APRIL 2021: THE BODY ISSUE by Aesthetics & CCR

S IC ET S H D E! ST AR 28 AT AE AW AY E D M H T

Understanding Wound Healing

Practitioners review methods to enhance wound healing in this month’s CPD

VE SA

VOLUME 8/ISSUE 5 - APRIL 2021

Post-Pregnancy Treatments A summary of procedures which can help body-conscious mothers’ concerns

Enhancing the Buttocks Mr Deniz Kanliada explores the use of HA fillers in buttock augmentation

Onboarding a New Device

Nurse prescriber Sara Cheeney advises on introducing new machines to clinics

THEIR LOOK *Juvéderm® offers a range of facial fillers to answer a variety of needs, each of which is administered at a different dermal layer. We believe natural-looking, long lasting results are achieved by enhancing your client’s features, not changing them. The Juvéderm® Vycross® range of fillers includes five tailored products designed for a specific area of the face at the optimum dermal level. Which means you can offer your clients a bespoke and tailored treatment to help suit their needs.

To find out why Juvéderm® could work for your clients and your clinic on every level, visit juvederm.co.uk

Produced and Funded by Allergan Aesthetics. UK-JUV-2150067 March 2021 ©2021 Allergan. All rights reserved. Model treated with Juvéderm®. Individual patient results may vary. Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/ Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.

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Contents • April 2021 08 News The latest product and industry news 18 Increasing Patient Safety Aesthetics outlines the JCCP’s 10-point Plan 20 News Special: Dermal Fillers and COVID-19 Aesthetics explores new guidance on the vaccine’s impact on fillers

CLINICAL PRACTICE 22 Get Your Patients Summer Ready Dr Selena Langdon shares her tips on summer body treatments 23 Special Feature: Considering Post-Pregnancy Treatments Procedures that can boost the confidence of body-conscious mothers 28 The Elite Experience Meet your potential – the evolution of body contouring 30 CPD: Wound Healing Practitioners review methods to enhance wound healing and reduce scarring 35 Treating Thin Lips Aesthetic nurse Emma Coleman describes her technique for thin lips 38 Introducing Sculptra How the collagen stimulator can help your patients 40 We’re Here for You this Spring Merz Aesthetics has developed its own road map 41 Treating the Neck Dr Jemma Gewargis explores the Nefertiti Neck Lift technique 45 Enhancing the Buttocks Mr Deniz Kanliada introduces the use of HA fillers for buttock augmentation 48 Recognising Tear Trough Ligaments Dr Uche Aniagwu details the anatomy of the under-eye region 51 Case Study: Treating the Lower Face Dr Priya Verma discusses her approach to treating laxity and jowling 55 Lifting the Breast with Radiofrequency Two surgeons present their non-surgical approach to breast lifting 58 BELOTERO Balance Dr Kim Booysen shares a case study using BELOTERO Balance for fine lines 60 Thermage FLX Treating the periorbital area using radiofrequency 61 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 63 Onboarding a New Device Nurse prescriber Sara Cheeney advises on introducing new machines 65 Building Passive Income Dr Uma Jeyanathan discusses how GetHarley can help you sell skincare 67 Utilising Facebook Groups Digital consultant Rick O’Neill explores the benefits of Facebook groups 70 Advertising Weight-loss Services Dr Kam Lally discusses the repercussions of advertising weight loss services 73 In Profile: Dr Nestor Demosthenous The clinic owner explains why aesthetics is more than fillers 74 The Last Word, Fox Eye, Trend Dr Sieuming Ng assesses the controversy of the, Fox Eye, trend NEXT MONTH IN FOCUS: SUMMER • Choosing an SPF • Treating Photo-damaged Lips

