heights in 2019!” L’Oréal launches wearable skin pH sensor Global personal care company L’Oréal has released a prototype for the first wearable sensor and app to measure the skin’s pH levels to create a customised skincare regime. By wearing the My Skin Track pH on the inner arm, it captures trace amounts of sweat from skin’s pores providing an accurate reading within 15 minutes.

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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ACE networking sponsor

Enhance Insurance to sponsor ACE 2019 Networking Event Insurance and risk management broker, Enhance Insurance will be hosting this year’s ACE Networking Event at ACE, held at the Business Design Centre in London on Friday March 1. The event will take place between 6-7pm, where practitioners will have the chance to meet new friends, mingle with other practitioners and get their questions answered by experts in the specialty. Business development executive, Sharon Allen, said, “I am really looking forward to the Networking Event because everyone can catch up with fellow exhibitors, clients and meet practitioners new to the industry. I encourage all delegates to join after a hard day of learning.” Enhance Insurance are also the proud sponsor of the Business Track agenda, which provides delegates with business advice from industry-renowned speakers on topics such as marketing, risk management and much more. Enhance Insurance will be holding two sessions on the Business Track agenda, focusing on medical tourism, travel regulations and liability insurance. Hair removal

Alma Lasers launches hair removal device Laser and light-based device manufacturer Alma Lasers has launched a new hair removal device, the Soprano Titanium. The device features the company’s new Quattro 3D applicator handpiece, which has a spot size of 4cm, and delivers three laser wavelengths: 755 nm, 810 nm and 1064 nm to treat all skin types. It also features a dual connector, enabling two different applicators to be connected to the platform at all times. According to the company, the device includes a technology called super hair removal, which damages the hair follicle and hinders re-growth whilst preventing injury to the surrounding tissue, meaning that sun exposure is less traumatic following the treatment. It also features a cooling technology called the ICE Plus, which aims to continuously cool the skin and minimise the risk of burns on the skin’s surface, whilst maintaining heat within the dermis where hair follicles are treated. Incorporated into the device is a new business development tool called the Smart Clinic, which can be controlled from any smartphone, tablet or desktop. The company explains that it offers access to live data, such as statistics, new product information and event invitations. Lior Dayan, CEO of Alma Lasers said, “We are thrilled to launch Soprano Titanium, reinventing laser hair removal technology by addressing the gold formula of speedefficacy-comfort. Soprano Titanium demonstrates excellent outcomes for the practitioner, owner and patient, offering 40% shorter and effective treatment time, higher return on investment and extremely comfortable patient experience thanks to the new ICE Plus cooling technology.” This platform is available in the UK through Alma Lasers’ distributor, ABC Lasers.

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News in Brief Save Face renews PSA Accreditation Independent accreditation body Save Face has received accreditation from the Professional Standards Authority (PSA) for the second year in a row, with commendations on public engagement. This recognition means that the body is accepted by the government as an Accredited Register. Emma Davies, Save Face clinical director, said, “I am grateful to those professionals who have chosen to be part of the Save Face register; without that support we wouldn’t have been in a position to achieve all we have done.” S-Thetics wins iS Clinical award Skincare company iS Clinical has announced the winner of the iS Clinical World Star Contest 2018, presenting Beaconsfieldbased clinic S-Thetics with the title of World Star UK Clinic of the Year. Surgeon, aesthetic practitioner and medical director of S-Thetics clinic, Miss Sherina Balaratnam, has won a round-trip to Los Angeles, which includes a tour of the corporate iS Clinical office, as well as advanced VIP training, a $300 shopping fund and three nights stay in deluxe accommodation. IQ Resources releases Level 7 eLearning course UKAS accredited certification body IQ Resources, a sister company to IQ Verify, has launched a new eLearning package titled Botulinum Toxin and Dermal Filler Level 7 eLearning. IQ Resources states that the new course meets current UK cosmetic training guidelines and aims to support the delivery of the IQ Level 7 certificate in Injectables for Aesthetic Medicine. It’s designed to support all other forms of injectables training (regulated or unregulated) and further learning or upskilling of existing practitioners. Modules include: history, ethics and law, cosmetic psychology, dermal filler use, ageing and photoageing, plus many more. New recruit for Venus Concept Manufacturer of non-invasive aesthetic devices Venus Concept has appointed Paul Talbot as its new UK sales director. Talbot started his career in the beauty and aesthetic market in 1999 and has worked for many companies within the sector. He will be responsible for building a strong sales team to elevate Venus Concept’s global success and increase its profile. Anisah Vidale, business manager at Venus Concept UK and Ireland said, “I am extremely excited to have Paul join the Venus vision. He has always been renowned in the industry with an individual commitment to a group effort.”

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


BOO FRE K YOU R ED TOD EMO AY

Appointment

Roseway Labs recruits new team member Pharmaceutical company Roseway Labs has appointed a new account director, Despina Giannopoulou. She has 30 years’ experience in IT and made the decision to make a change in her career path and venture into the health and aesthetic sector in September 2016. Roseway Labs has stated that Giannopoulou will be focusing on the business development programme for the company, working closely with prescribers to build relationships. Giannopoulou said of her new appointment, “I’m so very excited to put my extensive account management expertise to use in the healthcare industry, while at the same time contributing to the growth of a start-up company with a passion for personalised medicine.”

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On the Scene

Cosmetic Courses training centre launch, Nottingham

On January 19, aesthetic training provider Cosmetic Courses launched its new training centre, based in Nottingham. The purpose-built centre offers four large modern clinic rooms, a conference room and a large reception area. The event began with medical director Mr Adrian Richards introducing the new premises to delegates and models from Cosmetic Courses. Following this, Dr Olha Vorodyukhina, clinical director of the company, introduced the courses that would be available including the facial aesthetic contouring training Stage 1, Rederm: the injectable skincare course and the non-surgical blepharoplasty course. Dr Olha said, “We are very excited by the new premises. With the growth of the company with new and existing courses, this is something that we have needed for a while. The launch event was a great success and we received great feedback from everyone who came.” Mr Richards added, “Dr Olha and the rest of the Cosmetic Courses team have done a great job in building the new clinic, it looks great and we are very excited.”

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Trending on Social Media: The 10 Year Challenge Aesthetics investigates the new consumer craze that puts the spotlight on ageing and explores its potential positive and negative impacts From buttock implants and overfilled lips to cupping therapy and unusual eyebrow shapes, fads are common and popular in the cosmetic and aesthetic field. These days, it is usually social media that fuels trends and they can quickly go viral, with millions of people taking part. By now you have probably heard about the latest craze that took over social media in January – the ‘10 Year Challenge’. This movement is similar to other viral social media challenges, such as the ‘Cinnamon Challenge’, the ‘Ice Bucket Challenge’ and more relatable to the current viral movement, the ‘No Makeup Selfie’. The difference is that the 10 Year Challenge draws a clear, and direct comparison to one’s image, and more specifically, how well they have aged. It involves individuals posting a then-and-now comparison image of themselves in 2009 vs. 2019 on Instagram, Facebook and less commonly Twitter, using the hashtag #10YearChallenge. It is also going by different names such as ‘Glow-up Challenge’, ‘2009 vs. 2019’, and ‘How Hard Did Aging Hit You’. How or where it originated is unclear, but what is clear is the number of people taking part – at the time of publication, there were more than four million posts on Instagram alone using #10YearChallenge.1 So, with a craze that is directly exploring the process of ageing, how is this affecting patients, and what do aesthetic practitioners think about it?

What’s the point? Unlike the ‘No Makeup Selfie’ campaign back in 2014, which raised money for cancer research,2 as well as offering support to actress Kim Novak, whose looks were criticised at the Oscars,3 the 10 Year Challenge has no obvious point. So why are people doing it? “Society is much more image focused than the past and many people feel that it’s important to show what they have achieved through their image,” says consultant dermatologist Dr Alia Ahmed, who has a particular interest in psychodermatology. She believes the

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reasons why people partake in such a campaign is complex. “Some people will take part in this challenge because they want to show how well they are doing in terms of how well they look. Peer pressure is also a factor; I think if your friends and everyone else are doing it, you feel the need to do it as well. Some people might want to show that they have had cosmetic treatments, while those who know they look good want to show others they do. There also might be a number of people who are joining in because they feel insecure, so the campaign may be helping them get over their insecurity by saying, ‘Actually, I look really good compared to 10 years ago’. While others will just do it for fun,” she explains. Dr Ahmed believes the comments on the images are also noteworthy – people are saying things like, ‘You look better on the right’, ‘That is a glowup’, and ‘You haven’t aged a day’. She explains, “There will be a subset of people who are doing the challenge purely to receive positive comments. But issues could arise with people with a negative or insecure disposition – if they receive even one negative comment they may focus on this rather than the other positive comments that are there.”

Issues to consider

Plastic surgeon Mr Olivier Branford is an avid user of social media with more than 250,000 followers on his various platforms. He highlights that there are positive and negative aspects to any image-related trend, including this one. “I think the 10 Year Challenge can be a good thing if users are showing how they have overcome adversity; for example, reconstruction after trauma or cancer, if someone has ‘grown older gracefully’ or has used fitness to get into shape. However, I think that to some extent, all types of before and after images have a negative aspect in that they celebrate how good someone is looking now in relation to how bad they looked before,” he explains, adding, “The 10 Year Challenge may make people feel the need to be ‘frozen in time’ or to ‘roll back the clock’, rather than accepting that they look great for their age.” Dr Ahmed highlights the negative implications this challenge may have on one’s mental health. “This can be particularly negative for susceptible individuals who already have negative body image issues; potentially sending them into a spiral of negativity,” she explains, adding that there may also be people looking at the pictures who have diagnosed or undiagnosed body dysmorphic disorder (BDD). She says, “The challenge may make them feel even worse about themselves when they look at their own pictures over 10 years or when they look at other people’s.” The multiple comparisons with one’s self, as well as with others, can also impact people who are usually confident too, warns Dr Ahmed, emphasising that anyone can be negatively affected by the challenge. Aesthetic nurse prescriber Claudia McGloin adds, “As the challenge is being portrayed by the media in more of a positive light, a lot of people just don’t stop to think about BDD. This kind of challenge can magnify what a person believes to be their flaws, either driving them to want to have cosmetic treatments, causing them to manipulate their images or get them to start thinking about their appearance a little bit more when they otherwise might not have.” McGloin also thinks that many people have been tempted to alter their

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


images using photo editing apps. “People who haven’t aged that gracefully are thinking that they can’t put their picture up, or to feel included they are tweaking the image or are choosing ones that are not very clear. The same thing happened with the ‘No Makeup Selfie’, a lot of people uploaded images that were black and white, altered, had bad lighting or they were wearing a bit of makeup,” she says. Celebrities such as Reese Witherspoon, Lea Michele and Jessica Biel have also taken part; showing how well they have aged, or rather, how they haven’t. Mr Branford comments, “Celebrities have been showing us how amazing they look, how they haven’t aged at all or how they look better or younger than they did a decade previously. Consequently, most people are using the challenge to show that they look better or exactly the same. However, celebrities in 2019 have the best skincare regimes, personal trainers, professional photographers, lighting, and retouching available. One doesn’t see the 100 photos that were discarded.” Most of the celebrities’ before and after images also don’t disclose they have had any treatment, therefore not providing the public with a true reflection of their ageing, practitioners note.

A positive effect for aesthetic practitioners? “It is very hard to say for sure if social media has a direct impact on the take up of aesthetic treatments, although it is certainly held responsible for it,” notes Mr Branford, while McGloin believes that the campaign will encourage more people to seek treatment. She says, “People who have never thought about getting treatment are suddenly comparing two pictures and may think, ‘Oh I didn’t have that line on my face 10 years ago and I don’t like it’. This could potentially have a huge impact and benefit to the industry where people will enquire about treatment.” Mr Branford notes that some of the images people are sharing can negatively affect the aesthetics sector. “When the 10 Year Challenge shows distorted images of people with excessive aesthetic treatments it can reflect negatively on the industry as a whole. More worryingly, by normalising these distorted images it can affect what we perceive as beautiful, making the unnatural ideal the norm to be aspired to,” he says.

Just another phase? All interviewees note the importance of understanding a patient’s motivation to seek treatment, highlighting the issues behind mental health and noting that it’s useful for practitioners to understand how these kinds of crazes might affect the public. McGloin concludes, “I think this is just a phase and it will die out and something else will take over, maybe something about the body for example. However, I think it’s good for us as aesthetic practitioners to discuss this kind of thing because it all helps us understand why people might be motivated to get treatment.” REFERENCES 1. Instagram, #10YearChallenge, January 24 2019. <https://www.instagram.com/explore/ tags/10yearchallenge/> 2. The Guardian, No-makeup selfies raise £8m for Cancer Research UK in six days, 2014. <https://www.theguardian.com/society/2014/mar/25/no-makeup-selfies-cancer-charity> 3. Penny Stretton, The Daily Mail, 12 March 2014. <https://www.dailymail.co.uk/femail/article-2579248/ Crime-novelists-make-free-selfie-solidarity-actress-Kim-Novak-sparks-Twitter-Facebook-trenditsokkimnovak.html>

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Explore the Exhibition at ACE 2019 Aesthetics looks at the unique opportunities available to delegates at the unmissable Aesthetics Conference and Exhibition on March 1-2 It’s where new connections are made, the latest innovations are showcased, live demonstrations are performed and lifelong friends and colleagues share experiences. Set across an impressive 2,500m2 space, the Exhibition Floor at the Aesthetics Conference and Exhibition (ACE) 2019 on March 1 and 2 really is the heart of the two-day event. The buzz of those keen to learn is almost tangible, with more than 2,000 delegates interacting with 80 of the best aesthetic companies, learning techniques and treatment advances from key opinion leaders and skilled aesthetic trainers, as well as getting the latest product updates and deals from company representatives. So, whether you are an experienced practitioner eager to hear about the new launch from one of your favourite companies, a clinic manager looking to introduce a new device into your practice, or an aesthetics-newbie who needs tips on how to market yourself; ACE 2019 is the place to be!

Make the most of show offers

Take advantage of amazing show offers available on the exhibition stands, exclusive to ACE 2019. For two days you’ll have access to huge discounts, giveaways and special offers from some of the top manufacturers, distributors, suppliers and training providers in the field.

Discover the latest innovations Keep your knowledge up-to-date by watching the on-stand live demonstrations, where companies will be showcasing their new products and treatments. Topics covered will include body contouring, injectables, skin rejuvenation and so much more. Seeing this work live in action will allow you to discuss tips and techniques with those who know best!

Meet the Aesthetics team! Have you ever wanted to write for the Aesthetics journal? Maybe you want to appear in the ACE highlights video? Don’t miss out on the chance to meet with the Aesthetics journalists who would love to hear your article ideas and interview you on-camera about your experiences at ACE and in the aesthetics specialty. It’s a great way to share your opinions and boost your profile! So, if you are interested, head to the Exhibitor’s Office and ask for a member of the editorial team!

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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Aesthetics aestheticsjournal.com for in-depth discussions and advice. If you want a quick learning experience without having to compromise on quality then a 30-minute Expert Clinic session may be for you; held by AestheticSource, AesthetiCare, BioActive Aesthetics, Church Pharmacy, Cutera Medical Ltd, Dermalux LED (also confirmed as Headline Sponsor), Enoura, Fusion GT, Invasix, Naturastudios, Thermavein and Venus Concept.

Develop key connections The networking opportunities available to you are endless at ACE with around 2,000 other delegates and industry professionals in attendance. The official Networking Event on Friday March 1 from 6-7pm, hosted by Enhance Insurance, will provide you with the opportunity to sit back and relax after a day’s learning and enjoy a complimentary beverage whilst meeting new friends. So, start making an action plan of who you might want to meet or build relationships with by viewing the ACE speakers and exhibitors on our website.

It doesn’t stop there… Even more fantastic companies are confirmed as hosts for our clinical agendas, so learn from some of these leading aesthetic companies and top up your CPD points. AestheticSource, BeamWave Technologies, BTL Aesthetics, Church Pharmacy, Galderma, Lumenis, SkinCeuticals, will all be hosting one-hour Masterclass sessions, perfect for those looking

There are also 19 free business session on a range of topics including clinic growth, social media and regulation on the Business Track agenda, sponsored by Enhance Insurance. There’s something for everyone at ACE, so ensure you don’t miss out! Register today at www.aestheticsconference.com. *Please note that access to some of the clinical sessions are restricted to certain professionals so check the session information beforehand

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Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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Aesthetics aestheticsjournal.com Aesthetic practitioner Dr Galyna Selezneva, who practises at The Rita Rakus Clinic, and surgeon and aesthetic practitioner Miss Sherina Balaratnam, who runs her own clinic in Beaconsfield, agree that body contouring for men is a growing market, with each having a male database of 30% and 25%, respectively. Aesthetician Cristina Ucci, who works alongside Dr Neil Walker at his clinic in Oxford, adds that this time of year is the perfect time to target men, who will be thinking ahead of how they can be in their best shape for summer.

Consultation

Contouring the Male Body Practitioners discuss their approach to body-contouring procedures for men A market for men? For thousands of years, artists and sculptors have depicted the image of the ‘ideal’ man as an athletic and muscular figure. Think Greek statues such as Doryphoros dating back to circa 440 BC1 and Leonardo Da Vinci’s Vitruvian Man in 1487.2 Today, performers such as Zac Efron and Hugh Jackman are portrayed as body icons, with both featuring on the front pages of magazines across the world. Research indicates that there is an ‘emphasis on lean and well-defined muscle mass’ when it comes to male body shape,3 and that the majority of women prefer men’s figures to be muscular.1 According to a number of authors, muscularity may be seen as the physical manifestation of specific traits such as discipline, dominance, resilience, attractiveness, sexual experience and the absence of imperfections.3 Of course, regular exercise and maintaining a healthy lifestyle can offer men an ‘ideal’ physique, but some men may not have the time or inclination to spend hours lifting weights. Additionally, how does physique change as men age? And what can they do about those stubborn-to-shift pockets of fat that appear? It is also important to acknowledge that while this figure may generally be regarded as ‘ideal’, it is of course not everyone’s preference and each man will have his own goal in mind of how his body shape can be enhanced. Just as they are successful for women, body-contouring procedures are an option for men too. However, as the practitioners featured in this article emphasise, a different approach is often needed – both in terms of consultation and treatment. For practitioners aiming to target a male demographic for the first time, promoting your contouring procedures to them is a good place to start, according to aesthetic practitioner Dr Ravi Jain. In his experience of running a clinic with an approximate 50% male database, he says men are more concerned with their body than their face.

Enquiries Practitioners agree that consulting a man is often very different from consulting a woman. “By the time a male patient comes to you for a consultation, he will have done his research and done it thoroughly,” says Dr Selezneva, highlighting that, “With women, treatments are much more of an emotional buy – they may call in the morning and if an appointment is available they’ll go for it.” Dr Jain agrees, noting, “I’d say men are definitely less spontaneous than women. They’ve normally done a lot more research; they’ve watched every video online – they just need to know facts.” Miss Balaratnam adds, “When consulting men I tend to find they are less nervous and self-conscious as a whole, and more directive in approach; they know exactly what they want to target and what results they expect, while wanting to know what devices we have, how these work, the scientific data behind the technologies and evidence of our results, which I’m delighted to say we have.” Suitability While male patients may be keen to undergo a body-contouring procedure, the practitioners interviewed stress that not everyone is suitable for treatment immediately. The main factor restricting a man’s imminent treatment is his current lifestyle. “My direction is clear in both male and female consultations,” says Miss Balaratnam, adding, “We discuss their diet and alcohol consumption, and level of exercise regime as these are key factors to cover when carrying out body-contouring consultations.” She explains that her patients are asked to rate each on a scale of non-existent, low, moderate to high so she can assess what can be optimised pre-treatment. If, for example, they have a poor diet, consume excessive alcohol, lead a sedentary lifestyle and have little or no exercise regime, Miss Balaratnam advises patients to improve each prior to commencing treatment. She explains that with negative lifestyle factors, the lymphatic system will be congested, and the broken down fat cells will not have the opportunity to be effectively processed by the body. “I explain to patients that when they address and optimise these factors for the duration of their treatment and follow up, their results will follow, it’s as simple as that,” Miss Balaratnam says. When assessing suitability, the first thing Dr Jain asks his patients is what they’ve had for breakfast. “I ask what they eat on a typical daily basis and suggest some modifications. I explain to them that if they want to lose weight, they need to be in a calorie deficit,” he says, explaining, “To me, it’s simple – you’ve got to burn off more energy than you’re putting in.” He adds, “If someone’s got a poor diet, they’re overweight and they’re not exercising, then we’re not going to start treatment on

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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Figure 1: Before and one month after four sessions of EMSculpt. Images courtesy of Miss Sherina Balaratnam.

Figure 2: Before and after eight treatments with Venus Freeze. Images courtesy of Body Care by Angie via Venus Concept.

them. They’re unlikely to maintain the results so we advise them to come back after they’ve improved their lifestyle.” The type of fat requiring treatment is also important, according to Dr Selezneva. She says, “We have to be very careful that the fat we are treating is subcutaneous. Lots of men present with visceral fat, which is stored around a number of important organs such as the liver, pancreas and intestines and can only be targeted with diet and exercise.4 It’s important to explain that if they work on this, then in a few months’ time we can assess them again and offer a range of treatments for the remaining subcutaneous fat. The good news is the patients usually trust you and will be motivated to work on this to undergo treatment.” On the other hand, men may be put off by some types of treatment if they will be unableto keep it private. Dr Jain, who offers Vaser to his patients, explains, “Compression vests can sometimes put a man off having treatment. They say ‘Oh I can’t do that’ and that’s it; if they can’t keep it secret, they won’t go through with treatment.” The main reason men will typically choose not to have treatment, however, is the price. “If they are completely unaware of how much treatments will cost, then usually they’re the ones that drop off,” says Dr Jain, adding, “But if they’re aware of cost before consultation then we know that the ones that come in will tend to convert. We therefore tend to tell them what typical cost they would be looking at over the phone, as well as outlining on the website, before they come in.”

fat cells and are then gradually eliminated from the body through the lymphatic system.5 Dr Selezneva says, “For those pockets of fat that are difficult to shift, cryolipolysis gives excellent results. I use Cristal Cryolipolysis particularly for male patients due to its applicator options. The two plate-style applicators can often cover an abdominal area, meaning the practitioner doesn’t have to squeeze the fat into a suction handpiece. As men’s subcutaneous fat can be denser and harder than women’s, it’s a lot easier to achieve good results with the plates.” Dr Jain offers cryolipolysis to his patients using the CoolSculpting device. According to Dr Jain, it takes from four to 12 weeks for the body to excrete the dead fat cells. During that time, he explains that patients may notice some tenderness and mild swelling. “The procedure itself can be uncomfortable; as if someone’s pulling your skin firmly,” he says. Once it freezes, the treated areas go numb and patients then have to wait about 25 to 50 minutes for the treatment cycle to be completed, depending on the applicator used. Dr Jain has Netflix set up in the treatment room so patients can relax and watch television while they wait. He goes on to explain, “At the end of the procedure, when the skin starts to thaw, patients may experience chilblains – small, itchy swellings on the skin that occur as a reaction to cold temperatures6 – and that’s uncomfortable for about five to 10 minutes. The protocol suggests we massage the area for about two minutes during that time, which further increases fat cell death.”