News Special: Dermal Filler and COVID-19 Page 20

Clinical Contributors Miss Priyanka Chadha currently works as a plastic surgery registrar in London and is co-director of Acquisition Aesthetics training academy. Her academic CV comprises national and international prizes and presentations. Miss Chadha is a KOL for Galderma. Miss Lara Watson is dual-qualified in medicine and dentistry and works as a registrar in oral and maxillofacial surgery. She is a faculty member for Galderma and is also a co-founding director of Acquisition Aesthetics with a background in anatomy and scientific research. Dr Nihull Jakharia-Shah is an internal medicine trainee with an interest in dermatology. He has an academic background having published in dermatology, plastic surgery and aesthetic journals. Dr Jakharia-Shah has presented his work at international conferences. Emma Coleman is a dermatology and advanced aesthetic nurse practitioner. She gained a distinction in her Clinical Dermatology Diploma with the University of South Wales in 2019. Coleman is clinical director at four Emma Coleman Skin clinics across Kent and London. Dr Jemma Gewargis is an aesthetic practitioner and cosmetic dentist, splitting her time between two private dental practices and multiple aesthetic clinics in West London, as well as being the leading clinical trainer at the Aesthetic Foundation Academy on Harley Street. Mr Deniz Kanliada is a consultant ENT and facial plastic surgeon. He has been practising in aesthetics for more than 14 years and has completed more than 2,000 surgical procedures in Istanbul, the UK and Cyprus. He is also a KOL for Genefill Contour. Dr Uche Aniagwu is an aesthetic practitioner specialising in under-eye rejuvenation. He is a resident injector at Beyond Medispa, Harvey Nichols, as well as the founder and clinical lead of the Under Eye Masterclass training programme. Dr Priya Verma is an aesthetic practitioner and NHS academic clinical fellow in general practice at King’s College London. Dr Verma is completing her post-graduate certificate in skin ageing and aesthetic medicine, while practising from Nova Aesthetic Clinic. Mr Massimiliano Cariati is a consultant oncoplastic and reconstructive breast surgeon. He is the clinical lead for breast services at University College London Hospital and is honorary associate professor with the Institute of Women’s Health, UCL. Mr Rishi Mandavia is an ENT surgical doctor and managing director of the Dr Tatiana Aesthetic Clinic. He holds an MSc in health policy, is carrying out a PhD at University College London and has published and presented his research widely.

Editor’s letter Beyond Beauty is here! After months of planning, we’re delighted to share the very first issue of our new magazine for consumers with you. Dedicated to breaking down the science behind treatments and informing the general public of how to make safe and results-driven Chloé Gronow choices when it comes to aesthetic procedures Editor & Content and cosmetic surgery, Beyond Beauty will Manager become the go-to resource for your patients. @chloe_aestheticseditor If you’re listed as a Full Member or medical professional within our database, you will have received a free copy with your journal. Have a flick through and tell us what you love! Think your patients will enjoy? Get in touch to order more copies that you can retail from your clinic, making a little profit for you too! It’s been a long time coming, but we’re almost ready for the Aesthetics Awards! Of course we would have loved to see you in person for all the overdue celebrations, but a virtual ceremony is the safest approach for this year. We’ll soon share details of how you can register to attend the event on May 28, which you’ll be able to join for free via the Aesthetics

website. A special celebrity guest will host the ceremony, with lots of fun surprises thrown in! We encourage everyone to get dressed up, join with your team and share your experiences with us on social media for a truly interactive evening. I’ll certainly be getting my best dress out after spending so many months working from home in loungewear! So, what can you expect in this issue? Focused on the body, we’ve covered lots of device-led treatments from post-partum options on p.23 to onboarding a new clinic machine on p.63. Now that more people are being vaccinated against COVID-19, are you finding your patients are worried about the impact it could have on their filler treatments? We spoke to Dr Martyn King, founder of the Aesthetic Complications Expert (ACE) Group World, about his research into the concerns. Check out p.20 for his insight. This month I’ve particularly valued learning about the controversy surrounding the ‘Fox-Eye’ trend. Dr Sieuming Ng outlines the negative cultural connotations associated with the procedure, while sharing advice on how practitioners can approach this with their patients. It’s an important read, so do check it out on p.74.