Treatment So, what are men’s main body concerns? Dr Selezneva says there are two top complaints she treats. “Unsurprisingly, the number one area of concern is the abdomen – men are looking to reduce fat and tone muscle,” she explains, adding that the second is the flanks, commonly referred to as a ‘muffin top’. “They’re often impossible to get rid of with exercise and when one develops, it is a sign of ageing,” says Dr Selezneva. Dr Selezneva also explains that the chest is also a very popular area for male patients who seek treatment for gynaecomastia, colloquially referred to as ‘man boobs’. She says, “In the same way as women’s, men’s chests can drop and when they do, often men want to perk them back up. This is actually much easier to achieve in men because they don’t have as much breast tissue.” Various treatments for body contouring are available, with numerous technologies on the market. In this article, however, practitioners discuss their preferred methods to use on male patients. Cryolipolysis When delivering a cryolipolysis treatment, practitioners apply a high-pressured suction handpiece to the target areas of the body, which are cooled to negative temperatures to induce apoptosis of

Side effects and complications After cryolipolysis, the area can be numb for up to three weeks, says Dr Selezneva, while Dr Jain points out that there’s a risk of cold burns, but hasn’t experienced this on patients he’s treated. He adds that paradoxical adipose hyperplasia is regarded as the main complication, albeit very small, which means that there is an area of localised fat after cryolipolysis,7 making it look like the patient has gained more weight in the area treated. He explains, “I’ve seen one case of this and the only way to fix it is liposuction. My patient wasn’t that fussed as it was relatively mild, so didn’t have it treated; however, we’ve Before

After

Figure 3: Before and after two Cristal treatments, administered two months apart. Images courtesy of Dr Galyna Selezneva.

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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been referred other cases where we’ve had to treat them.” A substandard response to treatment can also be regarded as an adverse event. Dr Jain explains, “It’s slightly more common in men, which I think could be because there’s not enough of the tissue in the suction cup as their skin and fat is generally firmer, so it can be harder to get a good vacuum full of their tissue.” Laser-assisted lipolysis Miss Balaratnam notes that she also offers body-contouring treatment to her patients via laser-assisted lipolysis – heating the tissue as opposed to freezing it with cryolipolysis. This procedure uses laser energy to adipose tissue, to permamently destroy fat cells.8 While lots of devices are available, Miss Balaratnam uses SculpSure, which she explains takes approximately 25 minutes and aims to destroy up to 24% of treated fat in problem areas such as the abdomen and flanks. “Results can start to be seen as early as six weeks following treatment, with optimal results usually seen at 12 weeks. We’ve been treating patients for more than two years with a 100% success rate,” she says. Dr Selezneva also uses this device and emphasises that two or three treatments are often necessary to see results. Side effects and complications Thermal injury is generally regarded as the main risk of laser-assisted lipolysis, while the risk of nerve damage should also be considered.8 Dr Selezneva notes, however, that the risk is of course minimised if practitioners follow official protocols carefully. In addition, she notes, “When taking a medical history, practitioners should also consider any contraindications such as abdominal scarring and ensure the patient is made aware of the pain factor, as I have found that it can be a painful treatment.” Radiofrequency Often used to tighten and rejuvenate skin, radiofrequency (RF) can also be utilised to offer body contouring procedures through heating and melting away fat cells. Various devices are available that use radiofrequency energy alone, as well as combined with other methods such as suction. By heating the adipocyte layer to 43-45°C, research has indicated that the RF will induce selective apoptosis in fat cells, with sparing of surrounding cells, with volume reduction three to eight weeks following treatment.9 Ucci explains, “RF is fantastic for skin tightening so it’s very popular for neck and faces, but specifically the abdomen in men.” She offers treatment with the Venus Freeze, which despite its name, heats the tissue using a combination of multi-polar RF and pulsed electromagnetic fields. She advises, “When treating the abdomen in men, they should have about eight to 10 treatments, preferably done once a week.” Dr Selezneva uses the Vanquish ME, a belt-like device that wraps

around the abdomen and flanks which she says is particularly beneficial when treating men as it doesn’t depend on having to administer the device multiple times. She explains that most patients undergo four treatments, scheduled one week apart, with results visible as early as two weeks later. Side effects and complications Again, contraindications should be considered such as metal implants in the treatment area and a current/history of cancer. Modern devices generally have in-built temperature sensors to prevent overheating of the surface of the skin; however, to a large extent, they are operator dependent so complications such as burns can still occur.10 According to research, some older monopolar RF devices have been associated with uneven depths of RF penetration and later unevenness of fat breakdown and associated surface contour abnormalities.10 Ucci notes that posttreatment effects such as erythema are common and expected. High-intensity focused electromagnetic technology One of the newest treatments on the market aims to build muscle, as well as burn fat. The non-invasive high-intensity focused electromagnetic (HIFEM) technology used in EMSculpt induces supramaximal contractions which, according to the manufacturer, are not achievable through voluntary contractions, for example, through exercise. The muscle tissue responds to these supramaximal contractions by remodelling its inner structure, resulting in muscle building and fat burning.12 Both Miss Balaratnam and Dr Selezneva offer EMSculpt procedures to their patients. “EMSculpt targets abdomen muscles to achieve a flatter appearance and improve core strength, which men absolutely love,” says Dr Selezneva. The protocol involves a series of four treatments, all done within a two-week period, and each session takes just 30 minutes. Miss Balaratnam highlights that the treatment is ideal for men who want to take their exercise regime to the next level. “EMSculpt is great for someone with a good baseline of fitness and muscle tone, wanting to be more defined. When we treat men they enjoy the sensation of the highintensity focused electromagnetic contractions and feel stronger in their core,” she explains, continuing, “By their eight-week follow up we see enhanced muscle definition, fat loss and sculpting. We can now also treat diastasis recti in both men and women. This is a real gamechanger.” In terms of discomfort, Miss Balaratnam explains that the treatment does not feel painful, instead like ‘an intense muscle contraction’. She adds, “As a result, patients report that they feel stronger after each session and are standing taller with improved posture and due to core strength increasing, we are seeing patients whose lower back pain has also improved.”

Transgender patients Dr Selezneva has had some experience of masculinising procedures in transgender patients, which involves reducing the appearance of the waist line and hips, as well as feminising procedures to create a waist line and the appearance of hips. She says, “I don’t think we’re at a point where body contouring is hugely popular with transgender men and women – currently they are more focused on facial treatments. However, I want to encourage the community to explore the options available.”

Side effects and complications At the time of publication, there have been no reported complications from HIFEM technology12 and neither practitioners who offer it have had any adverse reactions in clinic. However, Dr Selezneva advises practitioners to find out whether the patient has any metal in or near the treatment area and stick to protocol to avoid risk of an adverse event. While this article focuses on men, it is important to note that this consideration is particularly relevant for women who may have a contraception implant.

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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incorrectly.”14 He notes that patients could also experience a seroma, which is a collection of inflammatory fluid.14 “That’s one of the reasons we offer lymphatic drainage to reduce the chance of it occurring,” he says. Of course, contour irregularities can occur with any body contouring procedure and Dr Jain highlights that following treatment for gynaecomastia there can be asymmetry and nipple sensitivity changes.

Considerations

Figure 4: Before and after Vaser treatment. Images courtesy of Dr Ravi Jain.

Vaser liposuction An alternative, more-invasive treatment that Dr Jain offers his male patients for body contouring is Vaser liposuction. Patients treated with Vaser are generally in good physical condition and are looking to contour their body, compared to traditional liposuction patients looking to achieve weight loss.13 The FDA-approved technology involves the injection of tumescent liquid, or a saline solution mixed with anaesthetics, into the area being treated. High-frequency ultrasound vibration is then used to break fat cells apart, using probes inserted into the fatty tissue.13 Dr Jain explains, “We’re using ultrasound energy to emulsify the fatty globules that are in our body from pea-sized to liquid. These fat cells are not killed; they are still living fat cells, so we can use them to transfer to other areas of the body for fat grafting, if necessary.” To perform the treatment, Dr Jain explains that he begins by infusing the area with tumescent fluid which minimises bleeding, softens tissue and provides a medium for the ultrasound to work without burning the tissue.13 Then he uses the Vaser probes to administer high frequency ultrasound to the area. “You can adjust the power and strength according to the type of tissue you’re dealing with,” he explains, continuing, “We then use a relatively gentle suction procedure to remove the emulsified fat and carefully shape the body.” Treatment time is dependent upon on surface area and number of sites. Dr Jain says that he often users Vaser to treat gynaecomastia, which takes roughly an hour, while the abdomen and the flanks take approximately two hours each. Dr Jain explains that patients can usually go home approximately two or three hours following treatment; however, he emphasises that it is an invasive procedure so patients should be prepared to take time off work – usually about a week. If they’ve had treatment to their abdomen, patients will need to wear a compression garment and require aftercare with five to 10 manual lymphatic drainage sessions. He explains that the lymphatic drainage sessions involve a gentle massage, which aims to minimise the accumulation of inflammatory fluids that occur after a procedure. “By minimising these and draining them away, you find that patients recover quicker with smoother outcomes,” he says. According to Dr Jain, the treated area will swell a small amount over the couple weeks following treatment, which gets better daily.

Dr Selezneva warns practitioners about the risk of feminisation in a male patient. “When you’re treating a man, make sure you have that male body type – usually an inverted triangle – in your mind. In the same way as a woman usually wants her treatment to give her an hourglass figure, you should understand what a patient wants to achieve and make sure you do not demasculinise their figure and give them a waistline, unless this is what they’ve requested.” Choosing an appropriate body contouring device for your clinic can be also challenging, especially if you’re on a budget. Ucci advises considering the developments of the device and whether the supplier will provide ongoing training. “These machines progress so quickly nowadays, so you don’t want to be stuck with the same technology for 10 years,” she says. When practitioners adopt a device and plan to target a male demographic, Dr Jain recommends considering branding. He says, “Ensure your literature for men is male-orientated, with masculine branding. On the other hand, they don’t need to be made to feel like they’re going into a sports bar either. They want a clinical environment that is safe and effective.” Dr Selezneva concludes by highlighting that practitioners shouldn’t assume that men don’t need to be cautioned of discomfort. She says, “Pain is very subjective, so explain to your male patient exactly what it’s going to feel like. Don’t be shy – warn them!” REFERENCES 1. Ancient Origins, Doryphoros: Greek Art Imitating Ideal Form (UK: Ancient Origins, 2018) <https://www. ancient-origins.net/artifacts-other-artifacts/doryphoros-greek-art-imitating-ideal-form-009942> 2. Leonardo da Vinci, The Vitruvian Man (UK: Leoardo da Vinci, 2011) <https://www.ancient-origins.net/ artifacts-other-artifacts/doryphoros-greek-art-imitating-ideal-form-009942> 3. Sell et al., ‘Cues of upper body strength account for most of the variance in men’s bodily attractiveness’, The Royal Society Publishing (2017) <https://royalsocietypublishing.org/doi/10.1098/ rspb.2017.1819> 4. Diabetes, Visceral Fat (UK: Diabetes, 2019) <https://www.diabetes.co.uk/body/visceral-fat.html> 5. ASPS, What is cryolipolysis? (US: ASPS, 2019) <https://www.plasticsurgery.org/cosmetic-procedures/ nonsurgical-fat-reduction/cryolipolysis> 6. NHS Inform, Chillblains (UK: NHS Inform, 2019) <https://www.nhsinform.scot/illnesses-and-conditions/ skin-hair-and-nails/chilblains> 7. American Society of Plastic Surgeons, Complication of ‘Fat Freezing’ Procedure May Be More Common Than Thought (US: ASPS, 2018) <https://www.plasticsurgery.org/news/press-releases/ complication-of-fat-freezing-procedure-may-be-more-common-than-thought> 8. J McBean, ‘Laser Lipolysis: an update’, J Clin Aesthet Dermatol, 4 (2011), pp.25-34. 9. Dr David Jack, ‘An Overview of Non-surgical Body Contouring Treatments’, Aesthetics, January (2017). 10. Franco W, Kothare A, Goldberg DJ. Controlled volumetric heating of subcutaneous adipose tissue using a novel radiofrequency technology, Lasers Surg Med, (2009);41(10):745–750. 11. Jack DR, ‘Radiofrequency: an important tool in the aesthetic practitioner’s repertoire,’ Aesthetics, January (2016). 12. BTL Aesthetics, A Revolution in Body Sculpting (US: BTL Aesthetics, 2019) <https://www.btlaesthetics. com/en/btl-emsculpt> 13. Dr Norma Kassardjian, Vaser – Ultrasonic Liposuction (US: Liposuction.com, 2019) <https://www. liposuction.com/vaser-liposuction.html> 14. AE Hoyes, JA Millard, ‘VASER-assisted high-definition liposculpture’, Aesthetic Surg J, 27 (2007), pp.594-604.

Side effects and complications Pain, infection, bleeding and anaesthesia risks apply to Vaser liposuction procedures.9 Dr Jain adds, “Specific to Vaser, there’s a small chance that the Vaser probe can burn the skin if applied

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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Temple Anatomy Cosmetic and dermatology nurse practitioner Anna Baker details the anatomical features of the temple for safe and successful dermal filler placement Historically, the anatomy of the temporal fossa has been inconsistently described.1 Effective treatment of the ageing temple, manifesting through volume loss, can achieve an excellent cosmetic outcome. These defects are caused by the senescent boney and soft tissue changes.2 Conversely, a hypertrophied temporalis muscle can be a cause of migraine, headache secondary to temporo-mandibular disorders, and bruxism.3 This paper will explore the current literature to inform an advanced anatomical awareness; imperative to safely analyse and correct such changes at this anatomical region. This knowledge will help to minimise the risk of bruising, product migration, erythema and devastating complications such as blindness.4 In light of the inconsistent nomenclature, the following terms are suggested in reference to the fascial layers, consistent with the work of Sykes et al. to provide clarity, where appropriate5 • Superficial temporal fascia – STF. It lies just beneath the skin and superficial fat of the temporal region. It is a thin, pliable, and vascular layer that is tightly bound to the overlying skin.5 The STF is also the superior extension of the superficial musculoaponeurotic system (SMAS) of the mid-face.6 • Superficial component of deep temporal fascia – SDTF. This is also described as loose areolar tissue,5 which thickens at its superior attachment at the temporal crest, fusing anteriorly at the tail of the brow. The SDTF overlies the deep temporal fascia, which is a thickened layer of connective tissue that covers the underlying temporalis muscle.5 • Deep component of deep temporal fascia – DTF. The DTF is a single layer in the superior portion of the temporal fossa, whilst in the inferior temporal fossa the DTF splits into two layers to unsheathe the zygomatic arch.7

Background A consistent challenge for the clinician in analysing human cadaveric research is data extrapolated from small sample sizes.8 This is significant in terms of limiting the validity of conclusive findings; equally in terms of the complex anatomy of the temporal fossa, and may account for the many inconsistencies described in the literature.9,10 Tissue ‘matting’ in embalmed specimens presents a challenge in terms of establishing accuracy11 poignant in terms of studies pertaining to the fascial layers of the temple, adopting formalin as part of their methodology.12 In this approach, embalmed specimens are typically treated with formalin, which is generally formulated with formaldehyde, phenol and potentially glycerine.13 Depending on the purpose, this can mean that fine fascia can become thickened and stiff, with an unnatural texture. Formalin specimens may also impede the required clarity to delineate fine fascia in the temporal region as these may appear uncharacteristically thicker, distorting generated data.14 Unembalmed (fresh/frozen) specimens may closely resemble fine structures and vessels more accurately as no fixative is used.15

Temporal fossa The temporal fossa is bounded superiorly by the superior temporal septum, which extends as a curvilinear boundary posteriorly, the periorbital septum anteriorly, the lateral brow thickening of the periorbital septum anteriorly and the superior border of the zygomatic arch.16 The temporalis muscle spans the entire temporal fossa, attaching directly onto the coarse surface of the temporal bone.17 The temporalis inserts onto the apex, inferior and posterior borders of the coronoid process and extends inferiorly on the anterior border of the mandibular ramus, to approximately the third molar tooth.18 The temporalis is innervated by the anterior and posterior deep temporal nerve from the mandibular division of the trigeminal nerve.19 The temporal fossa undergoes a degree of bone resorption, though not as profoundly as other areas of the facial skeleton such as the orbit, maxilla and mandible.20 This may contribute to an overall hollowed appearance, which manifests more profoundly in some individuals, than others.21

Fat pads The number and location of temporal fat pads are inconsistently conveyed throughout the literature. In my experience, this may be due to the variability noted within anatomical specimens. As part of a postgraduate clinical anatomy programme, I have undertaken a comparative study of embalmed and unembalmed tissue in the temple region.22 It was apparent that a superficial fat pad was evident in 25 out of 26 dissected specimens (left and right), caudal and deep to the STF, which concurs with data from Beheiry et al., who locate it caudally between the fascia of the lower part of the STF and the SDTF23 whereas, Babakurban et al., identify the superficial fat compartment superiorly between the STF and SDTF.24 In addition, I noted a remarkable difference in the measurements of the skin, subcutaneous and superficial temporal planes within the unembalmed specimens, with micrometre variation in thicknesses reported between 1.7mm-3.3mm.22 Little is available within the literature to support this anomaly; mastication, age, sex, BMI, and ethnic origin may be contributing factors.25 These potential variances can be considered significant in terms of augmenting the temporal fossa, potentially influencing the choice and injection planeof dermal filler necessary to achieve the desired result.17 The presence and location of an intermediate fat compartment is widely discussed, but inconclusive within the anatomical literature.26 Babakurban et al. state that this is located on the ‘upper’ part of the deep temporal fascia as it descends to the zygomatic arch; located between the STF and the DTF,24 which conflicts with findings from Beheiry et al., who advocate a SDTF plane exists.23 Yet, Behirey et al., refute that this is where the superficial temporal fat pad is located, maintaining that the subcutaneous layer adherent to the skin of the temple represents the superficial fat compartment.23 It is unclear within the literature why the presence of this fat pad seems so variable.27 By contrast, the presence of a deep fat pad presents as a fibro-fatty pocket, contained between the temporalis muscle, caudally, and the zygomatic bone has been described by Lee et al.15 Conversely, Song et al., and Sykes state that there is no fat compartment present that is deep or immediately superficial to the temporalis muscle or DTF.17,28

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Lateral pterygoid Corrugator supercilii

Procerus

Posterior auricular Occipitofrontalis (occipital belly)

Depressor supercilii

Trapezius

Levator labii superioris alaeque nasi

Semispinalis capitis

Orbicularis oculi

Rectus capitis posterior minor

Levator labii superioris Levator anguli oris Nasalis

Rectus capitis posterior major

Depressor septi nasi

Obliquus capitis superior

Orbicularis oris Mentalis

Digastric anterior belly Longissimus capitis Splenius capitis Sternocleidomastoid

Figure 1: The anatomy of the face

Orbicularis oris (mandibular insertion)

Stylohyoid Stylopharyngeus

Depressor labii inferioris

Styloglossus Masseter Temporal

Ligaments The ligaments within the temporal fossa have been isolated and well described within the literature.9 The SDTF and STF are adherent by ligamentous attachment to the periosteum,16 and the temporal ligament inserts into the STF at the junction between the galea and STF, deep to the frontalis.12 Furthermore, Moss et al., approximate the height of the ligament to be 20mm, with its base located parallel to the arcus marginalis of the orbital rim, 10mm superiorly.16 Sedlmayr et al. describe the superior temporal septum arising from the periosteum along the superior temporal line of the skull, inserting between the STF and the galea, blending into an adhesion at its anterior termination.19 From my clinical research and experience, the superficial temporal fascia and the superficial component of the deep temporal fascia consistently adhered to the zygoma in both embalmed and unembalmed subjects, reinforcing findings from Babakurban et al.24 Moss et al., describe the inferior temporal septum extending on an oblique course from the lateral corner of the temporal ligament towards the external acoustic meatus with insertion points on the SDTF and the STF located 27mm above the zygoma.16 Histological findings from Hwang and Kim extrapolated from 16 unembalmed specimens demonstrated that the STF, SDTF and DTF fuse inferiorly, inserting on to the anterior margin of the zygomatic arch in 56% of specimens, and the superolateral surface in 14% of specimens.12 A number of studies concur that the STF and SDTF insert onto various crests long the anterior aspect of the zygomatic arch.12,25,26

Vessels In my research/experience, the superficial temporal artery can be present within the subcutaneous layer, or embedded within the STF, or enveloped between the two planes.9 Upon entering the temporal fossa, the superficial temporal artery transitions from the SMAS, as it crosses the zygomatic arch on its superior course.8,29 Once it crosses the zygomatic arch, it lies within the subcutaneous layer under the skin.10 Beheiry et al. report the superficial artery to have an external diameter of 1-2mm at its entrance to the temporal fossa,23 crossing the zygomatic arch at 1-1.5cm anterior to the tragus. Tayfur et al. extracted data from their cohort of 13 embalmed specimens to report bifurcation of the superficial temporal artery in 90.9% within 0.5-2cm above the tragus with 60% bifurcation above the superior border of the

Buccinator Zygomaticus minor

Depressor angularis oris Platysma

Zygomaticus major

zygomatic arch.30 The middle temporal artery is a proximal branch of the superficial temporal artery, originating below the zygomatic arch. It divides into a superficial and deep branch and supplies the temporalis muscle, forming anastomoses with the deep temporal arteries.31 The sentinel vein can be consistently located lateral to the orbital rim, passing from the subcutaneous layer through the STF, and then through a perforation or attenuation in the deep temporal fascia to the temporalis.32 In addition, the middle temporal vein receives several veins, including the sentinel vein, and traverses the temporal fossa deep to the superficial layer of the DTF. It then joins the superficial temporal vein just above the level of the zygomatic arch.18

Nerves In my dissection experience, the facial nerve passes from beneath the SMAS, on a superior course towards the temporal fossa.9,25 As the nerve traverses the zygomatic arch, it transitions from under the SMAS, to the subcutaneous layer, where it branches to form multiple rami to innervate the frontalis fibres and orbicularis oculi.33 Oâ&#x20AC;&#x2122;Brien et al. concur that the rami of the temporofrontal branches of the facial nerve travel superficially to the subcutaneous plane as they traverse the zygomatic arch.11 However, the wider literature reports the facial nerve to have a variable course within this region.34 Agarwal et al., report findings to indicate that the frontal branch of the SDTF within the temporal region has a transition zone of 1.5cm above the zygomatic arch and 0.9-1.4cm posterior to the lateral orbital rim.25 In 1966, Pitanguy and Ramos described a Pitanguy line to identify the path of the temporal branch of the facial nerve, which has been criticised owing to the variability in soft tissue land marks, as well as the level of accuracy in predicting nerve distribution.34,35 This method relies on locating the facial nerve 0.5cm below the tragus to 1.5cm above the lateral brow.35 Conversely, Hwang and Kim contest that the point at which the zygomaticotemporal nerve appears at the margin of the zygomatic bone is an area to be approached with caution for injectable procedures, proposing the landmark of the zygomaticofrontal suture to locate this and avoidance of an approximate 10mm diameter posterior.12 The zygomaticotemporal nerve passes through the zygomaticotemporal foramen, as well as the temporalis muscle, through the deep temporal fascia, embedded within this plane.36 Agarwal et al., propose that if the zygomaticotemporal

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nerve was inadvertently damaged, any implications of sensory loss in the temple may be lessened due to a potential communication with the auriculotemporal nerve.25

Injectable approaches These anatomical reports suggest that placement of dermal filler with a blunt cannula, and appropriate technique, can provide a safer approach as it’s feasible to visualise the tip of the device in most planes to ensure that product is placed in the desired plane.17 A sharp needle has the potential to pierce the fine fascia of the temple and it may be challenging to ensure product is placed within the correct plane and depth, unless it is placed supraperiosteally.37 In view of the attachment of the STF and SDTF onto the anterior aspect of the zygomatic arch, placement with dermal filler between these planes can be considered a safer option without the risk of product migration.18 Placement of dermal filler superficial to the temporalis muscle may have the potential to migrate to the premasseteric space – a rhomboidal-shaped space that overlies the lower half of the masseter, under the zygoma.38 In view of the consistent presence of the superficial artery within the subcutaneous and/or the superficial temporal fascia, subdermal or subcutaneous placement of dermal filler could compromise the vascular structures. Virtually all anatomic areas where dermal filler can be injected are at risk of blindness.39 The proposed theory behind the devastating complication is that of retrograde pressureinduced embolisation of material through the vascular anastomosis of arterial vessels in the facial region, with a final common pathway ending in the end arteries of the retinal artery.40 The superficial temporal artery may anastomose with the supraorbital and/or supratrochlear arteries, and use of an appropriately-sized blunt cannula and suitable technique may reduce the risk of compression, or embolisation of such vessels,17 if used without force in the appropriate plane. Equally, supraperiosteal injection requires a high G’ prime product to withstand forces of mastication and minimise risk of migration at this plane.1 The latter approach carries the risk of intracranial penetration when sufficient force is applied, as described by Philipp-Dormston et al.41 The underlying bone in the temporal region is known as the pterion and has been shown to vary in shape, as it is a point of convergence of the sutures between the frontal, sphenoid, parietal, and squamous temporal bones.11 An injection approach superior to the inferior temporal septum could be advocated,as no motor branches of the facial nerve nor the superficial temporal artery are identified here.41

Conclusion The apparent inaccuracies and inconsistencies within the temple anatomical literature may be owing to several factors. Firstly, the anatomy is frequently exposed and described through a layer-bylayer approach, and locating and identifying planes during a clinical dissection may be viewed as technique dependent, potentially contributing to the varied nomenclature. The sample/cohort sizes within the literature are considered low, which limits the potential for the reader to grasp the scale of how varied the anatomical variances may be across specific population groups. It could be argued that cannula and sharp needle placement both have a justified place in effective augmentation; however, the safety of both approaches rests on a detailed medical and aesthetic analysis and consultation, a sound technique, as well as product selection based upon appropriate characteristic(s) for correcting the desired plane.

Anna Baker is a qualified tutor, cosmetic and dermatology nurse prescriber who has been involved in developing Dalvi Humzah Aesthetic Training with lead tutor, Mr Dalvi Humzah, since 2012. She is the coordinator and a faculty member for this teaching. REFERENCES 1. Breithaupt A.D., Jones D.H., Braz A., Narins R., Weinkle S. (2015) Anatomical Basis for Safe and Effective Volumization of the Temple Dermatol Surg. 41(Supp 1):S278-283 2. Moradi A., Watson J. (2015) Current Concepts in Filler Injection Facial Plast Surg Clin North Am 23(4): 489-494 3. Lee J.Y., Kim J.N., Kim S.H. (2011) Anatomical verification and designation of the temporalis muscle Clin Anat 25(2):176-181 4. Woodward J (2016) Review of Periorbital and Upper Face: Pertinent Anatomy, Aging, Injection Techniques, Prevention, and Management of Complications of Facial Fillers J Drugs Dermatol 1:15(12): 1524-1531 5. Sykes J.M., Cotofana S., Trevedic P., Solish N., Carruthers J., Carruthers A., Moradi A., Swift A., Massry G.G., Lambros V., Remington B.K. Upper Face: Clinical Anatomy and Regional Approaches with Injectable Fillers Plastic & Reconstructive Surgery, 2015, 136:5s(204s-218s) 6. Mitz V., Peyronie M. (1976) The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area Plast Reconstr Surg 58:80-88 7. Stuzin J.M., Wagstrom L., Kawamoto H.K., Wolfe S.A. (1989) Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad Plast Reconstr Surg 83:265-271 8. Pinar Y.A. Govsa F. (2006) Anatomy of the superficial temporal artery and its branches Surg Radiol Anat 28(3):248-253 9. Baker A. (2015) Temporal fossa anatomy: a review of the literature and safe planes of augmentation Journal of Aesthetic Nursing 4(9):372-379 10. Davidge K.M., Van Furth W.R., Agur A., Cusimano M. (2010) Naming the soft tissue layers of the temporoparietal region: unifying anatomic terminology across surgical disciplines. Neurosurgery 67(3 Suppl Operative): S120-129 11. O’Brien J.X., Ashton M.W., Rozen W.M., Ross R. (2013) New perspectives on the surgical anatomy and nomenclature of the temporal region: literature review and dissection study. Plast Reconstr Surg 132:461e-463e 12. Hwang K., Kim D.J. (1999) Attachment of the Deep Temporal Fascia to the Zygomatic Arch: An Anatomic Study. The Journal of Craniofacial Surgery: 10(4):342-345 13. Eisma R, Wilkinson T, From “silent teachers” to models, PLoS Biol. 2014 Oct 21;12(10):e1001971 14. Bancroft J., Gamble M. (2008) Theory and Practice of Histological Techniques 6th Edition, Churchill Livingstone, London, England 15. Eismer R., Wilkinson T. (2014) From “Silent Teachers” to Models. Plos Biology 12(10): 1-5. 16. Moss C.J., Mendelson B.C., Taylor G.I. (2000). Surgical Anatomy of the ligamentous Attachments in the Temple and Periorbital Regions. Plast. Reconstr. Surg. 105(4):1475-1490 17. Sykes J.M. (2009) Applied anatomy of the temporal region and forehead for injectable fillers. Journal of Drugs in Dermatology. (8):10: 24-7 18. Jung W., Youn K.H., Won S.Y., Park J.T., Hu K.S. Kim H.J. (2014) Clinical implications of the middle temporal vein with regard to temporal fossa augmentation Dermatol Surg 40(6):618-623 19. Sedlmayr J.C., Kirsch C.F.E., Wisco J.J. (2009) The Human Temporalis Muscle: Superficial, Deep and Zygomatic Parts Comprise One Structural Unit. Clinical Anatomy. 22:655-664 20. Shaw R., Katzel E.B., Koltz P.F., Yaremchuk M.J., Girotto J.A., Kahn D. M., Langstein H.N. (2011) Aging of the Facial Skeleton: Aesthetic Implications and Rejuvenation Strategies Plast Reconstr. Surg. 127(1):374-383 21. Avelar L.E.T., Cardaso M.A., Bordoni L.S., Avelar L.M., Avelar J.V.M. (2017) Aging and Sexual Differences of the Human Skull PRS Global Open 22. Unpublished dissertation by Anna Baker. More information available from Anna Baker upon request. 23. Beheiry E.E., Abdel–Hamid E.A.M (2007) An Anatomical Study of the Temporal Fascia and Related Temporal Pads of Fat. Plast Reconstr Surg. 119 (1):136-44. 24. Babakurban T., Cakmak O., Kendir S., Elhan A., Quatela V.C. (2010) Temporal Branch of the Facial Nerve and Its Relationship to Fascial Layers. Arch Facial Plast Surg. 12 (1):16-23. 25. Agarwal C.C., Mendenhall S.D., Foreman K.B., Owlsey J.Q. (2010) The Course of the Frontal Branch of the Facial Nerve in Relation to Fascial Planes: An Anatomic Study. Plast Reconstr Surg. 125(2):532-7 26. Vasconcellos J.J.A., Britto J.A., Henin D., Vacher C. (2003) The fascial planes of the temple and face: an enbloc anatomical study and a plea for consistency. The British Association of Plastic Surgeons 56:623-629 27. Kim S., Matic D.B. (2005) The anatomy of temporal hollowing: the superficial temporal fat pad J Craniofac Surg16(4):651-654 28. Song W.C., Choi H.G., Kim S.H., Hu K.S., Kim H.J., Koh K.S. (2009) Topographic anatomy of the zygomatic arch and temporal fossa: a cadaveric study. J Plast Reconstr Aesthet Surg 62(11):1375-1378 29. Humzah, D & Baker, A, ‘Anatomical Concepts of the SMAS, Aesthetics journal, 2017. <https:// aestheticsjournal.com/cpd/module/anatomical-concepts-of-the-smas> 30. Tayfur V., Edizer M., Magden O. (2010) Anatomic bases of superficial temporal artery and temporal branch of facial nerve. J Craniofac Surg 21(6):1945-1947 31. Rubio R.R., Lawton M.T., Kola O., Tabani H., Yousef S., Meybodi A.L., Burkhardt J.K., El-Sayed I., Benet A. (2018) The Middle Temporal Artery: Surgical Anatomy and Exposure for Cerebral Revascularization. World Neurosurgery 110 E:79-83 32. Trinei F.A., Januszkiewicz J., Nahai F. (1998) The sentinel vein; an important reference point for surgery in the temporal region Plast Reconstr Surg 101(1): 27-32 33. Youssef A.S., Ahmadian A., Ramos E., Vale F., Loveren H.R V. (2012). Combined Subgaleal/Myocutaneous Technique for Temporalis Muscle Dissection. Journal of Neurological Surgery. 73:387-393 34. Davies J.C., Agur A.M.R., Fattah A.Y. (2013) Anatomic landmarks for localization of the branches of the facial nerve. Clinical Anatomy 1(4):33-40 35. Pitanguy I., Ramos A.S. (1966) The Frontal Branch of the Facial Nerve: The Importance of Its Variations in Face Lifting. Plast Reconstr Surg 38(4): 352-356 36. O’Brien J.X., Ashton M.W. (2012) Relationship of the Temporofrontal Rami of the Facial nerve to the Fascial Layers of the Temporal Region. Annals of Plastic Surgery. 68(6):547-548 37. Rose A.E., Day D. (2013) Esthetic rejuvenation of the temple Clin Plast Surg 40(1):77-89 38. Mendelson B.C., Jacobson S.R. (2008) Surgical anatomy of the mid-cheek; facial layers, spaces, and mid-cheek segments 39. Beleznay K., Carruthers J.D.A., Humphrey S., Jones D. (2015) Avoiding and Treating Blindness From Fillers: A Review of the World Literature Dermatol Surg 41:1097-1117 40. Humzah M.D., Ataullah S., Chiang C.A., Malhotra R., Goldberg R. (2018) The treatment of hyaluronic acid aesthetic interventional induced visual loss (AVIIL): A consensus on practical guidance. J Cosmet Dermatol 41. Philipp-Dormston W.G., Bieler L., Hessenberger M., Schenck T.L., Frank K., Fierlbeck J., Cotofana S. (2017) Intracranial Penetration During Temporal Soft Tissue Filler Injection-Is It Possible? Dermatol Surg 44:84-91

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Male Chin and Jawline Ageing Dr Raul Cetto discusses the ageing process of the male lower face and possible treatment approaches The number of men who are interested in and who are seeking aesthetic treatments has been on the rise over recent years.1 As life expectancy increases, our expectation and demands of ourselves in our mature years have drastically changed. Certainly, we now expect to continue to be competitive in our work as well as active in our social and family lives for longer than our parents and grandparents. Improvements in the quality of non-surgical treatments with more developed techniques, scope and minimal downtime mean that we really can choose to stay looking and feeling youthful for longer. Generally speaking, we now enjoy a greater cultural acceptance of aesthetic treatments, which has undoubtedly contributed to higher numbers of men seeking treatment.2 Facial bone structure influences how others perceive us; more specifically, our physical ability. Recent studies carried out on male patients suggest that a thinner facial structure with a shorter bizygomatic distance can make one appear less trustworthy; conversely, a wider bi-zygomatic distance indicates higher competence.3,4 Commonly, male patients seek aesthetic treatments to not only look younger or less tired, but also to improve their competitiveness in their work environment.5 A chiselled jawline and strong chin are characteristic and classically preferable male features. Male patients typically seek non-surgical treatments in order to enhance and restore these features as they become less defined during the ageing process. It is important to recognise that while their range of motivations to seek treatments and treatment indications will be similar, male and female patients require very different treatment protocols to restore the correct desirable features.5

Anatomical considerations of the male lower face In the developmental stage, both male and female faces are essentially the same. The male face later develops its characteristic features due to multiple peaks of testosterone. The aesthetically ideal male lower face is characterised by a square projected chin and well-defined jawline. The chin-neck angle Young

Old

(submental-neck line) of <130 degrees is considered optimal for a man.6,7 While female attractiveness mostly lies in the cheekbones, male attractiveness is thought to be in the chin and a stronger masculine appearance can be achieved by creating a square chin.7 Mandible projection is more acceptable in men; the chin is flatter and wider and has the same width of the mouth. In female patients, the width of the chin is the same as that of the nose and it also corresponds to where most of the volume of the lips is.7 When treating all genders, it is important to be cognisant of the five layers: skin, superficial fat, superficial musculo-aponeurotic system (SMAS), deep fat and bone. An in-depth knowledge of the pertinent structures is crucial to understanding the process of ageing and the development of a successful treatment strategy. Both male and female patients have the same anatomy and go through the same steps during the ageing process, which are described below. Interestingly, female patients can appear masculinised as part of the ageing process as the soft tissues around the mandible prolapse and give the appearance of a square face. Anatomy of the chin The mandibular septum plays an important role in the formation of melomental folds and jowls. It is a membranous structure that separates the two compartments located over the edge of the submandibular fat compartment.8 Fibres of the platysma mix with the mandibular septum and are inserted in the anterior border of the mandible behind the depressor anguli oris (DAO) muscle.9 The mental area musculature is comprised of three muscles: DAO, depressor labii inferioris (DLI) and mentalis muscle. These three muscles are in relation to the orbicularis oris muscle (OO) sharing fibres along the lips. The OO muscle closes and pouts the lips and plays an important role in the formation of perioral rhytides.10,11 Anatomy of the jawline The masseter muscle has a square shape, which comprises deep and superficial parts. Its superficial component is the largest and its insertion is located at the angle of the mandible and its inferior portion.12 There are four fat compartments in the mandibular region, two deep compartments over the inferior mandibular border and one large superficial component covering the parotid-masseteric fascia.13 The mandible has an inferior portion called the body of the mandible and two perpendicular parts, which are the mandibular rami.13 The facial artery is located 3cm in front of the angle of the jaw, anterior to the border of the masseter muscle. It is easy to feel the anterior border of the masseter when an individual is clenching their teeth, and we can palpate the pulse of the facial artery here. At the level of the mandible, the artery is deep â&#x20AC;&#x201C; on the surface of bone â&#x20AC;&#x201C; and then runs to become more superficial superiorly, but still underneath muscle, to the modiolus: 2cm lateral to the oral commissure. From here it gives rise to several branches, including the superior labial artery, mental and inferior labial, which become superficial to muscle at different times.13

Ageing of the lower face

Figure 1: Changes in the mandible due to ageing â&#x20AC;&#x201C; the mandible looses height and angulation.18

The ageing process of the lower face will follow this sequence: atrophy of deep and superficial fat, dehiscence of the mandibular septum, resulting in the downward migration of both fat compartments towards the neck.9

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definition as the sequence of ageing continues. An uninterrupted mandibular line will no longer be present due to jowling and loss of definition of the gonial angle.14,15

Treatment strategy for the male lower face

Before

After

Figure 2: Patient before and after treatment. Images courtesy of ’MascuLook’ trademarked by Dr Sina Djalaei, which Dr Raul Cetto is a UK partner and contributor.

To develop a successful treatment strategy, a consultation and detailed assessment should be carried out. After establishing what the patient’s aesthetic wishes are, a comprehensive facial assessment must take place. Anterior, lateral and dynamic assessment of the lower face should be performed. For men, we pay particular attention to chin projection, chin line and lateral mandibular projection from the anterior view. The male chin, as discussed, is broader and flat distally. The chin’s width will usually correspond to the width of the mouth. From the same anterior perspective, we evaluate the lateral projection of the mandible, which in the male patient is also broader, and when compared to the midface, a vertical line can be drawn from the point of maximum lateral projection of the zygoma to the mandible, giving the male face a squared appearance, responsible for the characteristic chiselled male ideal.7 In a lateral view, we assess the gonial angle, which is sharper in a male patient (<130) and the mandibular line towards the chin, which should be uninterrupted. The pogonium should be within 0.5mm from a vertical line drawn from the nasion (the most anterior point of the frontal-nasal suture) perpendicular to the Frankfurt plane.16 Restoration of mandibular and chin projection is essential when treating agerelated changes of the male lower face. In my experience, this is Before

There is a progressive loss of definition of the jawline as bone is resorbed and remodelled.9 Around the age of 35, bone resorption begins to take place in the mandible. This results in a loss of mandibular height and length, leading to a more obtuse mandibular angle, chin retrusion and an accentuated pre-jowl sulcus.14 The jowl and melomental folds only develop with ageing. Laxity develops in the roof of the pre-masseter space with laxity of the anterior and inferior boundaries; however, the major retaining ligaments remain strong with the superficial fascia staying firmly attached to the deep fascia. As the buccal fat descends within the buccal space, the weaker masseteric ligaments at the anterior border of the lower pre-masseter space distends downward – this gives the melomental fold. The jowl develops by the distension of the roof of the lower pre-masseter space, which causes tissue to hang below the body of the mandible.14 The ageing process results in the symptoms that often bring our patients to seek treatments. These symptoms are commonly: melomental folds, labiomental crease, double chin, jowls and poorly defined jawlines. Our understanding of this multi-layered ageing process will allow us to deliver targeted treatments.14,15 Melomental folds, also commonly referred to as marionette lines, are a crease formed between the oral commissures beside the chin. This is characterised by a sharp transition between the cheek and chin, medial to the mandibular ligament. Inferior to the melomental folds, jowling can occur, which is a disruption of the mandibular line with sagging of the soft tissues. Medial to the jowl a sharp depression can also be noted, which is the pre-jowl sulcus.14,15 The labiomental crease is caused by an upwards rotation of the mentalis muscle due to hyperactivity. The mentalis muscle becomes hyperactive due to repositioning of the surrounding tissues and loss of bony support.14,15 Along the lateral aspect of the lower face, the jawline will lose

Before

After

After

Figure 3: Patient before and after treatment. Images courtesy of ’MascuLook’ trademarked by Dr Sina Djalaei, which Dr Raul Cetto is a UK partner and contributor.

best achieved by layering soft tissue dermal fillers deep in the supra periosteal plane and at the level of the superficial fat.7 Mandibular remodelling can be restored at several points: gonial angle, prejowl sulcus, pogonium, gnathion and menton. Volume loss of the fat pads can be restored at the level of the superficial fat. Jawline projection can be achieved by placing soft tissue dermal fillers

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at the level of the latero-temporal superficial fat pad. The superficial fat pad planes of the chin can also be used to restore projection and camouflage a melomental fold or jowl. Hypertonic or hypertrophic muscles can be relaxed by using neuromodulators; however, this should be performed after adequate volume restoration with dermal fillers as the position of the lower face musculature can be influenced by loss of volume in the underlying and overlying tissues that occurs during ageing.9,17 When treating male patients, I use the trademarked ‘MascuLook’ concept, which was developed by German-based cosmetic surgeon Dr Sina Djalaei. This approach aims to highlight and restore masculine features. In particular: anterior mid-face projection, lateralise and define the jawline. It also defines and gives anterior projection of the chin and chin line.