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

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

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 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 for botulinum toxin and dermal fillers.

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

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon at the Cadogan Clinic in Chelsea. She specialises in blepharoplasty surgery and facial aesthetics. Miss Hawkes was clinical lead for the emergency eye care service for the Royal Berkshire NHS Foundation Trust. She is an examiner for the Royal College of Ophthalmologists.

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

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

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

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

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

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Webinar

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

#Peels Dr Varna Kugan @dr.kugan Giving a talk in #Wuhan on mixed acid peels in aesthetic medicine for @dermaceutic thanks to @pico_clinics. Fascinating to visit this city a year on from its lockdown #aestheticmedicine #Vaccine SpringPharm @springpharmltd We are excited to announce that we are commissioned to administer the COVID-19 Oxford AstraZeneca vaccine to eligible cohorts… #vaccination #Panel BCAM @britishcollegeofaestheticmed Thanks to everyone who joined our members-only complications panel discussion today - what an enlightening session! #complications

Global pharmaceutical company Galderma is relaunching the poly-L-lactic acid (PLLA) filler Sculptra. On April 15 Aesthetics will host an exclusive webinar with Galderma, which will provide a comprehensive overview of Sculptra, including insights from aesthetic practitioners Dr Kuldeep Minocha, Dr Kathryn Taylor-Barnes and Dr Marwa Ali. They will talk about the science behind Sculptra and share their inclinic experiences and the business potential this product can offer your clinic. Topics covered during the webinar will include: introducing a new era for Sculptra, the science behind Sculptra, expert opinions, the Sculptra value proposition, and an interactive Q&A session. Katie Bennett, senior brand manager at Galderma, said, “Galderma are excited to have taken over distribution of Sculptra and have revamped the training and injection technique protocols in line with clinical best practice. Our upcoming webinar will provide expert insights from several leading UK KOLs on the science behind Sculptra, clinical best practice and advice, alongside discussions on the brand value proposition and how this innovative product can amplify and complement your clinic treatment portfolio. It promises to be an engaging and informative session and we hope you can join us!” To register for the free webinar, visit the Aesthetics website. Suncare

#Frontoplasty Dr Shino Bay Aguilera @shinobay Awesome to see our paper on the cover of JCAD about Frontoplasty on the Mestizo forehead. This has been a dream come true for the last four years! #Conference Dr Greg Williams @drgregwilliamsuk It was a real honour to be invited to speak at the Permanent International Conference in Berlin on Scalp Micropigmentation (SMP). An opportunity to share with practitioners how SMP can be used of or in #hairtransplantsurgery!

Galderma relaunches Sculptra on April 15

iS Clinical releases two SPF products Skincare brand iS Clinical has launched the Extreme Protect SPF 40 and the Liprotect SPF 35. According to the company, the Extreme Protect SPF 40 is formulated using transparent zinc oxide, extremozymes, tocopherol (vitamin E), transparent titanium dioxide, asiaticoside, asiatic acid and madecassic acid, and aloe barbadensis leaf juice. iS Clinical explains that the product is designed to provide multilevel broad-spectrum UVA/UVB protection, protection against environmental damage, as well as to hydrate the skin. The Liprotect SPF 35 is formulated to protect the lips from sun damage, according to iS Clinical, and contains transparent zinc oxide dispersion, transparent titanium dioxide dispersion, cocos nucifera (coconut) oil, caprylic/capric triglyceride, linoleic acid, glycine, soja (soybean) sterols, phospholipids, tocopherol (vitamin E), and dipalmitoyl hydroxyproline.