Conclusion

Bony and fat volume restoration should be the first step in treating age-related changes in the male face and this can be achieved with soft tissue dermal fillers using a targeted layered approach. The second step is to use neuromodulators to relax hypertonic or hypertrophic muscles, if required. Treatment of the lower third of the face can be challenging and requires in-depth knowledge of facial anatomy. This allows the practitioner to avoid danger zones and perform effective, safe treatments. The chin is a critical component to the perception of facial attractiveness and a defining characteristic of the male patient and therefore reshaping the jawline can provide a significant improvement to facial ageing. An uninterrupted jawline with adequate mandibular and chin projection is a sign of youthfulness and of particular importance when treating age-related changes of the male face. Dr Raul Cetto specialises in non-surgical facial medical aesthetics and practises at Clinic 1.6. He is medical director of aesthetic training provider Harley Academy and is also a medical board member and international speaker for Swiss aesthetic manufacturer Teoxane. REFERENCES 1. Cosmetic Physicians College Australia, The Changing Face Of Male Cosmetic Surgery In Australia, 2016. <https://cpca.net.au/wp-content/uploads/2017/03/24-03-2017_Mens_trends_in_cosmetic_ surgery.pdf> 2. Monheit GD, Prather CL. Hyaluronic acid fillers for the male patient. Dermatol Ther. 2007; 20(6): 394-406. 3. Schmerler J, Your Facial Bone Structure Has a Big Influence on How People See You. Scientific American. June 2015. 4. Torodov A, Baron SG, Oosterhof OO. Evaluating face trustworthiness: a model based approach. Soc Cogn Affect Neurosci. 2008 Jun; 3(2): 119–127. 5. Wieczorek IT, et al. Injectable Cosmetic Procedures for the Male Patient. J Drugs Dermatol. 2015;14(9):1043-1051. 6. Mommaerts MY. The ideal male jaw angle e An Internet survey. Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 381e391. 7. de Maio, M. Ethnic and Gender Considerations in the Use of Facial Injectables: Male Patients. Plastic and Reconstructive Surgery. November Supplement, Volume 136, Number 5S 2015. 8. Reece EM, Pessa JE, Rohrich RJ. The mandibular septum: anatomical observations of the jowls in aging-implications for facial rejuvenation. Plast Reconstr Surg. 2008;121:1414–1420. 9. Braz A, et al. Use of Fillers in the Lower Face. Plastic and Reconstructive Surgery. November Supplement 2015. Volume 136, Number 5S. 10. Marur T, Tuna Y, Demirci S. Facial anatomy. Clin Dermatol. 2014;32:14–23. 11. Pessa JE, Rohrich RJ. The lips and chin. In: Pessa JE, Rohrich RJ, eds. Facial Topography, Clinical Anatomy of the Face. Missouri: Quality Medical Publishing; 2012:251–291. 12. Lee JY, Kim JN, Yoo JY, et al. Topographic anatomy of the masseter muscle focusing on the tendinous digitation. Clin Anat. 2012;25:889–892. 13. Pessa JE, Rohrich RJ. The cheek. In: Pessa JE, Rohrich RJ, eds. Facial Topography, Clinical Anatomy of the Face. Missouri: Quality Medical Publishing; 2012:47–93. 14. Mendelson B, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesth Plast Surg 2012;36:753–60. 15. Coleman SR, Grover R. The anatomy of the aging face: volume loss and changes in 3-dimensional topography. Aesthet Surg J 2006;26:S4–9. 16. Vanaman MJ, et al. Role of Nonsurgical Chin Augmentation in Full Face Rejuvenation: A Review and Our Experience. Dermatol Surg 2018;00:1–9. 17. De Maio M. Myomodulation with Injectable Fillers: An Innovative Approach to Addressing Facial Muscle Movement. Aesth Plast Surg (2018) 42:798–814. 18. Mendleson B & Wong CH, ‘Changes in the Facial Skeleton with Aging: Implications and Clinical Applications in Facial Rejuvenation’, Aesth Plst Surg, (2012) 36:753–760.

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Infiltration Anaesthesia in the Periorbital Area Dr MJ Rowland-Warmann shares her technique for the use of infiltration anaesthesia in the eyelids during plasma treatment There has been a rise in the popularity of plasma devices for the treatment of the periorbital area in recent years.1 In my experience, the use of plasma for the treatment of periorbital rhytides or eyelid laxity has proven remarkably successful. However, when it comes to plasma treatment, like the saying goes ‘beauty is pain’ as the procedure itself can be uncomfortable and the aftercare is often lengthy, with swelling and crusting featuring as part of the healing process. Currently, most practitioners use topical anaesthetic gels to reduce intra-operative pain in plasma treatment. Even with the use of topical anaesthetic creams and gels – those that I have trialled range from 4% to 24% lidocaine – the procedure can still be intensely unpleasant for the patient. With this in mind, I felt there was a need to introduce a more comfortable alternative hence the introduction of my anaesthesia protocol, which has been modified from an existing technique, for injecting anaesthesia when performing plasma treatments.

Understanding the anatomy In order to achieve pain control, it is important to consider the sensory innervation of the eyelids. Unfortunately, a single point injection will not anaesthetise the entire area, so I sought a technique utilising multiple but easily accessible sites, which I discuss later. Treatment of the eyelid with plasma devices often involves treatment of most of the lid, or both upper and lower lids. I have found that treatment of the lateral canthal rhytids (commonly known as crow’s feet) concomitantly improves aesthetic outcomes and patient satisfaction. In such cases, it is necessary to achieve profound anaesthesia of the eyelid in order to make the procedure not only efficient, but also painless. Sensory innervation to the upper eyelid is derived from ophthalmic branches of the trigeminal nerve via the lacrimal, supraorbital, supratrochlear and infratrochlear nerves, shown in Figure 1. 2 The infratrochlear nerve additionally supplies

Lacrimal

the medial aspect of the lower eyelid. Lower eyelid sensory innervation is derived from the zygomaticofacial and infraorbital nerves, branches of the maxillary division of the trigeminal nerve. As with any infiltration anaesthesia, the sensory innervation is effectively subdued without affecting the patient’s motor function; the ability to open and close the eye and move the eye remain unaffected.2

Adaption of an existing technique In 2014, Trapasso and Veneroso2 described a technique for the introduction of local anaesthesia to the upper eyelid using a cannula. I have modified this technique for use in my patients receiving treatment with a plasma device to deliver anaesthesia to a wider area, adding a further injection point and altering delivery method and anaesthetic used. It was found by Trapasso and Veneroso that techniques utilising injection of local anaesthetic with a needle could cause haemorrhage and excessive lid swelling, in addition to septal contraction, pigmentation disorders and ectropion. In their study, they utilised a 26 gauge cannula to administer 2% lidocaine with 1:100k adrenaline. One entry point was used inferior to the point of the mid brow; a further accessory entry point was utilised at the outer canthus for additional anaesthesia.3 My technique Infiltration anaesthesia is almost instant, and due to this you can start work on the area immediately, as opposed to the 30-40 minutes expected with numbing gel. To start, I mark the treatment area with a surgical pen or marker. This is important as the anaesthetic will distort the tissues, making the proposed treatment area less distinct. I prefer the use of a wider bore cannula for the placement of anaesthetic sub-dermally, either a 25 gauge or a 22 gauge; this not only facilitates blunt dissection through the tissues but is for safety – the area around the eye is delicate and I prefer to minimise the risk of vessel trauma. The first point is the lateral cheek. This lets me access the lower eyelid in its entirety, anaesthetising the branches of the infraorbital and zygomaticofacial nerves and thus the sensory innervation to the lower eyelid with ease (see Figure 2). Anaesthetic can be delivered in this way continually to increase patient comfort. A further option to achieve anaesthesia to the lower lid would be to deliver an infra-orbital block (either through the cheek or intra-orally), but this does not anaesthetise the lateral part of the lower eyelid; I have found that access to the lower lid via the lateral cheek point results in better anaesthesia for this treatment. From Point 1, I access the lateral part of the eye to the tip of the brow in a fanning pattern in order to distribute further anaesthetic to the lateral

Supraorbital

Zygomaticofacial

Supratrochlear

Infraorbital

Infratrochlear

Figure 1: Sensory innervation to the eyelids2

Figure 2: Point 1 for infiltration anaesthesia is accessed via the lateral cheek to reach the lower eyelid

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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no concerns over patients making their way home if they have control over the movement of their lids and I find it is well tolerated.

Risks

Figure 3: Access to the corner of the eye and crow’s feet area; anaesthetic is simultaneously delivered to Point 2.

Figure 4: Access to the upper eyelid via Point 2 for delivery of anaesthesia.

canthal rhytides and Point 2 (Figure 3 & 4). The second access point is lateral to the outer canthus of the eye, lateral to the bony margin of the orbit. At this stage, the area is already numb from the previous point of entry, and patient comfort is ensured. The tissue is lifted in order to introduce the priming needle. In this area, there is an enhanced risk of bruising, and indeed in patients with very delicate tissue, haematomas can be observed. Access from Point 2 is with the intention of anaesthetising the lateral aspect of the upper lid; the cannula can be advanced gently from this point by pulling the tissue taut with the other hand and guiding the cannula. Force is not required, and the cannula should move freely under the skin of the upper lid. The patient may report slight stinging with the introduction of the anaesthetic, but otherwise the procedure is painless. The majority of the eyelid can be anaesthetised from this point and the lacrimal and supraorbital nerves are easily anaesthetised. The third and final entry point is inferior to the mid-point of the brow (Figure 5). From here, the medial part of the upper eyelid can be reached and infiltrated, allowing complete anaesthesia of the upper lid. The three points of entry and subsequent infiltration of anaesthetic can be Figure 5: Access via Point 3, inferior rapidly undertaken; I perform this to the mid brow. The branches of the procedure in around three to supratrochlear and infratrochlear nerves, along with any medial five minutes depending on the branches of the supraorbital, are patient – the more nervous the effectively reached. individual, the more time it will take. However, patients accept it readily and whilst many describe the feeling as ‘odd’, it makes the subsequent treatment virtually painless.

Choice of anaesthetic Trapasso and Veneroso used 2% lidocaine with adrenaline in their study.2 I prefer using non-adrenaline local anaesthetic for my treatments, and use 3% mepivacaine hydrochloride which produces less vasodilation than lidocaine.3,5 Between 2-3ml per side is usually sufficient to fully anaesthetise both upper and lower eyelids, including crow’s feet areas. I find that the anaesthesia is profound within three to five minutes and short-acting, and mepivacaine hydrochloride has no adverse effects locally.4 The period of anaesthesia is around 20-30 minutes. It is for this reason that I anaesthetise one eye and treat it immediately, followed by anaesthesia and treatment of the second, as the period of anaesthesia is not long enough for both eyes to be treated. With anaesthesia, the eyelid becomes droopy and heavy. With 3% mepivacaine hydrochloride anaesthesia is so short acting that patients find that their eyelid recovers often before they leave the practice. There are

The patient will experience a little pain on infiltration of the anaesthetic, a slight stinging sensation which lasts only a few seconds. It is important to inject slowly to minimise pain. There is no doubt that injection of anaesthetic will cause more swelling around the treatment site. Plasma treatment already has the propensity to cause significant swelling post-operatively, and I counsel my patients regarding this. In order to minimise swelling, I prescribe a short course of prednisolone to my patients – 10mg (two 5mg tablets) taken once for three days goes a significant way to reducing post-operative swelling from both the procedure and the anaesthetic delivery without significant systemic effects. Patients may furthermore cool the treatment site, sleep with their head elevated, and some report that additional use of non-steroidal anti-inflammatories additionally alleviates both swelling and post-operative discomfort from swelling and tissue trauma. There is risk of bruising due to the delicate nature of the periorbital tissues and if bruises occur, application of pressure is usually sufficient to control this. Bruising resolves within the time it takes for the treatment sites to heal and they are usually self-limiting. Patients should be coached regarding the possibility of bruising as part of their consent process.

Conclusion I have used this method of anaesthesia of the eyelid in well over 100 treatments thus far and have had positive outcomes. In my patients receiving plasma eye lifts, I find that multiple sessions are required for best results. My method for anaesthesia is well tolerated and allows my patients to return for their second and often third treatment sessions without the fear of pain. I find that infiltration anaesthesia has revolutionised my approach to plasma treatment and my patients tolerate it well. There is no doubt that the application of a topical anaesthetic is technically less demanding than infiltrating the periorbital tissues with anaesthetic. This method will not be suitable for everyone, and whilst this article may serve as a guide, there will be practitioners who will benefit from further explanation and hands-on training. Care in exploring this technique has meant that I can give my patients a comfortable and relatively painless treatment experience. As aesthetic practitioners, we should be versed in the use of cannulas, so the administration of anaesthetic rather than filler should not strike fear into our hearts. At a time when we should be working on our skills to improve patient satisfaction, this has made a significant difference to my practice. Dr MJ Rowland-Warmann is a dentist, the founder and lead clinician at Smileworks in Liverpool. In 2016 she completed her MSc in Aesthetic Medicine (with distinction) from Queen Mary University of London. Dr Rowland-Warmann has a special interest in the management of complications, writing extensively on the subject. REFERENCES 1. Scarano A et al, ‘Treatment of perioral rhytides with voltaic arc dermoabrasion’, European Journal of Inflammation, 10 (2012), p.25-29. 2. Tyers, A.G. and J.R.O. Collin, Colour Atlas of Ophthalmic Plastic Surgery E-Book. Elsevier Publishing, 2017. 4th Ed. 3. Trapasso, M. and A. Veneroso, Local anesthesia for surgical procedures of the upper eyelid using filling cannula: our technique. Plast Reconstr Surg Glob Open, 2014. 2(5): p. e143. 4. Septodont, Scandonest 3% Plain Patient Information Leaflet. 2011. 5. Brockmann, W.G., Mepivacaine: a closer look at its properties and current utility. General Dentistry, 2014. p.70-75.

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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monophosphate (cGMP).3 ED medication (sildenafil, vardenafil and tadalafil), which inhibit PDE-5, all act to promote smooth-muscle relaxation by their ability to allow cGMP to Mr Amr Raheem discusses the various options accumulate when nitric oxide is released, as is the case when sexual stimulation is present.3 available for successfully correcting erectile Erection issues can have an organic or dysfunction with non-surgical procedures psychogenic cause. However, in practice, most patients suffering from ED will have a It is estimated that around 20% of all adult men suffer from erectile mixed aetiology i.e. an organic cause that is usually exacerbated by problems, this figure rises to 50% in men aged 40 and above.1 The performance anxiety and stress. 2 In my experience, very few men aetiology of erectile dysfunction (ED) is multi-factorial, including various suffer from pure psychogenic ED. I have found that once erectile organic and psychogenic factors, but for the majority of these men, dysfunction occurs it progressively gets worse due to persistence their issue is of vasculogenic nature and related to the functioning of the risk factors (ageing, genetic and lifestyle factors) which cause of the endothelium and smooth muscle cells that line the arteries worsening endothelium/smooth muscle dysfunction and, in turn, including those of the penis and the gradual development of penile leads to poor penile blood flow, scarring and atrophy of the erectile fibrosis.2 Oral medications such as sildenafil, sold under the brand tissue, creating a vicious circle as shown in Figure 2.2 In short, name Viagra, and other similar drugs (known as PDE-5 inhibitors) the cycle starts with moderate signs of ED, which then leads to a have proved very successful in helping millions of men, however reduction of night erections (the body’s way to keep the erection these treatments do not really heal the erection mechanism and this is mechanism healthy), which in turn can lead to tissue hypoxia, explained in more detailed below. With that in mind, I believe that the scarring and deterioration of ED. holy grail of treatment for these patients has always been a therapy that rejuvenates the damaged erection mechanism and helps to Male sexual rejuvenation restore their natural erections. This article discusses the latest research The theoretical aim of male penile rejuvenation, as opposed to and clinical application of male sexual rejuvenation treatments and the on-demand ED medication is to break this vicious circle of ED by various options available. improving the function of the endothelium. In terms of expected clinical outcomes, these will generally depend on the severity of the Physiology of the erection mechanism and erection issues but could be any of the following:

Erectile Rejuvenation

pathogenesis of erectile dysfunction The erectile tissue consists of smooth muscle lined by endothelium and divided by fibrous bands or trabeculae into a number of small compartments or cavernosal spaces. Penile erection is a neurovascular phenomenon, which results in relaxation of the cavernosal smooth muscle, which lowers the pressure inside the penis allowing blood to enter and fill the sinusoids leading to expansion of the penis. At the same time, the emissary veins are compressed between the expanding penis and the tough outer layer of tunica albuginea, causing the state of hard erection, because the blood stays in the penis rather than escaping back to the circulation. 2 On a cellular level, nitric oxide is released from nerve endings or from endothelial cells and activates a cascade reaction, which ultimately leads to an increased cellular concentration of cyclic guanosine Superficial dorsal vein

• Patients might stop needing ED medication altogether • Patient response to ED medication might improve • Unresponsive patients to ED medication might be salvaged, hence alleviating the need for irreversible and expensive surgical interventions such as a penile prosthesis surgery10 • Deterioration of the erection issues might be delayed or prevented altogether It should be made clear that appropriate patient selection is particularly important and that any male sexual rejuvenation treatment is unlikely to be completely curative since the underlying causes of endothelium and smooth muscle dysfunction are usually related to a patient’s age, lifestyle and other comorbidities, which will

Dorsal nerve of the penis

Endothelium Dysfunction

Deep dorsal vein Dorsal penile artery

At initial stage mild/ moderate presentation

Darte’s fascia

ED Deterioration Corpus cavernosum

Buck’s fascia Tunica albuginea

Progressive endothellium/smooth muscle dysfuntion + penile fibrosis + performance anxiety

Performance Anxiety Initial organic ED exacerbated by performance anxiety

Circumflex vein Corpus spongiosum

Cavernosal artery Urethral artery

Urethra

Penile Fibrosis Tissue hypoxia leads to increasingly fibrotic erection mechanism

Reduced Night Erections Penile tissue hypoxia due to reduced night erections

Figure 1: Anatomy of the penis3

Figure 2: The cycle of endothelium dysfunction

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


@aestheticsgroup continue to affect the erection mechanism. With respect to sexual rejuvenation, this is an area of active research and various treatments are being offered in private practices. In this section I review what I believe to be the most promising, with a particular focus on the mechanism of action and the evidence base regarding their safety and efficacy, so as to help practitioners evaluate whether they should offer them to their patients or not. The reviewed treatments are the following: 1. Extracorporeal shockwave therapy (ESWT) 2. Intracavernosal stem cell and platelet rich plasma (PRP) injections 3. Intracavernosal botulinum toxin (BTX) injections Extracorporeal shockwave therapy Extracorporeal shockwave therapy (ESWT) works by passing shockwaves; which are an intense but short energy wave that travels faster than the speed of sound into the tissues.4 Shockwave treatment initiates a pro-inflammatory response in the tissue where the shockwaves have been applied. It is theorised that the body responds by increasing the blood circulation and metabolism in the impact area, which in turn accelerates the bodyâ&#x20AC;&#x2122;s own healing processes and leads to angiogenesis.4 There are various commercial machines which operate with slightly different mechanisms for shockwave generation, but the clinical application is similar. The practitioner slowly uses a probe through the whole penis to apply the shockwaves. Each treatment session lasts 20-30 minutes, delivering between 3,000 to 5,000 pulses. One important parameter is the energy of the delivered shockwaves and different clinical applications will, in general, require different energy levels, such as orthopaedic for example. For ED, this is an area of active research but the current evidence suggests that an energyflux density level of around 0.09 mJ/mm2 is safe and effective.4 Another area which is being researched is the number of treatment sessions that patients should receive.4 This will usually depend on the severity of the issue but in my clinic we recommend a minimum of six (one to two per week) and up to 12 sessions. Treatment is well tolerated by patients with minimal pain during and after the procedure. Evidence base on safety and efficacy From all the sexual rejuvenation methods reviewed in this article, ESWT has the strongest evidence base supporting both the safety and efficacy of the treatment. In particular, the mechanism of action has been investigated and established in animal studies5 and there have been numerous successful double-blind placebo-controlled trials and systematic reviews in humans.4 Although almost all of the trials had limitations (such as the number of subjects, blinding procedure and follow-up periods) this is to be expected, given that there are various options regarding the optimum protocol in terms of the machine used, energy levels, number of pulses and sessions, as Figure 3: BTX intracavernosal injection. Image courtesy of Mr Amr Raheem. well as patient

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selection. Given that ESWT is not a pharmacological and patentable treatment, I am sceptical that the necessary trials will be carried out in order to establish the optimum protocol and physicians will need to personalise this to individual patients. Intracavernosal stem cell and PRP injections As in many other medical fields including aesthetics, hair loss and orthopaedics, it has been hypothesised that stem cell and PRP intracavernosal injections can rejuvenate the erection mechanism.6 Commercially, due to strict regulatory constraints regarding labcultured stem cells, stem cell intracavernosal injections are not widely available in Europe and are more often used in places like the Middle East and the US.7 As an alternative, many clinics offer PRP injections for sexual rejuvenation under the name P-Shot. Unfortunately, many clinics also advertise the P-Shot as a penile enlargement option but there is no theoretical framework to suggest that a PRP injection has any effects on penis size. Administration of intracavernosal injections of stem cells or PRP is quite straightforward. After preparation of the injectable, local anaesthetic cream is applied to the penis and the preparation is injected in each of the corpora cavernosa. The amount, injection site and post-treatment protocols are not standardised and I expect this to be an area of active research. Evidence base on safety and efficacy In terms of safety, both PRP and stem cell injections seem to be safe to inject in the corpora cavernosa, with no significant adverse effects on the erection mechanism or significant risk of malignancies in the case of stem cell injection.8 Unfortunately, the evidence base for the efficacy of these treatments is still absent. Regarding stem cells, animal studies and initial clinical trials are encouraging6 but there has not been any double-blind placebo controlled trials yet and these results cannot be extrapolated to draw any conclusions about efficacy in human patients. For PRP, the evidence base is even weaker with very few animal studies and human trials. Given that PRP injection is unpatentable, it is questionable whether there would be adequate commercial interest to fund high powered studies to establish efficacy. My view of stem cell injections is that the research is more active and it is likely that, with time, the evidence base will become available. Until then and given the regulatory constraints, complicated process and costs involving preparing the stem cell injections, I would discourage offering it beyond clinical trials. Intracavernosal botulinum toxin injection Over the past three years, I have been involved in human and animal studies, which have suggested a possible role for the intracavernosal injection of botulinum toxin (BTX) in the treatment of ED.9 The hypothesis is that because cavernosal smooth muscle relaxation is an integral part of the development of an erection and BTX is a strong inducer of smooth muscle relaxation, then BTX might be effective in the treatment of ED not responding to other forms of non-surgical treatment. As opposed to the other treatments reviewed in this article, the BTX injection is not expected to heal the damaged erection mechanism but can be periodically applied (every four to six months) so as to enhance erections and the response of patients to pharmacological treatment. The application is fairly straightforward and it involves injecting 50-100 units of BTX (not brand specific) into two points on each side of the penis (see Figure 3). To decrease the risk of systemic absorption, compression of the penile base is applied using a rubber band placed over the base of the penis before the injection and removed after 20 minutes.9

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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Evidence base on safety and efficacy The BTX treatment is still very new and should still be considered experimental. I would note that this should only be carried out by urologists. Our initial human clinical trial with 23 men suffering from very severe ED (unresponsive to any conservative treatment) indicated that the treatment is both safe and effective however we are currently running a double-blind placebo-controlled trial with 160 patients and will be reporting results this year.9 Owing to the simplicity of the treatment and relatively low costs, I believe that BTX injections could revolutionise the field of male penile rejuvenation and reduce the number of patients requiring penile prosthesis surgery, however further research is needed before becoming a routine treatment.