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Patient education

Beyond Beauty magazine now available for retail Following the long-awaited launch of the brand-new consumer magazine Beyond Beauty this month, aesthetic clinics can now purchase copies to sell or giveaway to patients. Brought to you by the Aesthetics team, Beyond Beauty will educate your patients on the best procedures and treatments, while building their trust in the aesthetics speciality. Chloé Gronow, editor and content manager of Aesthetics and Beyond Beauty, commented, “We’re so excited that our patient magazine Beyond Beauty has finally launched, and I can’t wait for everyone to read it! We know how important it is to show people the positive side of aesthetics and to combat the negative perception of treatments in the media. This is why we’re giving practitioners and clinics the opportunity to retail the magazine themselves! Beyond Beauty offers a unique and valuable tool for clinics and brands to engage with consumers.” You can buy the magazine for £2 and the RRP is £5. If you are a Full Member or listed as a medical professional in the Aesthetics database, you will have received the first copy free with your journal. You can order more copies and subscribe to future issues by emailing katie.gray@easyfairs.com or visiting www.beyondbeautylive.com.

Vital Statistics In a survey of 789 adults, more than 60% of men were conﬁdent about their appearance compared to 44% of women (Cosmetic Surgery Solicitors, 2020)

60% of Americans are more likely to shop from brands who support the Black Lives Matter movement (Mintel, 2021)

63% of 220 patients who suﬀer from rosacea and acne are experiencing worsening symptoms related to face mask wearing, including redness and increased ﬂare-ups (Galderma, 2021)

Conference

CCR 2021 announces ISAPS Symposium For the first time the International Society of Aesthetic Plastic Surgery (ISAPS) Symposium UK will be housed at CCR in October 2021. With a focus on breast and body, the ISAPS Symposium will feature an internationally-renowned faculty from across the globe, as well as the latest surgical equipment and solutions at the accompanying exhibition. Attendees will also have access to the full agenda of free-of-charge non-surgical education at CCR, and the opportunity to meet with the leading suppliers of non-surgical products and practice management solutions. Plastic and reconstructive surgeon Mr Naveen Cavale, ISAPS UK national secretary, commented, “It’s great to be working with CCR for the fourth year running and we’re thrilled to be able to host the ISAPS meeting at CCR for the first time this year. The ISAPS Symposium provides expert education for plastic surgeons each year and because CCR provides such an open forum for medical aesthetic professionals, all surgeons involved in the aesthetics sector will be able to join the ISAPS meeting, giving them the opportunity to be educated by, and learn best-practice from, the best of the best.” CCR 2021 will take place on October 14 and 15 at ExCeL London.

49% of 1,000 consumers who haven’t had plastic surgery said they are open to cosmetic or reconstructive treatment in the future (American Society of Plastic Surgeons, 2020)

In a survey of 300 global retail leaders, 74% of respondents allocated at least one third of their marketing budget to social media advertising (Global Social Advertising Trends, 2021)

In a survey of 459 adults, the main four sources leading to pressure and body dissatisfaction were friends, (68%), social media (57%), advertising (53%) and celebrities (49%) (Global Health and Pharma, 2020)

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Celebration

Aesthetics Awards goes Digital this May

JOIN T H E VIRTUA L CEREM O NY

Business development

SIAB confirms two conferences The Success in Aesthetic Business (SIAB) conference will take place in June this year, with a separate day planned exclusively for nurses. The SIAB for doctors and surgeons will take place on June 4 in Birmingham. Speakers include consultant, plastic and reconstructive surgeons Mr Dalvi Humzah, Mr Jeyaram Srinivasan, branding professional Russell Turner, and business consultant Danny Large. The day features six sessions on how to run an aesthetic business, tax planning, branding and marketing, business plan templates, and customer service. SIAB for nurses will take place on June 12 in Manchester, led by aesthetic nurse prescriber Rachel Goddard, and will cover the same topics. Mr Humzah commented, “SIAB will be a unique event that will allow medical practitioners to develop all aspects of their medical aesthetic business. This will provide you with all the inside knowledge to get you ahead in developing and keeping your practice at the forefront of aesthetics.” Aesthetic booking platform Étre Vous will run a special offer in which anyone who signs up will be entered into a prize draw to win a pass to the event, worth £500.

Prepare for an exciting afternoon of virtual glamour on May 28 when the prestigious Aesthetics Awards will take place via Zoom at 4pm. The afternoon will feature a celebrity host soon to be announced, winner announcements, cocktails, and more! Chloé Gronow, editor and content manager of Aesthetics, commented, “The Aesthetics Awards are a key event in the industry calendar, and with everything going on this year we still wanted to make sure that we got to celebrate everything that the industry has achieved. Although it will be digital this year, it will still be an event to remember, and we encourage you to get together with your teams to watch the virtual ceremony! We’re so excited for you all to find out what we’ve got planned, and more announcements will be coming soon!” Events manager, Courtney Baldwin, said, “We made the decision to move the Aesthetics Awards online in order to run the event safely and successfully, while also enabling us to truly unite the aesthetics industry for a real celebration of all the achievements over the last year. The past 12 months have been very difficult for everyone, so we hope that the Awards will bring some much needed positivity. We’re working on a few fun additions to the evening to make us all feel united, albeit virtually, so watch this space. The registration is free to attend, so please do join us for our virtual celebration and we look forward to seeing you in real life at CCR this October!” Make sure you save the date and stay tuned for registration opening so not to miss out! A brand-new Aesthetics Awards sponsor has also been announced, with medical device manufacturer InMode showing its support for Best Consultant Surgeon of the Year. Skincare

skinbetter science launches new AlphaRet serum Skincare brand skinbetter science has added a new cleansing serum to its AlphaRet range. The new AlphaRet Clearing Serum is formulated using salicylic acid, niacinamide, lactic acid and a botanical complex. According to the UK skinbetter science distributor AestheticSource, the serum has been designed to unclog pores, exfoliate and rejuvenate the skin, whilst also having a moisturising effect. In a study conducted by the company, 100% of 19 patients noticed a visible skin improvement after using the serum for eight weeks. Independent nurse prescriber Anna Baker commented, “skinbetter science AlphaRet Clearing Serum contains the highly effective patented AlphaRet skinbetter science retinoid and lactic acid technology. The formulation combines ingredients to rejuvenate and clarify the appearance of oily, blemish-prone skin for healthier, clearer-looking skin.”

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Conference

Business

Agenda released for BMLA digital conference The agenda for the British Medical Laser Association (BMLA) virtual conference held in association with the European Laser Association has been revealed. The two-day virtual conference on May 6-7 will include more than 20 medical and aesthetic educational courses, masterclasses and interactive sessions with leading industry speakers and course faculty. Four educational courses will be made available via the online platform ahead of the virtual meeting. The courses explore hair removal, vascular lesions, ablative laser treatment and energy-based devices. Each course will be led by industry experts, including clinical director at Lynton Lasers, Dr Samantha Hills, board member of the European Laser Association, Professor Harry Moseley, consultant dermatologists Dr Raman Bhutani and Dr Daron Seukeran, and more. Education

New injection anatomy book published Aesthetic practitioners Dr Lee Walker and Dr Raul Cetto have released a new book titled Facial Ageing and Injection Anatomy. They explain that it is an evidence-based resource suitable for all levels of clinicians who practice aesthetic medicine. The book is illustrated by aesthetic practitioner Dr Toni Burke. On the book launch, Dr Cetto commented, “Our aim was to create a compendium of facial ageing and injection anatomy pertinent to injectors. We are a multidisciplinary speciality and the evidence we use comes from a wide range of disciplines within the medical field, we critically appraised the latest evidence and summarised it in a package that is easy to comprehend and, most importantly, is pertinent to our practice.” Surgery

New post-surgical bra launches Italian manufacturer Qualiteam has released a new post-surgical bra. The company explains the Calla Cozy design is wireless and seamless, with front closures and adjustable shoulder straps. In addition, it has a long bra body which has optional pockets for prosthesis or for ice packs. Doris Hjorth, president of Qualiteam, commented, “Since most bras are short-bodied, they interfere with incisions and may cause unnecessary pain for the patient. We have taken such issues into account in the Calla Cozy design and added more features that makes it a perfect choice for any kind of breast surgery or reconstruction.” The product will be distributed by Pharmed UK.