Mr Amr Raheem is a specialist in andrology and practises privately with International Andrology, a healthcare group focusing exclusively on men’s health. He has 17 years of experience on complex urogenital surgery and his knowledge covers surgical, medical, hormonal, psychological and academic aspects of male health. Mr Raheem has published more than 80 articles and book chapters in international journals. REFERENCES: 1. Braun M, Wassmer G et al, Epidemiology of erectile dysfunction: results of the ‘Cologne Male Survery’, International Journal of Impotence Research, February 2001, <https://www.nature.com/ articles/3900622> 2. Robert D, Tom L, Physiology of Penile Erection and Pathophysiology of Erectile Dysfunction, Urologic Clinic of North America, January 2006 <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1351051/> 3. Fazio L, Brock G, Erectile dysfunction: management update, Canadian Medical Association Journal <http://www.cmaj.ca/content/cmaj/170/9/1429.full.pdf> 4. Hatzichristou D, Low-Intensity Extracorporeal shockwaves therapy for the treatment of erectile dysfunction: Where do we stand? European Urology, February 2017 <https://www. europeanurology.com/article/S0302-2838(16)30389-X/pdf> 5. Assaly-Kaddoum R, Giuliana F et al, Low intensity extracorporeal shock wave therapy improves erectile function in a model of type II diabetes independently of NO/cGMP pathway, September 2016, Journal of Urology <https://www.ncbi.nlm.nih.gov/pubmed/27038770> 6. Soebadi MA, Milenkovic U et al, Stem cells in male sexual dysfunction: are we getting somewhere? Sexual Medicine Reviews, April 2017 https://www.ncbi.nlm.nih.gov/ pubmed/28041853 7. European Medicine Agency, Stem-cell-therapy, March 2013 <https://www.ema.europa.eu/en/news/ stem-cell-therapy-treatments> 8. Casiraghi F, Remuzzi G et al, Multipotent mesenchymal stromal cell therapy and risk of malignancies, Stem Cell Reviews and Reports, February 2013 <https://www.ncbi.nlm.nih.gov/ pubmed/22237468> 9. Ghanem H, Raheem A et al, Botulinum neurotoxin and its potential role in the treatment of erectile dysfunction, Sexual Medicine Reviews, January 2018 <https://www.sciencedirect.com/science/ article/pii/S2050052117300859> 10. International Andrology London, Penile Implant <https://london-andrology.co.uk/services/ urogenital-health/penile-implant/>

Summary In this article, I have outlined the main options for male sexual rejuvenation that practitioners can offer to men suffering from erection issues or who are looking to improve their erectile function. Given the current evidence base, safety profile and simplicity of administration, I would say that ESWT is the most interesting option for non-specialist practitioners. In order to maximise patient satisfaction, appropriate counselling and patient selection is of paramount importance and we urge colleagues to refer patients to andrologists/urologists when appropriate.

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Correcting a Rhinoplasty Complication Mr Ayad Harb introduces non-surgical rhinoplasty as a viable alternative for patients seeking to correct the complications of surgery and presents a case study of a successful treatment Rhinoplasty has enjoyed rising popularity and acceptance throughout the years. According to the 2017 survey of cosmetic practice in the UK by the British Association of Aesthetic Plastic Surgeons (BAAPS), rhinoplasty was amongst the top seven cosmetic procedures for both men and women accounting for 2,703 of the surgeries that year.1 Similarly, non-surgical rhinoplasty (NSR) has also seen an increase in popularity2 and even since the 1980s, NSR has come a long way in providing a non-invasive and long-lasting nasal contouring effect.3 So how do the two link? In this article, I discuss how a non-surgical treatment can be an option for those who have experienced postsurgery complications. Managing a surgical complication is an extremely advanced procedure and should only be performed by those experienced in NSR treatments.

Rhinoplasty challenges As one of the most common facial plastic surgery operations performed today, rhinoplasty does, however, have its share of challenges and problems. Post-operative healing and final aesthetic outcome can be unpredictable even in the hands of world-class surgeons. Researchers in a US private hospital found statistically significant alterations on the anthropometric measurements of the nose.4 These included issues from slight depressions to contour irregularities, as evidenced by comparing pre-operative and postoperative photos. Furthermore, complications and adverse aesthetic sequelae may present several years after surgery.5 In 2017, Layliev et al. cited haematoma, infection, and pulmonary complications as the most common adverse reactions amongst 4,978 post-rhinoplasty patients in a cohort study.6 Generally, about 5-15% of patients require revision rhinoplasty, a complex operation with many variables, such as swelling, unpredictable scarring and elevated patient expectations that may influence the final aesthetic and functional outcome of the procedure.7 Saddle-nose deformity is another example of an undesirable complication that may arise after rhinoplasty and this will be the focus of the case study in this article. Depending on the surgeon’s skill, saddling rates vary from 0-2.6% in patients who have undergone submucous resection of the nasal septum.8 A saddle-nose deformity is characterised by a loss of nasal dorsal

height often described as a ‘pug nose’ or ‘boxer’s nose’, both of which refer to various degrees of nasal dorsal depression. In a retrospective study amongst 91 patients with saddle nose, 20 (22%) were found to have unsuccessful outcomes (fair or poor) and eight (9%) underwent subsequent revision rhinoplasty. Management of saddle nose deformities, therefore, still remains a challenge.9,15

Correcting a complication One has two options for correction; surgical or non-surgical. Surgical can be complex and often requires the introduction of exogenous material to support the collapsed septum. This may be in the form of autogenic cartilage or bone or allogenic material. Several studies have looked at the outcomes of these corrections, with variable and limited success rates.10,11 An increasingly discerning and demanding clientele now seek alternative methods, with fewer risks and shorter recovery, that cater to their ever-dynamic lifestyles. In my experience, this may be due to the fact that no other type of facial cosmetic surgery is more exposed to critical analysis than aesthetic rhinoplasty. Since the nose is the most central and prominent feature of the face, the responsible plastic surgeon has to take into account all anatomical and physiological details as well as consider ethical and psychological aspects in the pre-selection and post-operative care of the patient more than ever.12

Patients who have previously undergone surgical rhinoplasty can exhibit noticeable differences in the behaviour of the skin and soft tissues of the nose

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


@aestheticsgroup Recent advancements in medical technologies have led to a surge in demand for non-surgical rejuvenation procedures. Dissatisfied patients seek a myriad of techniques to restore nasal aesthetic such as botulinum toxin, threads and hyaluronic acid injections.13 All of these minimally-invasive facial aesthetic procedures are very frequently requested by a growing number of well-informed patients owing to the reduced risk of adverse events, decreased level of pain, and virtually negligible downtime compared to surgery.14 Non-surgical correction is an option for the external aesthetic of the nose by reducing the appearance of the characteristic saddling and collapse.

Before

After

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Before

After

Figure 1: Patient before and after one treatment session

Saddle deformity case study This case study involves a 24-year-old teacher, who previously underwent a cosmetic rhinoplasty in Turkey. She came in for a consultation two years following her rhinoplasty, with concerns about the appearance of her nose and dissatisfaction with her result. Her immediate post-operative recovery was unremarkable and she had been reasonably happy with her result. Around six months’ post operatively, however, she began to notice that her nose was losing its smooth lines and the bridge was starting to collapse. This was mostly observed from the view of her profile. She felt that the appearance of her nose had an impact on her selfesteem and confidence and that it was a noticeable problem because she felt that people would always look at her. She felt it also bore the hallmarks of a ‘botched’ rhinoplasty and this carried with it certain social stigmas. The patient had considered more surgery to revise this, but was too afraid of the process, recovery and unpredictable result. She therefore decided to live with her result, until she found out about the possibility of non-surgical repair. On examination, her nose showed the characteristic signs of a saddle deformity. The anterior aspect showed an inverted V and a bulbous tip. The side profile demonstrated a collapsed bridge, and an up-turned tip. The skin of the nose was soft and not exhibiting excessive scarring or tethering to the underlying tissues. There was no evidence of venous congestion or vascular compromise in the skin. Patient selection and considerations Upon clinical assessment, the patient was found to be a good candidate for non-surgical correction using hyaluronic acid dermal fillers. The patient’s suitability for this treatment was assessed; she had no contraindications to dermal filler injections. Based on my extensive experience in non-surgical repair of surgical complications, I was confident to recommend this treatment to the patient. The treatment was described to the patient and full, informed consent was obtained and high-quality images were taken. It was explained to the patient that the nose would appear slimmer and more contoured from the front profile. The existing abnormal shadows and inverted-V deformity would be improved. The side profile would also show a marked improvement in the overall straightness and smoothness. It was also explained that any treatment performed should avoid detrimental pitfalls such as overcorrection, which would make her nose appear larger or wider

and potentially give her a worse aesthetic outcome. We were careful not to overpromise a completely straight bridge, which is limited by the elasticity of the skin and existing scar tissue. It is always more reasonable and realistic to describe the likely results of the treatment as an improvement and a softening of the existing problem, but not a complete eradication or reversal. The main risks of the procedure were explained, including infection, bleeding, bruising, and erythema, which may last weeks or even months in the worst cases. The most important issue to clarify to the patient and warn them about was that of vascular compromise of the skin leading to potential necrosis.16 As mentioned above, this is always a quoted risk in non-surgical rhinoplasty and even more so in patients who have had surgery previously. In my experience, patients who have previously undergone surgical rhinoplasty can exhibit noticeable differences in the behaviour of the skin and soft tissues of the nose. The degree of scarring in the skin and cartilage can be variable and this can lead to a nose that is quite inflexible and skin which is thin and tethered. Scarred, post-surgical tissues, especially at the tip of the nose, usually do not accommodate the significant expansion that may be desired. Attempting to do this against the limits of the tissues can be disastrous, with risks of excessive tissue pressure and vascular occlusion. Careful assessment and appreciation of these factors are essential to providing safe and satisfactory results. Previous surgery will always have disrupted the natural blood supply to the skin and it is imperative that the practitioner accounts for the altered, unpredictable and likely compromised vascularity of the tissues before attempting to inject. A very meticulous injection technique and product selection are essential, as well as a heightened level of awareness to identify impending vascular complications, which must be treated immediately to avoid necrotic consequences. Correction of surgical rhinoplasty complications using dermal filler injections carries significant risks and should be reserved for practitioners who are highly experienced in this particular treatment and able to deal with any complications. Treatment Treatment was carried out using a serial micro-bolus technique using a 30 gauge needle. A needle is preferred in these patients for two main reasons. Firstly, in my personal experience, a needle offers more precise placement of the product than a cannula. The second reason, which is especially pertinent in post-surgical patients, is that the degree of scarring in the nose can obliterate

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Conclusion

Managing a surgical complication is an extremely advanced procedure and should only be performed by those experienced in NSR treatments the natural tissue planes17 and in my experience, can prevent the smooth glide of the cannula, while forceful advancement and blunt dissection can cause more localised trauma and pain. Injection depth was aimed at the sub-SMAS level in order to augment the bony and cartilaginous skeleton of the nose and affect the external changes, without jeopardising the vascular structures. A selection of three products were used for this patient. For the purpose of dorsal projection along the bridge of the nose, Teosyal Ultradeep was chosen for its localised lifting ability and minimal propensity for causing generalised volumisation, which is undesirable in the nose. This particular filler is my product of choice and is ideal for achieving good projection and sharp contour in the bridge of the nose. In areas of thinner skin such as on the lateral aspects of the nasal bridge, Teosyal RHA4 was chosen for its localised strength in tissue lifting, as well as a degree of stretch which would prevent visibility of the filler under the thinner skin. Finally, a superficial injection of Teosyal RHA2 filler was also used to smoothen any minor contour discrepancies that remained. All injections were performed by injecting the smallest aliquots possible, always injecting centrally, slowly and at minimal pressure, using a small calibre needle. A total of 1.6ml of product was used in a single treatment session. The treatment time was 25 minutes and there were no immediate or early complications seen. The patient experienced a minor degree of erythema and swelling at the site of treatment. A single application of fusidic acid ointment was used to cover her nose for prophylaxis. Overall the patient was extremely satisfied with her non-surgical rhinoplasty results, which showed a visible correction in the saddling of her nose. The patient was given post-treatment instructions to avoid exercise and strenuous activity for one week and avoid wearing makeup on the area of treatment for 24 hours. She was given an emergency contact number and instructed to monitor the area and report adverse changes, such as worsening pain, bruising or discolouration of the skin or any other concerns. Results would be expected to last between nine to 12 months. This level of close assessment before treatment, meticulous technique and careful product selection, followed by cautious postoperative observation and clear patient instructions are essential elements in maintaining safety standards in this patient group.

In an era where rhinoplasty has become popular, it is more important than ever to introduce non-surgical options that address postrhinoplasty complications and avoid the need for complex secondary surgery where possible. For patients who are reluctant to undergo surgical intervention, NSR is a great choice and a viable alternative. However, it must be stressed that this procedure is associated with high risks of complications, especially in inexperienced hands. It is imperative that the practitioner is experienced in NSR techniques before embarking on the treatment of post-surgical complications. Careful patient selection, cautious management of expectations, delicate technique and immediate and effective complication management are essential for the success of this procedure. Disclosure: Mr Harb is currently associated with Teoxane UK as a KOL and international trainer. Mr Ayad Harb is a consultant plastic and aesthetic surgeon. He has private practices in Oxfordshire, London and internationally, offering non-surgical and surgical aesthetics. Mr Harb has developed his own protocols in non-surgical aesthetics including the 3-point Rhino non-surgical nose correction, the 3-point Lift and the 3-year Rhino. Mr Harb is recognised as a key opinion leader, trainer and international speaker in medical aesthetics. REFERENCES 1. British Association of Aesthetic Plastic Surgeons. “The Bust Boom Busts”. Press Release (2017). Retrieved from https://baaps.org.uk/media/press_releases/29/the_bust_boom_busts 2. Aesthetics journal, Non-surgical rhinoplasty on the rise <https://aestheticsjournal.com/news/nonsurgical-rhinoplasty-on-the-rise> 3. Sang Min Hyun, MD; Yong Ju Jang, MD. “Treatment Outcomes of Saddle Nose Correction”. JAMA Facial Plast Surg. 2013;15(4):280-286. 4. Berger CA; Freitas Rda S; Malafaia O; Pinto JS; Macedo Filho ED; Mocellin M; Fagundes MS. “Prospective study of the surgical techniques used in primary rhinoplasty on the caucasian nose and comparison of the preoperative and postoperative anthropometric nose measurements.” Int Arch Otorhinolaryngol. 2015; 19(1):34-41 5. Foda, Hossam MT. “challenging Problems in Rhinoplasty.” Facial Plastic Surgery 32, no. 04 (2016): 331-332. 6. Layliev J; Gupta V; Kaoutzanis C; Ganesh Kumar N; Winocour J; Grotting JC; Higdon KK. “Incidence and Preoperative Risk Factors for Major Complications in Aesthetic Rhinoplasty: Analysis of 4978 Patients.” Aesthet Surg J. 2017; 37(7):757-767 7. Rosenberger ES; Toriumi DM. “Controversies in Revision Rhinoplasty.” Facial Plast Surg Clin North Am. 2016; 24(3):337-45 8. Tzadik A; Gilbert SE; Sade J. “Complications of submucous resections of the nasal septum.” Arch Otorhinolaryngol. 1988; 245(2):74-6 9. Hyun SM, Jang YJ. “Treatment Outcomes of Saddle Nose Correction.” JAMA Facial Plast Surg. 2013;15(4):280–286. doi:10.1001/jamafacial.2013.84 10. Bae JS; Kim ES; Jang YJ. “Treatment outcomes of pediatric rhinoplasty: the Asan Medical Center experience.” Int J Pediatr Otorhinolaryngol. 2013; 77(10):1701-10 11. Yoo DB; Peng GL; Azizzadeh B; Nassif PS. “Microbiology and antibiotic prophylaxis in rhinoplasty: a review of 363 consecutive cases.” JAMA Facial Plast Surg. 2015; 17(1):23-7 12. Gubisch W; Dacho A. “Aesthetic rhinoplasty plus brow, eyelid and conchal surgery: pitfalls complications - prevention.” GMS Curr Top Otorhinolaryngol Head Neck Surg. 2013; 12:Doc07 13. Schuster, Bernd. “Injection rhinoplasty with hyaluronic acid and calcium hydroxyapatite: a retrospective survey investigating outcome and complication rates.” Facial Plastic Surgery 31, no. 03 (2015): 301-307. 14. Raina Zarb Adami. “Non-surgical rhinoplasty: key indications and considerations for nasal augmentation”. Journal of Aesthetic Nursing, 5, 5, (227), (2016). 15. Daniel RK. Rhinoplasty: septal saddle nose deformity and composite reconstruction. Plast Reconstr Surg. 2007;119(3):1029-1043. 16. Lin YC, Chen WC, Liao WC, Hsia TC, ‘Central retinal artery occlusion and brain infarctions after nasal filler injection’, QJM, 108(2015) pp.731-2. 17. Beck, Daniel, O.; Kenkel, Jeffrey, M. Plastic and Reconstructive Surgery: December 2014 - Volume 134 - Issue 6 - p 1356–1371

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fats were never meant to be our cellular fuel. Unfortunately, these foods have become the norm in our diet, with most supermarkets filled with convenience meals and processed snacks – foods that are more like ‘food substitutes’ than offering real, nourishing meals. Never before has it been so important to nourish the skin well with a healthy and varied diet. A study in 2007 published in the American Journal of Nutrition showed that accelerated ageing occurs in people with a high intake of bad fats and processed carbohydrates (such as white bread, biscuits, processed foods), while a diet rich in vitamin C was found to reduce skin ageing.3 As we age our bodies have a higher nutrient requirement. The body becomes less efficient at utilising key nutrients and therefore needs more nutrient-dense foods.4 There is also the major issue of gut health. Most people born post 1950s have been exposed to significant amounts of chemicals, processed foods, high sugar foods and numerous Dr Johanna Ward discusses why practitioners medicines, including antibiotic overuse – all of which affect gut health.5 Our digestive tracts contain need to incorporate nutrition advice into trillions of beneficial bacteria with bacterial cells, far their consultation and explores some of the outnumbering human cells in our bodies. These gut ingredients to look for in skin supplements bacteria keep our digestive tract aligned and are essential for good digestion and absorption of our The skin is the body’s largest organ and has a huge physiological foods.6 Maintaining a healthy balance between the good and the need for nutrition and nourishment. It exists in a state of constant bad bacteria in our gut has huge implications for skin health7 and renewal and is a complex and dynamic organ that responds to a healthy gut is needed for optimal absorption of nutrients. The nutrition and protection from both outside and within. great thing about choosing foods that are good for gut health High-quality topical skincare products can protect, nourish and fortify is that they are also the foods that are good for skin and overall the skin; however, they cannot substitute for what the blood brings long-term health. to the skin in terms of vitamins, minerals and essential fatty acids. Because of the skin’s dual needs, a new concept has emerged in What nutrients affect skin health? skincare – one that embraces the synergy that exists between topical The skin depends on the blood supply to bring nutrients and oxygen skincare and optimal cellular nutrition. This new way of thinking to the dermis. The body requires an incredible number of delicately about the skin means that more and more people are embracing balanced nutrients to provide fuel for its cells. The best diet will the idea of beautifying nutrition and are starting to understand the include a wide selection of fruit and vegetables, nuts and seeds, oily importance that good nutrition plays in skin health. It moves away fish and legumes and will be low in sugar, trans fats and additives. from one dimensional, topical application of products and embraces Mother nature has cleverly placed an abundance of vitamins, the idea of creating synergy between topical and internal skincare. minerals and powerful skin-protecting antioxidants in healthy foods so So, a two tiered, inside-out approach is fast becoming the go-to for that supplementation should only be minimally required if a good diet anyone wanting to maintain long-term skin health and, as aesthetic is followed. The problem is that most modern diets have deviated practitioners, it’s important that we can understand what nutrients away from this kind of raw, organic, healthy eating and contain far too affect the skin and how to consult patients effectively. many sugars, carbohydrates and bad fats, so it’s up to practitioners to ensure our patients are educated about this.

Ingredients for Supplementation

Why do we need to support the skin from within? We live in a modern age that exposes us to chemicals, radiation, pollution, toxins and pesticides on a daily basis. More than ever our cells need nutritional support to prevent oxidation, glycation and methylation – the three biochemical processes at the centre of cellular ageing.1 The skin is the last place to receive nutrition because the body will always preferentially feed the major organs such as the heart, brain, liver and kidneys.2 It makes sense, therefore, to tackle the skin from outside and within to maximise the skin’s cellular protection and support. In the last 50 years, the modern Western diet has totally changed, but we haven’t genetically evolved to keep up. Processed foods that are high in sugar and hydrogenated

Vitamins A healthy intake of all vitamins will have a beautifying, antiageing and positive impact on the skin. They all exist in a state of delicate interplay and even small deficiencies can cause skin dryness, fragility and impaired healing.8 Notably, important vitamins for skin health are vitamin C, vitamin A and vitamin E – these all have duality in the skin in that they act as the skin’s first line of defence through their antioxidant activity, and they also have their own individual roles.10-16 Literature has suggested that antioxidants work best in synergy both orally and topically so a good intake of a variety of fruit, vegetables, nuts and seeds will ensure plentiful natural antioxidants to help the skin remain healthy, supple and youthful.9

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Vitamin C Vitamin C is an important co-factor for collagen production and one of the skin’s most important and natural antioxidants. Deficiencies in vitamin C cause collagen impairment and skin fragility, as seen in scurvy. Humans cannot manufacture vitamin C so it must be taken in adequate amounts daily in the diet.10 Vitamin C is vitally important for the protein collagen. It is an essential cofactor for the proline and lysine hydroxylases that stabilise collagen and promote collagen gene expression.11 The dependence of the collagen hydroxylase enzymes on vitamin C has been demonstrated in countless clinical studies with fibroblast cells in vitro where vitamin C absence causes decreased total collagen synthesis and decreased cross-linking.12,13 A diet rich in vitamin C has been shown to prevent skin ageing and wrinkling.14,15 Vitamin A Vitamin A is a fat-soluble vitamin. Deficiency rapidly leads to dry, scaling skin with follicular thickening. Vitamin A deficiency is becoming more of a problem in low income countries with an estimated half of all countries reporting it as a public health issue.16 There are two types of vitamin A found in foods. Active vitamin A is retinol – it does not need to be converted by the body and can be used immediately. It can be found in animal proteins, liver and fish, and organic dairy. Beta-carotene is the inactive pre-vitamin A that requires good gut health, well-functioning bile and specific enzymes to convert it. The best way to ensure optimal vitamin A is to eat a wide selection of vitamin A-rich foods such as eggs, meat, liver, fish and colourful vegetables.16 Vitamin E Vitamin E is a powerful skin antioxidant and functions primarily to neutralise free radicals in the skin. Free radicals are unstable molecules that form as by-products of oxygen use in the body. If they remain unpaired they can damage a cell’s DNA and cause accelerated ageing. A diet rich in antioxidants and vitamin E and C will help reduce skin ageing caused by oxidation. Smart dietary choices will ensure optimal vitamin E and can be found in foods such as spinach, broccoli and nuts (especially pecans, almonds and walnuts) olive oil, sunflower seeds and numerous legumes.17

Studies have also shown that omega 3 healthy fats protect skin cells against sun-induced inflammation and help control how the body responds to UV rays mitigating sun damage

Minerals Magnesium Magnesium is the fourth most abundant mineral in the body and plays an important role in cellular detoxification metabolism. To age well, it is important to receive enough magnesium so that cells detoxify and revive.23 A toxic cell will age rapidly. Magnesium helps minimise damage from environmental pollution and heavy metals.24 Even glutathione, the body’s master antioxidant, relies on magnesium for its production. Scientists have discovered more than 3,750 magnesium binding sites on human proteins, so this reminds us of the importance of adequate magnesium intake for protein function, with collagen being the most important protein for skin health and vitality.25 Foods rich in magnesium include spinach, avocados, pumpkin and sunflower seeds.