New aesthetic consulting service MiViVa launches A specialised consulting service targeted at the private aesthetics sector has been launched by Stuart Rose, previously managing director of Merz Pharma UK. MiViVa’s foundational culture and strategy approach has been created to provide advice for aesthetic practices to build a more cohesive, purposeful and effective business. Aimed primarily at established, full-time clinic owners with staff, MiViVa is launching three online foundational culture modules this month. The core module, called Creating a Culture for Success, aims to help define and establish your own winning culture to increase staff performance and profitability. The Recruitment and Retention module will tell you how to hire and keep great staff and the final module, Performance Management, aims to help promote authentic business growth. MiViVa has tailored an introductory module (Foundational Culture Light Touch) launching in July, for those new to aesthetic medicine which covers all three modules, but with an emphasis on creating a culture for success. Rose commented, “I’m passionate about the impact that culture and strategy can have on a business. I’ve learnt some valuable lessons, allowing me to develop a set of skills and techniques to spot, nurture, develop and retain talent, creating the right environment to let it flourish. That environment, or culture, can truly transform a business.” Visit miviva.org to book. Chemical peels

Mesoestetic formulates new micropeel Pharmaceutical company mesoestetic has launched the Ultimate Micropeel, a micro-exfoliant that aims to renew the skin and remove dead cells. According to mesoestetic, by combining AHAs and an enzyme exfoliant, the product performs an exfoliating and renewing action on the skin. It is also a bio-balancing, antipollution and antioxidant solution. The company states that the micropeel is suitable for all types of skin and ages. Adam Birtwistle, managing director of mesoestetic UK, said, “Adding a peeling treatment to a patient’s homecare ritual once or twice a week is very effective to regenerate the skin, restoring its youth and luminosity. The current trend of using regular face masks makes this product an essential element in our skincare routine, with increased sebaceous secretion and clogged pores due to pressure and lack of oxygenation leading to the appearance of spots and blackheads. More than ever the skin needs to be constantly renewed, which is why the Ultimate Micropeel is the solution to keeping it healthy.”

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

Avant-garde breast surgery and reconstruction deserves an avant-garde compression bra.

Six reasons Calla Cozy should be your post-surgical bra of choice: • Wireless and seamless in the true sense • Unmatched adjustability

- Adapts easily to changes in swelling

• Long bra body

- No interference with incisions

• Italian made fabric

- Sensitive Fabrics for maximum comfort

• Available with pockets for inserts • Beautiful design

Beautiful recovery starts here. Official UK representative:

Call now: 01295 753540 orders@pharmed-uk.com

Calla Cozy

- Choice of pretty multi-band or sporty racer back in black or white

Guess which product we’ll feature in this Journal’s May issue? Tell us at calla@qualiteam.com before April 30th 2021 and win a product if you guess correctly!

Calla by Qualiteam

Explore our range of postoperative care products on www.callabyqualiteam.com

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Skincare

GetHarley introduces new charity campaign Patient booking platform GetHarley has launched a new Instagram campaign designed to support industry skin professionals. GetHarley is asking people to repost its Instagram image (found via @getharley) to its own personal or professional Instagram accounts and tag a person who is their ultimate skin hero. For every tag (when also using the hashtag #supportskinheroes2021) GetHarley will donate £1 to the Hair and Beauty Charity to help those with financial needs. Founder and CEO of GetHarley, Charmaine Chow, commented, “Our industry needs so much support right now because unlike other industries, it has had so little government funding. We hope this campaign will spread some love and appreciation to all those who deserve it and hopefully donations will help support those in financial need too.” Learn more on p.65.