Vitamin B Vitamin Bs work as a collective to provide many of the behind-thescene daily cellular functions. Particularly important for the skin are B3 (nicotinic acid) and B5 (pantothenic acid). Research has suggested that optimising B3 and B5 can have a beneficial impact on acne through reduction of sebum output and anti-inflammatory effect.18 B3 also has an impact on wrinkles, pigmentation and skin smoothness.19 It is therefore worth optimising in your diet with a good intake of B3 from tuna, turkey, liver, peanuts, mushrooms or green peas.

Zinc Zinc plays an important role in skin health. It is needed for protein synthesis, wound healing and is a vital antioxidant. It also helps break down substance P, transports vitamin A from the liver and helps in the metabolism of omega 3s. Even mild deficiencies in zinc can impair collagen production, fatty acid metabolism and wound healing.26 The World Health Organisation has estimated that 30% of the world’s population are now zinc deficient.27 Zinc rich foods include animal protein, oysters, egg, shellfish and nuts. Vegetarians and vegans are particularly prone to zinc deficiency and may benefit from zinc supplementation.28

Vitamin D Vitamin D is not just needed for strong muscles and bones. It has important immune function and deficiencies exacerbate eczema, psoriasis and acne.20 Research has suggested that optimising vitamin D can help these skin conditions and with 40-50% deficiency rates being reported in the UK this is an easily preventable vitamin deficiency.21 Between the months of October to early March in the UK we cannot make enough vitamin D from sun, so Public Health England recommends all ages supplement with vitamin D.22

Selenium Selenium is another essential mineral that works to slow the signs of skin ageing. Like vitamin E, it has a key role in neutralising free radicals and works to safeguard cell membranes protecting against inflammation, UV cell damage and pigmentation. It is found plentifully in Brazil nuts but also in seafood (shrimp, crab, salmon), vegetables, beef and poultry. The selenium content in vegetables, grains and animal products are dependent on the amount of selenium in the soil – which, in recent years, has depleted.

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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A good intake of a variety of fruit and vegetables will ensure plentiful natural antioxidants to help the skin remain healthy, supple and youthful Fatty acids and omega 3 Omega 3s are long chain fatty acids that have a powerful antiinflammatory effect. They have been shown to help protect cardiovascular and brain health (the brain is 60% fat) as well as having a profound effect on skin health. Deficiencies in essential fatty acids cause skin dryness (snowflake skin) because lipiddepleted cell membranes cannot maintain their water content.29 Supplementation of omega 3 in clinical trials has been shown to be helpful in the treatment of acne, eczema and psoriasis.30 Studies have also shown that omega 3 healthy fats protect skin cells against sun-induced inflammation and help control how the body responds to UV rays mitigating sun damage.31 The best food source of omega 3s are oily fish like salmon, mackerel and sardines. If using supplements, then one with a high eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) content works best as these are the most bioavailable. For vegans, flaxseeds are high in alpha-linolenic acid (ALA) and can be converted to EPA and DHA in the body. However, some people convert ALA weakly so then an algal oil supplement is ideal.32

You are what you eat For practitioners who are invested in promoting good skin health for their patients, it is a good approach to nourish it using not just good quality topical skincare, but also good levels of nutrition. What patients put into their mouths can have a huge and powerful impact on their skin’s health and the right foods can help to fight free radicals, reduce redness, reduce inflammation, reduce dryness and fight the ageing process. Encouraging patients to change their diet to incorporate healthy, skin-loving foods is one of the easiest ways to influence patient’s skin health and overall wellbeing. However, if patients cannot get enough nutrients in their daily diet then supplementation with highly bioavailable ingredients can be beneficial for promoting skin health and it is certainly better than depriving the body of key, vital cellular nutrients. This way, you will be able to treat them from the outside in.

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REFERENCES 1. Oxidative stress and ageing, MA Birch Machin et Al, Brit J Derm, 2016 2. Linus Pauling Institute ‘Skin Health: Micronutrient Information Centre’ <https://lpi.oregonstate.edu/ mic/health-disease/skin-health> 3. Cosgrove MC, Franco OH, ‘Dietary nutrient intakes in skin ageing appearance among middle aged American Women’, American journal of Clinical Nutrition, 2007 86: 1225-1231 4. Christina Boufis, ‘How Nutritional Needs Change as you Age’ Web MD, <https://www.webmd.com/ healthy-aging/features/nutritional-needs-change-as-you-age> 5. Ruth K. Dudek-Wicher, The influence of antibiotics and dietary components on gut microbiota, Prz Gastroenterol. 2018; 13(2): 85–92. 6. Alexandra R Vaughn, et al., ‘Skin-gut axis: The relationship between intestinal bacteria and skin health’, Sivamani World J Dermatol. Nov 2, 2017; 6(4): 52-58 7. Iman Salem, Amy Ramser, The Gut Microbiome as a Major Regulator of the Gut-Skin Axis, Front Microbiol. 2018; 9: 1459. 8. Juliet M Pullar, Anitra C. Carr, et al., The Roles of Vitamin C in Skin Health, Nutrients. 2017 Aug; 9(8): 866. 9. JJ Strain & Mulholland CW, Vitamin C and vitamin E — synergistic interactions in vivo? Free Radicals and Aging, pp 419-422. 10. Guy Drouin, et al., The Genetics of Vitamin C Loss in Vertebrates Curr Genomics 2011 Aug; 12(5): 371–378. 11. S. R. Pinnell Yale J, Regulation of collagen biosynthesis by ascorbic acid: a review. Biol Med. 1985 Nov-Dec; 58(6): 553–559 12. Davidson JM et al., ‘Ascorbate differentially regulates elastin and collagen biosynthesis in vascular smooth muscle cells and skin fibroblasts by pre translational mechanisms’ J Biol Chem 1997 272: 345-352 13. Phillips CL, Pinnell SR ‘Effects of ascorbic acid on proliferation and collagen synthesis in relation to the donor age of human dermal fibroblasts’, J Invest Derm 1994: 103:228-232. 14. Cosgrove MC, Franco OH. ‘Dietary nutrient intakes and skin-ageing appearance among middle aged American women, American Journal of Clinical Nutrition 2007: 86: 1225-1231. 15. Purba MB, Kouris-Blazos A et al., ‘Skin Wrinkling: Can food make a difference? J Am Coll Nutr 2001: 20:71-80. 16. Julia Bird et al, Risk of Deficiency in Multiple Concurrent Micronutrients in Children and Adults in the United States Nutrients. 2017 Jul; 9(7): 655. 17. Maret G. Traber and Jeffrey Atkinson, ‘Vitamin E, Antioxidant and Nothing More’, Radic Biol Med. 2007 Jul 1; 43(1): 4–15. 18. Michael Yang, Betsy Moclair and Jillian Capodice, Dermatology and Therapy ‘A randomised Double Blind Placebo Controlled Study of a nove; Pathothenic Acid Based Dietary Supplement in subjects with mild to moderate acne’ 19. Bissett DL, Oblong JE, Berge CA, Niacinamide: A B vitamin that improves aging facial skin appearance. Derma Surg 2005 Jul;31(7 Pt 2):860-5; discussion 865. 20. Amestejani M et al, J Drugs Dermatology ‘Vitamin D Supplementation in the Treatment of Atopic Dermatitis’ 2012: 11:3 (327-330). 21. Judy More ‘Prevention of vitamin D deficiency’ British Journal of Family Medicine, March, 2016. 22. NHS, How to get vitamin D from sunlight, 2018.<https://www.nhs.uk/live-well/healthy-body/how-toget-vitamin-d-from-sunlight/> 23. Killilea DW, Maier JA, A connection between magnesium deficiency and aging: new insights from cellular studies’ Mages Resc 2008 june 21(2): 77-82 24. Margaret E. Sears, Chelation: Harnessing and Enhancing Heavy Metal Detoxification—A Review Sientific World Journal 2013: 219840. 25. Damiano Piovesan, Giuseppe Profiti, et al., The human “magnesome”: detecting magnesium binding sites on human proteins BMC Bioinformatics 2012; 13(Suppl 14): S10. 26. Barry C Starcher et al., ‘Effect of Zinc Deficiency on Bone Collagenase and Collagen Turnover’The Journal of Nutrition, Volume 110, Issue 10, 1 October 1980, Pages 2095–2102 27. World Health Organisation, World Health Report, Chapter 4. <http://www.who.int/whr/2002/chapter4/ en/index3.html> 28. Gandia P, Bour D, A Bioavailability study comparing two oral formulations containing zinc (Zn bisglycinate vs. Zn gluconate), Int Journal Nutr Resources 2007:July 77:(4): 243-8. 29. Linus Pauling Institute, Essential Fatty Acids and Skin Health. <https://lpi.oregonstate.edu/mic/healthdisease/skin-health/essential-fatty-acids> 30. C Koche et Al ‘DHA Supplementation in Atopic Eczema: A randomised, double blind controlled trial’, British Journal of Dermatology, Volume 158, Issue 4, pg786-792 31. S Pilkington et al., ‘Randomised controlled trial of oral Omega 3 PUFA in solar simulated radiationinduced suppression of human cutaneous immune responses’, American Journal of Clinical Nutrition, 2013: 97 (3) 646. 32. Differentiation of ALA (plant sources) from DHA & EPA (marine sources), DHA/EPA Omega-3 Institute. <https://www.DHAomega3.org>

Disclosure: Dr Johanna Ward is the director and founder of nutrition and skincare brand ZENii. Dr Johanna Ward is a GP with a special interest in clinical dermatology and nutrition. She has worked in clinical dermatology and aesthetics for more than 10 years, having run a chain of skin and laser clinics. She is passionate about the power of preventative and nutritional medicine and lectures nationally and internationally on antiageing and nutrition. She is currently Women’s Health magazine’s resident doctor and is often asked to comment in the media on all things skin and nutrition related.

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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and discrimination, with intimate care causing the most concern. Misgendering and inappropriate questioning were found to be some of the key causes of dissatisfaction.3 This highlights how imperative it is that aesthetic practitioners are fully aware of all aspects of the transitioning process and are also completely committed to building a relationship of understanding and trust between them and their patient through the promotion of education, safety and clinical excellence. This allows the patient to be confident that they have been dealt with sensitively and that they are being cared for. The transitioning process is a complex one and transgender patients may face unique dermatologic requirements in addition to routine care. It is important for practitioners to recognise that every transitioning journey is unique to the individual involved and that there are very specific considerations that need to be made when treating these patients as opposed to other individuals. It is also important to recognise the emotional impact of a transitioning journey and that there is no uniform approach. No Aesthetic practitioner Dr Rekha Tailor gives assumptions about the patient should be made. an overview of the most popular treatment For some patients, the process is something that’s happened over a short period of time, but options for transgender patients for others it’s been a lengthy process that has The process of an individual changing their gender presentation taken years, possibly decades to come to the stage of the journey so that it aligns with their internal sense of gender identity is called that they are at when they are first introduced to you. Therefore, it’s ‘transitioning’. It is difficult to confirm how many individuals identify as incredibly important to make that first meeting between patient and transgender in the UK as there is currently no census that captures practitioner count as, whatever the circumstances, I have found that data regarding gender identity. However, The Gender Identity the patient usually feels quite vulnerable. This also gives you a good Research and Education Society (GIRES) estimates that about 1% of opportunity to discuss a treatment plan, as well as different needs and the British population are gender non-conforming to some degree.1 It considerations in detail, which are explored below. is generally accepted that the increase in visibility of the transgender population over recent years means that this number will invariably Management of hormone-related changes continue to rise – a statement that is certainly supported with the Hormone therapy tends to be the first step for most adult statistic that referrals to adult gender identity clinics across the UK transgender people who are in the process of transitioning. have increased dramatically over the past 10 years.2 Given this rise, it Masculinising hormones (testosterone) and feminising hormones is reasonable to assume that the number of transgender individuals (oestrogen) will usually need to be taken indefinitely and both have seeking aesthetic procedures specific to their individual transitioning notable effects on the skin and hair that can be treated effectively journey will also increase, and we as aesthetic practitioners need to within a credible aesthetic clinic. ensure we are well educated and equipped to deal with their needs. Hormone therapy in transgender women (male to female) will This article aims to address the specific considerations that aesthetic generally result in a partial reduction in quantity and density of body practitioners should take into account when treating transitioning and facial hair. However, it is unlikely that hair will be eliminated, and patients to ensure that both their dermatologic and emotional needs this is often an area that individuals feel they would like addressed. are met in order for them to make a successful physical and emotional The most common aesthetic hair removal processes are laser hair transition throughout the process. removal (LHR), intense pulse light (IPL) and electrolysis. At my clinic Health & Aesthetics, LHR is one of the most popular treatments we Initial consultation offer. Although results can vary between individuals, on average, It is a privilege to work in an industry that allows you the opportunity to individuals in my clinic see up to a 60-80% reduction in hair growth really make a difference to your patients at every single stage of their after six to eight treatments with maintenance required one to two treatment experience. In my experience working with transgender times a year. In addition to hair reduction, oestrogen from hormone patients, I have found that this is particularly true as their personal therapy rapidly reduces sebum production that can result in itching journeys can hold another layer of meaning. The initial consultation and dry skin.5,6 This requires intense hydration using skin stabilisers to process is important with any patient, but particularly so with one reduce inflammation and itch. who is transitioning. A report commissioned by the LGBT Foundation It is common for a transgender man (female to male) experiencing found that 80% of transgender people experience anxiety before masculinising hormone therapy to experience increased sebum accessing hospital treatment due to fears of insensitivity, misgendering production caused by the dramatic increase in testosterone. This

Treating Transgender Patients

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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effectively mimics a second puberty and can often lead to an array of skin conditions that include acne vulgaris, acne scarring and postinflammatory hyperpigmentation.6 In my clinic, suggested treatments for the successful management of each condition include, but are not limited to: • Laser treatment with contact cooling and vacuum technology to treat acne vulgaris safely and effectively • Hydrafacial (also known as hydradermabrasion) – a non-invasive, soothing and non-irritating treatment for acne that removes dead skin and impurities leaving the skin smooth and radiant • Laser skin rejuvenation – ideal for eliminating areas of hyperpigmentation • Ablative fractionated laser – a new generation of fractional skin resurfacing that can reduce the appearance of pigmentation and scarring • Topical skincare treatments designed to significantly improve skin health and appearance It is also likely that transgender men will experience male-pattern baldness (MPB) due to hormone therapy.6 Also known as androgenetic alopecia and genetic hair loss, MPB can be an unwanted and extremely difficult side effect of hormone therapy to cope with emotionally. At Health & Aesthetics, we advocate and offer a combination therapy that includes three to five sessions of platelet-rich plasma (PRP) in the scalp. Treatments are carried out every four to six weeks. PRP is component of the blood that contains special proteins, known as growth factors. These growth factors aim to stimulate the activity of the hair follicles and promotes new hair growth. This is combined with a course of tablets that contain marine proteins and vitamins to stimulate hair growth across the scalp.7 This is a completely drug-free treatment which can boost hair growth and volume, resulting in thicker, longer and fuller hair for both men and women.8

Management of surgery-associated changes Breast augmentation in transgender women or removal surgery for transgender men will often result in scarring which can be unsightly, restrict movement or can be painful and itchy. For some individuals, they can also be an unwanted visible reminder of their previous gender identity. The appearance of surgical scarring can usually be improved by using a combination of the aforementioned nonsurgical resurfacing technique using ablative fractionated lasers or an advanced fractionated CO2 laser treatment that works more effectively on heavier surgical scarring than traditional resurfacing methods, and topical treatments that contain ingredients that will actively encourage cell renewal and hydration to soften and smooth the scar area (such as retinols).9

Management of facial transformation An emerging role for aesthetic practitioners in the physical transformation of transgender patients relates to facial transformation. I find this is an area that transgender women, in particular, feel that they need to address in their transitioning journey. Traditionally, male and female faces differ in several ways. Broadly speaking, the female face typically has a flatter forehead, smaller nose, and more prominent cheekbones, plumper lips and a small chin, whilst the male face has a broad well-defined jaw, prominent chin and nose and wider, thinner lips.10 Cosmetic surgery to achieve the desired results can often be extremely invasive and carry huge expense which rules it out as a viable option for many patients. Taking this into consideration, many individuals opt for a more non-invasive approach

to feminise or masculinise the face in a subtler way. This can involve the use of botulinum toxin in the upper face to give the appearance of a flatter forehead and open eyes, or dermal fillers to give greater volume to areas such as the lips and cheeks. It is important for most transgender patients that their appearance looks appropriate for their new gender identity and it’s therefore essential that the individuality of the patient is respected and taken into consideration, as should be standard practice with all patients. It is important to take all the usual considerations into account, to be mindful of their desired outcome and what their existing features are, to offer realistic expectations and to give patients a cooling-off period.

Aftercare As with the initial consultation, aftercare is paramount in ensuring that the patient feels they have been well-looked after and can discuss any concerns or anxieties they have about their treatment. Essentially the aftercare process would be exactly the same as for a non-transgender patient, but with added emphasis on review to ensure that the patient is happy with the outcome whilst they are getting used to their new identity and appearance.

A growing practice I believe the treatment of transgender patients is a growing area in medical aesthetics and practitioners should ensure that they educate themselves and their practice teams with the associated complexities of the transitioning process so that they can offer transgender patients a wholly positive and professional experience. Ensuring that you are well read about the subject, attending educational events and shadowing experienced colleagues will all contribute to providing the best possible experience and outcome for your patients. The unique needs of individuals should always be taken into account and a bespoke treatment plan discussed fully with the patient to ensure that any anxiety associated with the transitioning process is kept to a minimum and not exacerbated by their clinical experience. Dr Rekha Tailor is the founder and medical director of Health & Aesthetics clinic in Elstead, Surrey, which won The iS Clinical Award for Best Clinic South England at the Aesthetics Awards 2018. She trained at Manchester Medical School and is a fully accredited general practitioner and aesthetic practitioner. She is a full member of the British College of Aesthetic Medicine and the Royal Collage of General Practitioners. REFERENCES 1. Gender Identity Research and Education Society, Monitoring Gender Nonconformity – A Quick Guide, (United Kingdom: www.gires.org 2015) <https://www.gires.org.uk/wp-content/uploads/2014/09/ Monitoring-Gender-Nonconformity.pdf> 2. Kate Lyons, Gender identity clinic services under strain as referral rates soar, (United Kingdom: www. theguardian.com 2016) <https://www.theguardian.com/society/2016/jul/10/transgender-clinic-waitingtimes-patient-numbers-soar-gender-identity-services> 3. LGTB Foundation, Transforming Outcomes A review of the needs and assets of the trans community., (www.edf.org.uk, 2017), <http://www.edf.org.uk/wp-content/uploads/2017/09/Transforming-Outcomes. pdf> p.11. 4. Asscheman H, Gooren LJ, ‘Hormone Treatment in Transsexuals’, 1992, Journal of Psychology & Human Sexuality, 39-54. 5. Giltay EJ, Gooren LJ (August 2000). “Effects of sex steroid deprivation/administration on hair growth and skin sebum production in transsexual males and females”. Journal of Clinical Endocrinology and Metabolism. 85 (8): 2913–21 6. Kopera D, Impact of Testosterone on Hair and Skin. Endocrinol Metab Syndr, 2015, 4:187. <https:// www.omicsonline.org/open-access/impact-of-testosterone-on-hair-and-skin-2161-1017-1000187. php?aid=59770> 7. Viviscal Hair Growth Supplement, 2018. <https://www.viviscal.co.uk/clinical-trials-cj> 8. Ablon Glynis, A Double-blind, Placebo-controlled Study Evaluating the Efficacy of an Oral Supplement in Women with Self-perceived Thinning Hair, J Clin Aesthet Dermatol. 2012 Nov; 5(11): 28–34. 9. MH Gold, et al., Update on Fractional Laser Technology, J Clin Aesthet Dermatol. 2010 Jan; 3(1): 42–50. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921736/> 10. V Bruce, M Burtin et al., Sex Discrimination: How Do We Tell the Difference between Male and Female Faces?, 1993, Department of Psychology, University of Nottingham. <https://www.ncbi.nlm.nih.gov/ pubmed/8474840>

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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A summary of the latest clinical studies Title: Induction of Fat Apoptosis by a Non-Thermal Device: Mechanism of Action of Non-Invasive High-Intensity Electromagnetic Technology in a Porcine Model Authors: Weiss R A, Bernardy J Published: Lasers in Surgery and Medicine, December 2018 Keywords: Apoptosis, HIFEM, magnetic technology Abstract: This animal model study investigates the use of a noninvasive high-intensity magnetic field device to induce apoptosis in fat cells. Yorkshire pigs (N¼2) received one treatment (30 minutes) in the abdominal area using a High-Intensity Focused Electromagnetic (HIFEM) device. Punch biopsy samples of fat tissue and blood samples were collected at the baseline, 1 and 8 hours after the treatment. Biopsy samples were sectioned and evaluated for the levels of an apoptotic index (AI) by the TUNEL method. Statistical significance was examined using the rANOVA and Tukey’s test (a 5%). Biopsy samples were also assessed for molecular biomarkers. Blood samples were evaluated to determine changes related to fat and muscle metabolism. Free fatty acids (FFA), triacylglycerol (TG), glycerol and glucose (Glu) were used as the main biomarkers of fat metabolism. Creatinine, creatinine kinase (CK), lactate dehydrogenase (LDH) and interleukin 6 (IL6) served as the main biomarkers to evaluate muscle metabolism. In treated pigs, a statistically significant increase in the apoptotic index (AI) (P¼1.17E-4) was observed. A significant difference was found between AI at baseline (AI¼18.75%) and 8-hours post-treatment (AI¼35.95%). Serum levels of fat and muscle metabolism indicated trends (FFA _0.32 mmol _ l _1, _28.1%; TG _0.24mmol _ l _1, _51.8%; Glycerol _5.68 mg_ l _1, _54.8%; CK þ67.58 mkat _ l _1, þ227.8%; LDH þ4.9mkat _ l _1,þ35.4%) suggesting that both adipose and muscle tissue were affected by HIFEM treatment. No adverse events were noted to skin and surrounding tissue. Application of a high-intensity electromagnetic field in a porcine model results in adipocyte apoptosis. The analysis of serum levels suggests that HIFEM treatment influences fat and muscle metabolism. Title: Hyaluronic Acid Fillers for Correcting Midface Volume Deficit in Barraquer‐Simons Syndrome Authors: Razmi M, Vinay K et al. Published: Journal of Cosmetic Dermatology, January 2019 Keywords: Barraquer‐Simons syndrome, hyaluronic acid, lipodystrophy Abstract: Barraquer‐Simons syndrome (BSS) or acquired partial lipodystrophy is a disorder of loss of subcutaneous fat from the upper part of the body. The resulting cosmetic disfigurement causes significant psychological distress in the affected individuals. Fillers, autologous fat transplant or cosmetic surgeries can be used to correct the volume deficit. The authors report a case of a young woman, who presented with gradual loss of subcutaneous fat from the face, upper limbs, and trunk. On evaluation, she had low complement C3 levels, but there were no features to suggest any metabolic complication. She was diagnosed with BSS. Her volume deficit in the midface area was managed with hyaluronic acid (HA) filler. The treatment has resulted in the correction of her facial volume loss immediately following the procedure with a maintained effect at follow‐up visits.

She experienced no major adverse events. Hyaluronic acid filler is safe and effective for the management of volume loss in BSS. Title: Botulinum Toxin in the Management of Myofascial Pain Associated with Temporomandibular Dysfunction Authors: Patil S, Nagaraj M, et al. Published: Journal of Oral Pathology and Medicine, January 2019 Keywords: Temporomandibular disorder, botulinum toxin Abstract: Critical evidence on the therapeutic efficacy of botulinum toxins (BTX) is still lacking for most pain conditions. The aim of this review was to evaluate the therapeutic efficacy of BTX in the management of temporomandibular myofascial pain. Electronic databases PubMed, EMBASE, Scopus, Web of Science, and grey literature were searched for randomized clinical trials until February 2018 to answer a focused question “What is the effectiveness of botulinum toxin in the management of temporomandibular myofascial pain?” Two independent reviewers performed the study selection according to eligibility criteria. A total of seven studies that met the eligibility criteria were included. Two studies showed a significant improvement in temporomandibular myofascial pain, one study showed equal efficacy of BTX in comparison to facial manipulation, while the remaining studies did not report any significant difference between BTX and control group. Due to heterogeneity in the methodology and outcome assessment, a meta‐analysis and recalculation of risk could not be performed. Based on our findings, the therapeutic efficacy of BTX was unclear. Randomized controlled trials with better methodological criteria need to be carried out to evaluate the real effectiveness of BTX. Title: Tattoos and Skin Barrier function: Measurements of TEWL, Stratum Corneum Conductance and Capacitance, pH, and Filaggrin Authors: Serup J, Kezic S et al. Published: Skin Research & Technology, January 2019 Keywords: Capacitance, conductance, tattoo Abstract: The aim of this study was to investigate the long‐term effect on the skin barrier function in normal tattoos and examples of tattoos with chronic inflammatory complication. Participants were recruited from the “Tattoo clinic” of the Dermatological Department on Bispebjerg Hospital in Denmark, where patients with complicated tattoo reactions are treated. Transepidermal water loss (TEWL), conductance, capacitance, and pH were measured in tattooed skin with regional control measurements in normal non‐tattooed skin. Natural moisturizing factor (NMF) was measured in collected tape strips. Twenty six individuals with 28 tattoos were included, that is, 23 normal tattoos without any pathologic reaction and 5 tattoos with chronic inflammatory complications. No significant differences were found in tattooed versus non‐tattooed skin with respect to TEWL (median values 6.6 vs 7.2 g/m2/h), conductance (76 vs 78 a.u.), pH (5.94 vs 5.79), and NMF (0.58 vs 0.59 mmol/g protein). Capacitance (64 vs 57 a.u.) was higher in tattooed skin compared to non‐tattooed skin (P = 0.006). Similar results were found in tattoos with inflammatory reactions. Overall, skin tattoos do not affect the long‐term skin barrier function markedly. The skin capacitance was, however, affected in tattooed skin areas compared to non‐tattooed skin areas.

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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Causes of conflict

Managing Staff Conflict Staffing specialist Victoria Vilas offers tips on how to identify and manage conflict in the aesthetic workplace As full-time workers, we spend more of our waking hours alongside colleagues than we do enjoying the company of family and friends. We don’t get to choose our colleagues, we don’t all share the same views or personality traits, and a busy working week can lead us to feel more stressed than usual. It would take the patience of a saint to get through working life without experiencing some sort of disagreement with a colleague or manager. A team of employees in an aesthetic clinic will have to interact with each other on a regular basis to keep the clinic running like clockwork, and to ensure that patients have a seamless treatment journey. If team members fall out with each other, the bad feelings could negatively affect team morale and lead to a decline in performance. You may even end up losing key employees who feel uneasy in the tense environment or see an increase in sick leave caused by stress.1 According to a survey conducted by the Chartered Institute of Personnel and Development in 2015, stress is the most commonly reported consequence of conflict at work, followed by a drop in motivation or commitment, and a drop in productivity.1 The decrease in productivity or reduction in quality of work could seriously harm your clinic business, so it is vital that conflict in the workplace is dealt with objectively and swiftly. Though we can’t be prepared for every bad mood or dispute that occurs, as a manager of an aesthetic clinic team, it’s wise to have some knowledge on how to identify and manage conflict.

Symptoms of conflict Signs of conflict won’t always be obvious or follow the same pattern. For every employee who wears their heart on their sleeve and bursts into tears at the first sign of confrontation, there will be one who buries their emotions and tells no one of their anxiety. Some animosity doesn’t play out in a loud verbal argument, but simply in passing looks or the occasional comment when management aren’t within earshot. Your own emotional intelligence may help you spot a change in mood in your team, but an objective approach can be useful for managers when trying to identify staff issues. Are any of your team members acting out of character? Has anything changed in your clinic’s day to day interactions between staff? Have staff members been taking more sick leave than usual? Has the level of patient satisfaction dropped in feedback received recently? All could be signs that there is a problem in the team. If you believe that a team member’s unhappiness could be related to a grievance with a colleague or a situation at work, or you have an employee behaving in a negative way that could affect their team members, don’t overlook the issue.

The negative behaviour could be between two peers, or between a worker and their manager. Before jumping in to mediate, try to identify and understand the nature of the conflict. Could it be bullying or harassment? Issues relating to appraisals, pay or team organisation? Is it simply a clash of personalities? Also, try and work out whether the issue is work-related or personal, as some employees may spend time with each other outside of the workplace. As a team manager, you can help mediate and look at how to solve work-related issues, but employees should also act with professionalism and not bring their personal disputes to work. It may even be that you are one of the parties involved in the conflict. I would advise that you keep an open mind and consider whether you could be at fault, take the time to speak and listen to each other, and seek an amicable resolution. To get to the root of the problem, you may have to spend a little more time observing your team, and speak directly to those involved. Try and stay objective when speaking to your staff members, and do not pass comment or judgment until you have collected feedback and considered your approach. Use language that demonstrates your objectivity to avoid sounding accusatory. For example, instead of saying “why did you insult your colleague?”, try saying “can you please tell me, in your own words, what you said to your colleague, and why?” Instead of saying “why are you angry”, try saying “you seem to be acting out of character, can you please tell me what may have caused this?” Ask for accounts of actions and events, with details that can help you put together a clearer picture. For example, if a team member claims that “my colleague is horrible to me”, ask them for details of what has been said or done, when it happened and the frequency of these actions. Ask if they have responded, too. Be aware that sometimes those who shout the loudest are not necessarily the victims, and don’t assume that employees with supervisory responsibilities will always act in a manner fitting of their status. Managers can also cause issues when they communicate poorly with their team or offer their personal opinion on the situation – you should remain objective at all times.

Dealing with conflict There is no fail-safe method of managing conflict that can be applied to the many situations that could occur, but there are some useful tips and suggested strategies

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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Are you an employee involved in a dispute at work? 1. Acknowledge the issue and do something about it. Either speak to your colleague yourself or ask a manager to help adjudicate. 2. Don’t gossip or be negative about your colleague to other team members. If you’ve fallen out with a co-worker, it’s not fair to involve others, or make them take sides. 3. Don’t put up barriers and refuse to listen to the other side to the argument. Listen carefully to your manager if they are overseeing the mediation process and take heed of their advice. 4. Don’t let your emotions get the better of you. If you are angry or upset with a colleague, try and take some time to cool down and think of a rational approach before confronting them. 5. Be positive and open-minded about mediation. The mediation process may not be fun, but it will be much easier to find a resolution if all parties involved are willing to cooperate and communicate in a reasonable manner.

that are offered by workplace advisory organisations such as Advisory, Conciliation and Arbitration Service (Acas)2 and the Chartered Institute of Personnel and Development (CIPD).3 An informal chat may be a good place to start. Not every grumpy face is caused by a disagreement with a colleague, but if you notice unusual behaviour, or see a team member looking unhappy, it may be worth a quick check-in with them. It could be that there is no major issue to worry about, and perhaps an employee simply doesn’t feel right due to sleeping poorly, for example. It could also be a good way to catch staff conflict in its early stages, before the consequences ripple out to other team members. As part of an informal mediation process, you could encourage your staff to speak to each other, and work out a solution themselves, so you do not have to intervene and they can avoid a formal investigation. Sometimes the ‘sort it out yourselves’ approach may not be sufficient, though, especially if you have a headstrong employee who refuses to communicate with their colleague rationally. In more complex cases, you may have to take the lead, and follow a more structured mediation process. You may need to speak to your staff individually to get to the bottom of the matter, as some shy or anxious people may not want to speak their truth in front of another stronger, louder character. Here are my top tips for your mediation process: Be swift: Don’t leave the issue hanging around too long. You may have a busy clinic to run, but the quicker you deal with a dispute, the sooner you can resume normal service. Bad feelings left to linger could spread and

affect your entire team. Prioritise conflict resolution and make time for meetings. Be objective: Listen to both sides, focus on events and actions, and be objective when assessing the situation. Focus on the problem, not the people. Be clear: Define what is acceptable and unacceptable behaviour in the workplace and include your statement on this in your company handbook. Ensure that all new starters receive a copy of the handbook during their induction. Make clear the consequences if company policies are not followed, or company handbook rules are broken. Explain why it is important for you to resolve a conflict, for the benefit of the entire team. Be fair: Don’t punish a team member before you have sufficient evidence to know they have been at fault. You also have the same responsibility to follow company policies, so follow your own handbook when mediating or making a decision on disciplinary proceedings. Make a plan: Sit down with your employees and get agreement from both sides on how they will act towards each other going forward. Put this down in writing and get your employees to sign and date the agreement, so there is no future dispute over what was said or agreed.

If things don’t work out If a dispute resurfaces, you may have to implement disciplinary proceedings. Again, the process should be included in your company handbook, so employees are aware of what may happen if they don’t comply. Remember that actions that fit the description of ‘gross misconduct’4 and should be considered cases for immediate dismissal. Gross misconduct generally constitutes inappropriate behaviour or

actions considered serious enough to warrant dismissal. Each clinic owner may define what they consider to qualify as gross misconduct, but it would usually include verbal or physical abuse, bullying, unlawful discrimination, and serious insubordination.

Long-term strategies Effective management is of utmost importance when conflict arises. If you handle the situation badly, your team may not respect you as a leader. It’s worth considering management training courses, as it may be hard to put aside time to study management approaches while you are in clinic with patients to look after. Training courses can give managers time out of the workplace to focus on honing their skills, or to learn new and useful tips for looking after the team. To have a productive team and successful clinic, you will need to establish a company culture where team members feel happy and supported, and an effective management team who deal with issues fairly and effectively. As a clinic manager, you should also make time to check in regularly with all team members. Try and stay upbeat and look to the positives, even when you have to deliver some lessthan-positive feedback. Perhaps look at setting aside some time for a team outing, including team-building activities. If your team get to have fun with each other away from the stresses of their workplace, they may get on better at work, too. Victoria Vilas is the operations and marketing manager at the recruitment consultancy ARC Aesthetic Professionals. A manager of teams and projects in the health and wellness content sectors for over a decade, Victoria has spent recent years focusing on the issues of staffing and practice management in the aesthetic medicine industry. REFERENCES 1. Chartered Institute of Personnel and Development, Getting under the skin of workplace conflict: Tracing the experiences of employees (London: CIPD, 2015) <https://www.cipd.co.uk/ Images/getting-under-skin-workplace-conflict_2015-tracingexperiences-employees_tcm18-10800.pdf> (p.17). 2. Acas, Managing conflict at work (London: Acas, 2014) <http:// www.acas.org.uk/media/pdf/j/o/Managing-conflict-at-workadvisory-booklet.pdf> 3. Chartered Institute of Personnel and Development, Dispute Resolution (London: CIPD 2019) <https://www.cipd.co.uk/ knowledge/fundamentals/relations/disputes> 4. Acas, Discipline and grievances at work (London: Acas, 2017) <http://www.acas.org.uk/media/pdf/9/g/Discipline-andgrievances-Acas-guide.pdf> (p.32).

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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Changing Website Content for SEO Digital marketing consultant Adam Hampson and marketing content executive Lottie Staples explain how periodically changing and rewriting website content positively benefits your SEO Competing in an already competitive marketplace is not always straightforward, and appeasing a search engine’s constant algorithm updates can mean rethinking your digital marketing strategy. Because search engine giants like Google set the play by addressing how and why they’re going to rank websites in their search results, it’s very important that we cater our content to what they’re asking of us. Since 2011, Google has continued to update its algorithms to favour what it deems to be ‘quality content’, which is content that resonates most with the person doing the searching and is not reliant on keywords.1 In this article, we are going to explain how you can change your website content so that you may be featured higher in the search engine results, encouraging increased clicks and enquiries.

How changing your content benefits your SEO Google has defined what it deems to be ‘quality content’ as pages made for human users, not for search engines, with relevant information to the search query rather than insider tricks into improving search engine ranks.3 What this essentially means is that Google wants your website to provide

answers, knowledge, and guidance on your unique selling points to the many people that are scouring the internet for such. This is ‘quality content’. As a result, your website should be indulging your users in relevant information to do with treatments, services, products and devices. Google is clever and links synonyms together – if you search for ‘dermal filler’, for example, it will also show you results that use the phrases ‘hyaluronic acid’, ‘dermal filler’, and even ‘biodegradable’. It recognises the relationship between a certain keyword and its other related phrases, so you don’t need to fill your content with the phrase ‘dermal filler’ and compromise your communication to index for this term. The way we search has changed dramatically, so naturally search engines

are reconvening and adapting to this and Google’s recent update changed the way it interprets search queries.4 Instead of searching phrases or propositions like ‘dermal filler safety’, which was our previous relationship to searching, we increasingly search with questions like ‘are dermal fillers safe?’. Therefore, the websites that answer this question are shown in the search results. These colloquial questions are an increasingly growing aspect of searching. This could be because of the growth of voice search and personal assistants like Siri that search for answers on our behalf. Quality content is aimed at making sure your clinic is catering and valuable to human readers, not search engines. Your website should be figuratively (and sometimes literally) aiming to answer your traffic’s questions. By customising your website, blog posts, and pages to the patients or clients you’re trying to attract, search engines will invariably begin to note the value in your site. Writing content that is human-first improves your website’s usability, meaning it is simple to navigate and divulges the right information without deception. Because Google is always striving to provide a great user experience, your clinic needs to be too! Quality content might seem subjective and therefore ambiguous, but it isn’t as difficult to cater to as it may seem. For example, a regularly maintained blog with relevant posts form new and quality content, both of which Google and search engines value greatly, will get you ahead of those who are not ticking these boxes. Put yourself in your patients’ shoes and consider what concerns, questions, or uncertainties they may have. Consider the most common questions you’re asked as a practitioner – does it hurt? Are there side effects? Is it safe? Where does this treat? These are all questions you can answer in your written website content to spoon-feed Google the answers it needs.

How to update and add to your current content Updating your current content to boost your SEO begins predominantly with identifying

What is SEO? Search engine optimisation (SEO) involves gaining new and constant web traffic through appearing near the top of search engine results. SEO involves many different tasks to help increase enquiries and conversions through your website. Organic SEO (i.e. unpaid advertising) needs to be constantly worked at and invested in so to produce a return on investment. SEO is competitive, but when implemented successfully it can bring impressive returns.2

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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what you’re already doing well and what could do with some improvement. For example, a cluttered or confusing home page is difficult to navigate for users, leading to them potentially spend less time on your website and increasing your bounce rate, which is the percentage of website visitors who leave the site after viewing only one page.5 Search engines are very receptive to these kinds of behaviours and will penalise your website in the form of not ranking it in their search results. Strategic, clear, and effective design is always the most visually pleasing and the easiest to navigate.6 Redesigning or reconfiguring certain problematic pages will positively impact your SEO efforts because you’re making your site more engaging and accessible to your traffic and, by extension, search engines. Updating or rewriting your current content is always an easy step to take in boosting your organic SEO. Frequently asked questions regarding that page’s treatment and rewriting the main body text is a page update that keeps this information fresh and accessible, which search engines recognise as a step in the right direction of quality content. Consider the questions you commonly encounter at consultations and answer them on your page – does this hurt? How long will my results last? Will it look natural? Recognisably rewriting a page or adding an extra section or two shows search engines that you are actively trying to engage with and answer the questions of your users. Adding new pages Adding new content also satisfies search engines’ needs for well-maintained and semi-routinely updated websites. When seeking to add new and relevant pages, splitting one ‘umbrella’ page into two more specific pages is something we personally have found to be effective. For example, botulinum toxin (or anti-wrinkle treatments as they should be called in marketing) and hyperhidrosis attract two different types of patients. While they both use the same product, separating them into two different pages positively impacts your SEO because you’re doubling the number of treatment-specific keywords and indicators, while also providing unique information on each, rather than lumping them together onto one toxin page. Splitting these kinds of treatments or services into two pages where relevant, provides information and answers to two different searches, therefore benefitting your SEO, while marginally widening the traffic you relate to.

Aesthetics aestheticsjournal.com Provide information on separate treatments on dedicated pages and watch specific enquiries increase. Updating your blog A regularly maintained blog boosts your SEO, but what is also important is fresh content and quality content. Your traffic’s relationship to searching has changed to become more question-centred, as aforementioned, and a blog post is a great place to house the answers to these questions without changing your main treatment pages too much beyond their function. Provide the necessary information for a sale or conversion on your treatment or service pages and go into more colloquial detail in your blog posts. Pages are informational and should aim to convert, whereas blog posts should aim to communicate and soften the edges of the information a little more. A page may list what a certain treatment achieves for your skin, for example, and a blog post on the same treatment may go into more detail about the how, why, and aftercare of the treatment process. Adding new blog posts complete with text formatting, images, and easy readability keeps a reader’s interest and therefore the interest of a search engine. Even just one well-written blog post per month is a good SEO kick-start. There is no real number on how many blog posts you can provide, but adding too many may lead to accidental repetition, which Google penalises as duplicate content.7 Finding a balance between fresh subject matters and frequency is something unique to your clinic, but also needs to be given some strategic content thought.

What not to do Google has referenced in its Quality Guidelines that you should ‘avoid tricks intended to improve search engine rankings’,8 meaning that your content needs to be true to what you’re optimising. Using certain popular keywords purely for their reputation of good click-throughs without following up with information pertaining to them is now punishable in the court of search engines. Clinics have previously used terms such as ‘lip fillers’, because they’re popular, in their keyword strategy and meta data without actually delivering any information on lip fillers on most of their pages. This is a good example of what Google will be cracking down on, because if the page you’re trying to boost by including a popular term in the meta data doesn’t relate to this term, Google will

actually rank you lower than those adhering to their content guidelines. It’s no longer wholly acceptable to just use industry buzz words and reap the rewards,9 meaning you can’t boost a lesser-searched-for treatment by bolstering your content with more popular but irrelevant treatment keywords. Search engines are placing their value in relevancy, information, and honesty to deliver the best user experience to their searchers, which is what your clinic should be trying to emulate.

Conclusion Changing and updating your website content, whether you are redesigning your pages or rewriting them, will benefit your SEO efforts greatly. Ensuring your website caters to the people behind the search queries, is easy to navigate, and presents informative content, forces search engines into recognising you as a provider of quality content. With careful maintenance, you could climb the search engine ranks and be rewarded with more enquiries, conversions, and appointments from curious new patients and clients. Adam Hampson is the founder and director of Cosmetic Digital, a web design and digital marketing agency in Nottingham that works with clients in the cosmetic medical sector. He has recently launched 13 Digital Training and offers digital marketing training courses for dentists, doctors and nurses of all abilities. Lottie Staples is a content executive and copywriter at Cosmetic Digital, specialising in writing engaging content for websites, blogs, and marketing materials. Lottie has worked both as in-house marketing support for aesthetic clinics and within a specialist digital marketing agency. REFERENCES 1. Google Support, ‘How Search works’, <https://www.google.com/ search/howsearchworks/> 2. Eric Enge, Stephen Spencer, Jessie Stricchiola, The Art of SEO: Mastering Search Engine Optimization, 3rd edition, 2015, O’Reilly Media. 3. Google Support, Webmaster Guidelines, <https://support. google.com/webmasters/answer/35769?hl=en#3> 4. Crazy Egg, How Search Is Changing: 4 Ways To Stay Ahead in SEO, <https://www.crazyegg.com/blog/changes-in-seo/> 5. Tricky Enough, 7 Web Design Mistakes That Can Cause A High Bounce Rate, <https://www.trickyenough.com/web-designmistakes/> 6. Crazy Egg, 7 Reasons Your Bounce Rate Is High, <https://www. crazyegg.com/blog/reasons-bounce-rate-is-high/> 7. Google Support, Duplicate content, <https://support.google. com/webmasters/answer/66359?hl=en> 8. Google Support, Webmaster Guidelines, <https://support. google.com/webmasters/answer/35769?hl=en#3> 9. Google Support, Irrelevant keywords, <https://support.google. com/webmasters/answer/66358?hl=en>

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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VAT in Aesthetic Practice Chartered accountant Jonathan Bardolph explores common pitfalls surrounding VAT in aesthetics and explains the new regulations for making tax digital There is a fair amount of confusion within aesthetics when it comes to VAT. Often, I find clinic owners and aesthetic practice managers wondering whether or not they need to register and, if so, how does the practice account for VAT? This article will be looking at resolving common questions from aesthetic practitioners, including introducing the important Making Tax Digital changes, which come into force on April 1 this year.