Demonstrating your Professional Value

Photographer Hannah McClune’s monthly tips on how to strengthen your business through branding A way to compete on quality. And not on your price. Stand out by showing your value. A popular reason clinic owners come to me is to create a gallery of images that show their brand’s professionalism, which also connects with prospective patients. In turn this leads to a booking with them over alternative clinics.

Imagery’s influence

Vaccination

SpringPharm joins fight against COVID-19 Aesthetic pharmacy SpringPharm has reached a 4,000-vaccination milestone. Since January, SpringPharm has been administering the COVID-19 Oxford AstraZeneca vaccine to eligible cohorts to help with the fight against the virus. A range of staff are assisting in administering the vaccine at the Tamworth site, including colleagues from the aesthetics industry, nurses from NHS backgrounds and pharmacists. Pharmacy technicians are currently training to be able to administer the vaccine as well. Lee Ison, director of SpringPharm and superintendent pharmacist, says, “SpringPharm is incredibly proud to be part of the national effort to vaccinate the population against COVID-19 and we would like to thank all staff and volunteers who are supporting us as a vaccination centre.” Lasers

Candela launches the Frax Pro Aesthetic device company Candela has introduced a new diode laser system which is designed to treat acne scars, surgical scars, striae and actinic keratosis. The company explains that the Frax Pro is the first platform featuring dual-depth skin resurfacing with both the Frax 1550 and the Frax 1940 applicators. The two modalities are designed to target different skin layers, aiming to stimulate collagen growth. According to Candela, the Frax 1940 handpiece delivers a 1940 nm wavelength laser beam for a shallow, epidermal approach, with focal reach extending to approximately 200μm in depth. The 1550 nm wavelength of the Frax 1550 handpiece penetrates deeper, with histological analysis showing up to 800μm penetration.

When patients are searching for their perfect practitioner it can be hard to recognise value. Imagery is a clear way to show value. The pictures you choose to use in your marketing are a way to demonstrate why they should choose you. Photography has the ability to add this perceived value. But photography can also create the opposite effect. If you are using bad quality photos you will have a harder time earning loyalty and trust. Imagine your potential patient landing on your website or social media. If there are either no photos, selfies or amateur snaps, your credibility is limited at best. You are sending out key messages: • You are not professional, reliable and an expert at what you do. And even more importantly… • You don’t believe you are an expert. • You don’t value your business and your services enough to invest. As you know, in the aesthetics world you need to build trust and share the high quality of your services. Professional photos show both.

This column is written and supported by Hannah McClune, owner of brand photography company Visible by Hannah www.visiblebyhannah.com

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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

MARCH RECAP The BACN worked with Church Pharmacy in March to offer members digital events focused around ‘All Things Temples’. BACN regional leader Lou Sommereux caught up with Dr Vikram Swaminathan for the third ‘In Conversation With...’ series of the year. They spoke about assessing and treating the upper third with dermal filler. The full conversation is now on BACN’s Instagram TV. Later in the month, Dr Andrew Greenwood and Yvette Newman discussed the treatment of temporal hollows, brows and lateral orbital lifting using HICE technology HA fillers (YVOIRE). Dr Greenwood demonstrated his trusted methods and techniques for revolumising the area to create a smooth transition from the orbital rim to the temple. He also showed how adding ligament lifts can create a youthful appearance. Regional leaders Simone Sansom and Linda Strachan also spoke to members for March’s peer review about re-opening clinics this spring and provided an interactive checklist of considerations.