When you need to register for VAT The current VAT registration threshold for businesses are those that have a VATable income of more than £85,000 (2018-19).1 This means that if your VATable turnover (income that is classified as VATable, explained below) exceeds this threshold over a period of 12 months, you need to register for VAT. Please note that the threshold is not calculated with reference to either your accounting period or profit; these are common misconceptions. If the business’s turnover exceeds the threshold over any 12-month period, there would be a requirement to register. In aesthetic practices, income will likely fall into two categories: cosmetic treatments (VATable) and medical treatments (exempt). As the VAT threshold is based on ‘VATable turnover’, exempt income does not form part of the turnover test. So, for example, you could have a situation where your practice is turning over a total of £100,000 per year and you would not need to register for VAT on the basis that at least £15,000 of income is exempt.2

Is your treatment medical or cosmetic? We need to review whether a treatment is either cosmetic in nature or treating a medical condition so we can determine which category the treatment would fall into for VAT purposes. HM Revenue and Customs (HMRC) has released guidance that discusses how to qualify for the medical exemption, which is found in VAT Notice 701/57 (Health Professionals and Pharmaceutical Products).2 Section 2.3 reads: ‘If you’re a health professional as detailed in paragraph 2.1, your services are exempt when both of the following conditions are met: 1. The services are within the profession in which you’re registered to practice. 2. The primary purpose of the services is the protection, maintenance or restoration of the health of the person concerned. The meaning of ‘health professional’ (as explained in section 2.1 of HMRC’s guidance) refers to individuals enrolled or registered on the appropriate statutory register (and includes, but is not limited to: nurses, doctors, dentists, dental hygienists, pharmacists, paramedics).2 In order to meet the requirements of the medical exemption, both the conditions must be met. Unfortunately, HMRC does not provide more detail as to what type of treatments would be viewed as ‘protecting, maintaining or restoring’ the health of a patient. Also, there are currently no decisions from any VAT tribunal in the UK regarding aesthetic medicine and their

internal guidance refers to published cases which are not in the aesthetic field. If HMRC were to launch a VAT enquiry into your business sufficient records and evidence must be maintained as to what the underlying condition of the patient was, why the treatment plan was prescribed or decided upon and the treatment effect. I have come across some aesthetic practitioners who solely rely on psychological reasons (such as a patient’s low self-esteem) to apply the medical exemption. Accepted evidence would be normally be GP referrals, however, in practice the diagnosis is often done by the practitioner themselves. Unless sufficient evidence is retained (which is quite a loose term as HMRC do not specifically state what evidence is needed) HMRC may deny the medical exemption on these treatments and so these would be VATable at the standard rate of 20%. Accounting for VAT There are a number of different ways of accounting for VAT depending on the nature of your aesthetic practice. It is likely that most aesthetic practices will have a mixture of both exempt and VATable income. For the reasons mentioned above, where the VATable supplies (income) exceed the VAT registration threshold the practitioner must register for VAT.3 The practice would then be ‘partially exempt’. This means that some of the income would be subject to VAT and some would not.4 A VAT return is broadly calculated by deducting the VAT on expenses from the VAT on the income in a particular quarter; the net amount is then paid to HMRC. For example, the VAT on your income may be £20,000 for a quater and your VAT on your expenses to generate this income may be £2,000 for the quater. This would mean £18,000 would be payable to HMRC one month following the quater end. Under partial exemption rules you cannot claim VAT on every expense of the business. There are various rules when following this way of VAT accounting, but in essence you cannot claim VAT on expenses directly relating to exempt income. For example, if a particular treatment is medical this would be exempt, so the VAT on the expenses directly involved in providing this treatment cannot be claimed. It is possible that a particular practice may provide wholly cosmetic treatments. In this case, if the practice was VAT registered, there is the possibility of using the ‘flat rate scheme’.5 This is a scheme which is administratively easier to account for in terms of VAT. Under this scheme, you cannot claim VAT on your expenses, but

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


@aestheticsgroup you pay a reduced amount of VAT to HMRC based on the income in the quarter. Because of the simplistic nature of the flat rate scheme, VAT would be paid on all income using this method. I believe it is helpful to seek your accountant’s advice as to whether you would benefit from using the scheme. The flat rate percentage is determined by reference to HMRC’s list of trade sectors. Each trade has its own flat rate percentage. For aesthetic treatments (considered cosmetic), the closest description is likely to be ‘Hairdressing or other beauty treatment services’ (currently at 13%).6 You calculate the VAT you pay by multiplying your VAT flat rate by your ‘VAT inclusive turnover’. So, the business would add VAT (currently at 20%) but pay 13% of the VAT inclusive income. Please note that HMRC will not choose the relevant percentage, this is self-assessed by the practitioner, but it would be beneficial to check with your accountant before proceeding.6 There would be no way of claiming VAT on expenses using this method (with the exception of some capital expenditure amounting to £2,000, subject to the scheme restrictions which can be viewed online).6,7 For practitioners who feel they cannot add 20% VAT to their prices, they would pay the resulting VAT to HMRC out of their profit. This can be shown in the below example: • You bill a customer for £1,000, adding VAT at 20% to make £1,200 in total. You’re an aesthetic practitioner doing a cosmetic treatment, so the VAT flat rate for your business is 13%. Your flat rate payment to HMRC will be 13% of £1,200, or £156, which the patient has paid. • However, if you bill a customer for £1,000 and include the VAT in the price, you will need to pay this out of your profit (£1,000 x 13% = £130 to HMRC). Whilst the end user (the patient) would normally pay the VAT on the treatment or service, this could be shared between the practice and patient by altering the price of the service. In the past, some businesses, not necessarily in the aesthetic industry, were able to make money on the flat rate scheme, so HMRC issued anti avoidance for businesses that spend a small amount on goods, ‘the limited cost trader/business’.7 You would be classed as a ‘limited cost trader’ if your direct expenses (to generate income) cost less than either 2% of your turnover or £1,000 a year (if your costs are more than 2%).6,7 This means that if you are classed as a ‘limited cost trader’ then a default flat rate

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is administered for the business at 16.5%. In order to use the flat rate scheme at the lower percentage, you would need to have sufficient direct expenses; however, with normal aesthetic practices the products’ direct expenses would normally be sufficient.6 Another restriction of the flat rate scheme is that the business’s annual turnover must be below £150,000 to join. Whilst the annual income can increase after joining the scheme it must not exceed £230,000.7

Importance of record keeping

Record keeping is an important part of running an aesthetic practice and I have found that this is certainly an area that can get neglected to a degree. I am of the opinion that it is not sufficient to just hand a card terminal receipt to the patient once the treatment has been undertaken. Ideally, the patient should receive an invoice detailing the treatment or service they paid for. This is important because the business’s income should be derived by way of invoices raised, not necessarily monies deposited into the bank (or sometimes paid in cash). If HMRC were to perform a VAT enquiry, then the first port of call would normally be to look at the income streams of the practice and look at which ones would be subject to VAT. If the practitioner uses bookkeeping software, then whilst the figures may look like they add up, if the source income records just rely on entries in bank statements or card terminal banking, there is no link to the individual treatments to patients. So, consideration should be given to an audit trail. For example, consider the question, ‘How can Mrs Smith’s botulinum toxin payment be identified in the accounts?’ There are, of course, data protection issues and practitioners must remain compliant with The EU General Data Protection Regulation (GDPR).8

New changes to VAT For those who are VAT registered, the Government is introducing changes to the way taxation is administered. These changes are called ‘Making Tax Digital’.9 It is not only aesthetic practitioners who need to be aware of the Making Tax Digital changes. From April 1 this year, there will be a requirement for VAT-registered businesses to keep digital records and file VAT returns using software. In this digital age where so much information is available in electronic format, this should not be too onerous. However, if you are affected you should check that your bookkeeping records are capable of electronic transmission to the HMRC

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computer via their ‘Application Programme Interface’ (API) platform.9 This must be done on a transactional level; currently summary figures are used to populate the returns but a transactional level means that HMRC will be able to view the individual transactions that make up the VAT return, which means HMRC has more details. There are a number of different cloud based types of software available such as Xero, Quickbooks Online and many others. The HMRC guidance on Making Tax Digital can be found on VAT Notice 700/22: Making Tax Digital for VAT9 and there are sanctions for non-compliance.10

Summary Whether or not there is a need for your business to be VAT registered, now would be a good time to review your record keeping. If your business should one day become VAT registered, you will be affected by the Making Tax Digital requirements. Unfortunately, many practitioners are currently keeping manual records, which will not meet these requirements. The information within this article should be used as a guide and does not constitute advice; if in doubt you should discuss this with your accountant. Jonathan Bardolph qualified as a chartered certified accountant in 2007. He runs an accounting practice in the south of England and assists clients with personal tax, corporation tax, VAT, sole trader, partnership and limited company accounts including tax planning matters. He has developed a keen interest in medical aesthetics and tax compliance in this area and is the treasurer of the BACN. REFERENCES 1. Gov.UK, VAT Registration, 2019. <https://www.gov.uk/vat-registration> 2. Gov.UK, Guidance: Health professionals and pharmaceutical products (VAT Notice 701/57) <https://www.gov.uk/guidance/health-professionals-pharmaceutical-products-and-vat-notice-70157> 3. Gov.UK, Guidance: VAT guide (VAT Notice 700), Published 17 December 2014. <https://www.gov.uk/guidance/vat-guide-notice700#section4 4. Gov.UK, Guidance: Partial exemption (VAT Notice 706), Published 16 June 2011. <https://www.gov.uk/guidance/partial-exemption-vat-notice-706> 5. Gov.UK, VAT Flat Rate Scheme, Overview, 2019. <https://www.gov. uk/vat-flat-rate-scheme> 6. Gov.UK, VAT Flat Rate Scheme, Work out your flat rate, 2019. <https://www.gov.uk/vat-flat-rate-scheme/how-much-you-pay> 7. Gov.UK, Guidance: Tackling aggressive abuse of the VAT Flat Rate Scheme - technical note. Updated 5 December 2016. <https://www. gov.uk/government/publications/tackling-aggressive-abuse-of-thevat-flat-rate-scheme-technical-note/tackling-aggressive-abuse-ofthe-vat-flat-rate-scheme-technical-note> 8. Martin Swann, Getting Ready for GDPR, Aesthetics journal, 2017. <https://aestheticsjournal.com/hub/GDPR> 9. Gov.UK, Notice: VAT Notice 700/22: Making Tax Digital for VAT, Updated 18 January 2019. <https://www.gov.uk/government/ publications/vat-notice-70022-making-tax-digital-for-vat/vat-notice70022-making-tax-digital-for-vat> 10. Gov.UK, Consultation outcome: Making Tax Digital: interest harmonisation and sanctions for late payment, Published 1 December 2017 <https://www.gov.uk/government/ consultations/making-tax-digital-interest-harmonisation-and-sanctions-for-late-payment>

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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“For me, peer recognition is the highest accolade one can achieve” Professor Bob Khanna reflects on his career of more than 23 years in the industry and shares advice on what he has learnt Professor Bob Khanna was born and raised in Ascot, East Berkshire and in 1992 qualified as a dental surgeon from Cardiff University School of Dentistry and Medicine, before undertaking postgraduate education in surgical and cosmetic dentistry. It was just four years later that he was introduced to facial aesthetics and he now refers to himself as somewhat of a ‘dinosaur’ of the industry, thanks to his 23 years of service. So how did this dental surgeon become one of the first of his profession to explore medical aesthetics and become internationally recognised for his skills and techniques? “It was in 1996 at a conference that I met Dr Alastair Carruthers and Dr Jean Carruthers, who were spearheading a lot of clinical trials in the aesthetic sector at the time, and they introduced me to Botox. I hadn’t heard of it before but was amazed that people of such high intellect were entertaining the idea of putting a ‘poison’ into faces to make people look better,” he explains. It was at this point that Professor Khanna decided to find out more about how his background in advanced dentistry could work alongside this new concept. He says, “Cosmetic and surgical dentistry is a vital part of the aesthetic landscape and therefore the combination is a natural symbiosis.” Professor Khanna explains that this was at a time when there was no training available, so he’d frequently meet up with likeminded peers to discuss new concepts and share ideas. He notes, “All that we could do was learn from each other, here and abroad, whilst developing our own ideas and perfecting these through time. We were setting the ground rules I suppose, but one thing that remained stable was that patient safety was always a key priority.” This passion led to Professor Khanna being contacted by global pharmaceutical company Allergan in 1997, who asked him to train delegates, which at the time consisted of a number of doctors huddled around his computer. He says, “I didn’t come from a teaching background and suddenly I was tasked with the opportunity to teach my peers; I embraced that challenge

and things just progressed from there to a global level very quickly.” It was from this that Professor Khanna went on to open his clinic in Ascot at the age of just 27, as well as establishing his training academy, Dr Bob Khanna Training Institute (DrBKTI). Reflecting on his teaching, Professor Khanna says that one of the most common mistakes he sees around the world is the lack of understanding that men and women must be treated very differently. “I’m seeing so many males being feminised and so

children’s charities through his organisation, The International Academy of Advanced Facial Aesthetics (IAAFA), that ranks one of the highest. As well as that, he is honoured to be the chosen practitioner for many of his peers. “Around 35% of my patients last year were dentists, doctors and nurses from all over the world who have a specialist interest in aesthetics. In many ways, it’s more of a challenge treating one’s peers, but I relish the opportunity and thoroughly enjoy the experience. For me, peer recognition is the

Is there anything you would have done differently in your career? Research more on what equipment I actually needed when starting out; there’s so much out there and it can be so easy to buy something that you don’t need! What treatment do you enjoy giving the most? Full face profile management with dermal fillers; it allows me to express my artistry. Do you have any industry pet hates? Moaning clinicians on social media saddens me. Just run your own race and invest time and effort into making yourself better rather than ridiculing others. As an industry, we should be helping each other not bringing one another down. Success breeds success! What aspects of your work do you enjoy most? I love being invited to lecture at conferences around the world to share and showcase my latest concepts and techniques. many females becoming dehumanised, looking more animalistic, following aesthetic procedures. I’m finding that many practitioners seem to be using the same treatment approach for men as they do women, resulting in such anomalies.” So, what would Professor Khanna say is his biggest achievement to date? A few of his highlights consist of being appointed Professor of Facial Aesthetics of the University of Seville in 2012 (in which the university interviewed doctors from all over the world and after being shortlisted it was Khanna who was appointed to lead the postgraduates as Professor), being former lead clinical director in the Facial Aesthetics Masterclass at the Royal College of Surgeons in London, acting as an international KOL for Galderma and Filorga, and being invited to author the facial aesthetics module of the Aesthetics MSc at King’s College, London. But it’s his dedication to raising more than £220,000 for

highest accolade one can achieve, but it also serves as a constant reminder that I always have to be on top of my game,” he explains. Professor Khanna concludes, “I feel that too many people fear standing out in the crowd, but you should fear being a clone. I am where I am because I didn’t fear the unknown. One should stand for something, even if it means standing alone.”

E L I T E

T R A I N I N G E X P E R I E N C E

2019

Professor Bob Khanna will be hosting an exclusive three-hour training session at the Elite Training Experience at ACE 2019 on Saturday March 2. Visit aestheticsconference.com/elitetraining-experience to book tickets.

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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The Last Word Consultant plastic surgeon Mr Ali Juma outlines why he believes all aesthetic practitioners should undergo training with the use of cadavers Cadavers have, for many years, been used in medical education both at undergraduate and postgraduate levels, including in specialities like non-surgical aesthetic and cosmetic surgery practices. This article aims to highlight the benefits of donated human cadavers in non-surgical aesthetic procedures, including the learning process and ethical issues that are associated with such practises.

Current training practises To do no harm to the patients we treat is an important edict of the Hippocratic Oath and must be upheld for our patients’ protection.1 Training in non-surgical aesthetic facial treatments is not standardised, and often involves volunteer patients undergoing treatments administered by trainees, albeit under an experienced practitioner’s supervision. The trainee’s knowledge of the complex applied facial anatomy may be based on theory and two-dimensional diagrams in the literature, which do not have the same visual impact on the learning and practicality of three-dimensional cadaver dissected faces, supported by an appropriately trained, credentialed, and experienced practitioner. Anatomy knowledge and teaching has played a major role in optimising a crucial stage in the training of prospective physicians, which is reflected in one of the first portraits by Rembrandt in 1632 known as the ‘Anatomy Lesson’ in which medical

students study a cadaver under the director of their mentor, Dr Nicolaes Tulp.2 Hence, cadaver facial dissection provides an opportunity to better understand the facial tissues’ anatomy, the fat compartments, the structural relationship these tissues share and the relevance to surface anatomy.3

Benefits of cadaver use Studies have indicated that cadaver dissection, when connected to medical informatics, can expedite and enhance preparation for a patient-based medical profession.4 This is necessary for acquiring scientific skills, adding to a communicative, moral, ethical, and humanistic approach to patient care.4 The cadaver has been referred to as ‘the first patient’ during medical training and it allows the student to earn the privilege of bringing healing to the patient, i.e. the human cadaver acts as a surrogate patient contributing to the student learning process of medical healing.5 Hence, in my opinion, the interaction between cadaver and student is a ‘nodal point’ in medical education, from which evolves applying medical science to visual anatomy.6 The value and impact of cadaver training has been shown to improve applied facial anatomy knowledge for most candidates who participate in such training courses.3 It may also enhance the candidate’s confidence in performing non-surgical facial aesthetic procedures.3 It is important to add that cadaver courses and facial aesthetic training

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are not the only mechanism of improving safety; however, in my opinion, a structured training pathway, which includes theory of knowledge, cadaver dissections and applied hands-on learning must be contemplated. This should be followed by support from experienced and appropriately-credentialed practitioners. It is my belief that such a pathway makes for a safer patient journey. A detailed knowledge of facial anatomy vascular framework is crucial for delivering safe non-surgical aesthetic procedures.2 A study by Kumar et al. in 2018 documents that there is currently no core consensus for the teaching of facial anatomy to aesthetic practioners. This study’s purpose was to ascertain the critical anatomical structures to avoid serious complications resulting from non-surgical treatments.2 Based on an international experts’ survey, the researchers concluded, especially following the significant increase of aesthetic courses, that a ‘Core Syllabus’ would act as a blueprint for the educators while putting a programme together.2 Although this study was not about cadavers and anatomy, it did demonstrate that standardising a curriculum will help learners to have a comparable learning experience and also help educators to methodically see as to how effective the teaching is and whether improvement is required.

Ethical concerns and considerations With cadaver teaching comes regulations of handling cadaver’s tissue and of course the ethical considerations. The main ethical concern of cadaver dissection lies in respecting human life.7 Dissection laboratories have etiquette, including preserving dignity, respect, and limiting access to those who work there and the participating candidates.7 Also in the summary of the main points of The Human Tissue Bill 2003-04, the Government believes that this bill will; ensure that no human bodies, body parts, organs or tissue will be taken without the consent of relatives or patient. Once the coroner’s enquiries have concluded, then the organs and tissues taken will come under the authority of the Bill.8 The laboratory safety standards have to be respected and all the tissues collected from the cadavers must be disposed of according to regulations of the Human Tissue Authority, the regulator for human tissue and organs.9 Photography in the cadaver lab falls under the dissection room etiquette and must be respected. We must remember that we are not only dealing with human cadavers; we are

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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also dealing with their relatives, hence, both must be given the respect to dignity and privacy they are entitled to. Not everybody will agree on the use of human cadavers and teaching. The reasons may vary from personal reasons, moral, and religious beliefs; however, in my opinion in all circumstances, all those who participate in the dissection of cadavers must be from the medical profession and have a background of anatomical knowledge prior to their participation. In 2016 the Daily Express newspaper wrote that critics had said a two-day course using cadaver heads teaching nonmedics to inject wrinkle-relaxing injections was labelled as abuse of the good will of those who donated their bodies to doctors and specialists which ‘beggars belief’.10 Although I don’t approve of the training of therapists in these treatments, in my opinion, cadaver dissections in the relevant settings are of profound importance in training medics. This three-dimensional visual method makes it an essential part of the curriculum adding to and improving patient safety.

Summary The use of human cadavers and cadaver parts in non-surgical aesthetic treatment has, in my professional experience, become more popular in the last decade. This privilege has further fortified the training ladder of options to achieve a safe environment to trainee candidates, where they participate with an interactive group of likeminded individuals from an appropriate background of training, expertise, and experience. However, with this use of cadavers comes national rules and regulations, in addition to laboratory etiquette, all of which have to

be respected and implemented in order to instil not only respect from the public, but also acquiring their confidence to perpetuate the donation of human bodies and parts to allow us this precious privilege of learning. Disclosure: Mr Ali Juma is a trainer for LMEDAC and teaches with the use of cadaver. Mr Ali Juma practices privately in London and Wirral, and previously held a 12-year career as a consultant plastic surgeon in the NHS. He offers a range of cosmetic and plastic surgery procedures, along with aesthetic treatments. Mr Juma is registered with the General Medical Council, as well as a member of BAAPS and BAPRAS. REFERENCES 1. The Hippocratic Oath, (US: Medicine Net, 2018) <https://www.medicinenet.com> 2. N Kumar, Swift A, Rahman E., ‘Development of “Core Syllabus” For Facial Anatomy Teaching to Aesthetic Physicians: A Delphi Consensus’, Plastic & Reconstructive Surgery- Global Open, (2018) Volume 6 Issue3 – P E 1687. 3. Narendra Kumar and Egram Rahman., ‘Effectiveness of Teaching Facial Anatomy Through Cadaver Dissection on Aesthetic Physicians’ Knowledge’, Adv Med Educ Pract. (2017) 8: pp.475-480. 4. Aziz A M, McKenzie J C, Wilson J S, Cowie R J, Ayeni S A, Dunn B K., ‘The Human Cadaver in the Age of Biomedical Informatics’, The Anatomical Record (New Anat) (2002), 269, pp.20-32. 5. Kasper A., ‘The Doctor and Death’, In: Feifel H. Editor., ‘The Meaning of Death’, New York; McGrawHill. (1969) pp.259-270. 6. Pellegrino E D, ‘Educating the humanist physician: An Ancient ideal reconsidered’, JAMA (1974) 227, pp.1288-1294. 7. Shaikh S T, ‘Cadaver Dissection in Anatomy: The Ethical Aspect’, Anatomy & physiology: Current Research. (2015). 8. The Human Tissue Bill, Bill 9 of 2003-04, House of Commons 04/04, 9th January 2004 <https:// researchbriefings.parliament.uk/ResearchBriefing/Summary/RP04-04> 9. Human Tissue Authority (UK: Gov, 2018) <https://www.hta.gov.uk/donating-your-body>. 10. K Corcoran, Bodies donated to medical science used for BOTOX PRACTICE, 2016, Express, <https://www.express.co.uk/news/uk/631553/Bodies-donated-to-medical-science-used-for-BOTOXPRACTICE>

Reproduced from Aesthetics | Volume 6/Issue 3 - February 2019


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