APRIL EVENTS April’s digital events theme is ‘Prescribing within Aesthetic Medicine’. April 20: In conversation with Claire Pryor Senior lecturer in adult nursing and module lead for non-medical prescribing at Northumbria University Claire Pryor will be speaking with BACN Board member Linda Mather to discuss the V300 course and its importance in practice. April 27: In Focus Digital Webinar Helen Hunt will talk to Linda Mather about the challenges and rewards of doing the V300 course, Ex-Vice Chair Andrew Rankin will present on updated prescribing guidelines and BACN member Cheryl Barton will discuss advertising regulations. To submit questions in advance email, events manager Tara Glover at events@bacn.org.uk. April 29: a National Peer Review and social with regional leader for Northern Ireland Áine Larkin will take place. This column is written and supported by the BACN

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Skincare

AlumierMD launches at-home kit for eyes Skincare company AlumierMD has introduced The Eye Edit, a new at-home kit for patients to improve the appearance of tired eyes. The kit contains the AluminEye product, which aims to increase firmness, elasticity and hydration, and Eye Rescue Pads, which were previously reserved for inclinic use, and aim to restore moisture to the area. According to the company, these products work together to target dark circles, fine lines and puffiness around the periorbital region, and can be used by patients of any skin type. Training

Cosmo Pro launches new qualifications Aesthetic distributor and manufacturer Cosmo Pro has partnered with the Confederation of International Beauty Therapy and Cosmetology (CIBTAC) to offer its new training courses. The company explains that the Cosmo Pro Academy has launched the following Level 4 qualifications: Advanced Skin Science, Award in Microneedling and Award in Chemical Skin Peeling. Cosmo Pro states that the qualifications follow the Education and Training Standards and Competency Framework published by the Joint Council for Cosmetic Practitioners. Liz Cowan, business and training director for Cosmo Pro Academy, commented, “Cosmo Pro has developed a robust and quality-assured progression route for practitioners, and the achievement of these qualifications will provide assurance as to the knowledge and skills developed by those who wish to improve their employability and prospects in advanced aesthetic treatments.” Hair

New hair growth device released Aesthetic device distributor Beautyform Medical has launched a new device to help stimulate hair growth. According to the company, Tricopat combines pressure waves to promote cell regeneration and vascularisation. It uses electrostimulation for improving the blood microcirculation, Iontophoresis to deliver growth factors deep into the skin, as well as controlled microincisions which aim to stimulate fibroblasts to produce type 3 collagen. Blue and red LED is also used to encourage tissue repair and improve collagen reproduction. Beautyform Medical explains that the protocol consists of four sessions carried out every three weeks, with each session lasting for 20 minutes. Erkan Guroy, director of Beautyform Medical, commented, “We are extremely excited to introduce the Tricopat device. We believe in delivering our customers with revolutionary technologies so they can consistently deliver outstanding results. Tricopat is a highly advanced hair treatment device with a versatility that is unmatched. We believe that Tricopat will shortly become a popular alternative for hair treatments.”

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Hyaluronic acid

IBSA Derma releases Viscoderm Hydrobooster Cream Pharmaceutical company IBSA Derma has launched a new hydrating cream formulated using high molecular weight hyaluronic acid and jojoba oil. The company explains that the hyaluronic acid is used for hydration, while the jojoba oil provides a combined emollient and regenerating function, helping restore the hydrolipidic barrier of altered skin. Aesthetic practitioner and lecturer at the Agorà School of Aesthetic Medicine in Milan, Dr Patrizia Persini, said, “Patients today turn to the specialist to prevent skin ageing, improve the quality of their skin and the aesthetics of their face, and the doctor’s role in recommending the best possible treatment has become increasingly important. Aesthetic medicine treatments can have a significant impact on people’s quality of life, self-esteem, relationships and social life. I believe the Viscoderm range offers quality products for long-lasting results.” Business

New VAT Pack released The Aesthetics Accountant has launched a new digital pack to help practitioners understand the VAT exemption ruling. The VAT Pack contains explanations on business taxes, the VAT exemption rules and tips for implementing the guide into your day-to-day clinic. The pack also contains add-ons with templates for cosmetic and medical turnover which can be used to send to your accountant monthly, and a monthly turnover monitor, which can be used as evidence to HMRC to prove that you are aware of the rules regarding exemption and are actively monitoring your revenue. Samantha Senior, founder of The Aesthetic Accountant, said, “Despite the rumours and popular opinions circulating in the industry, there is no grey area! A treatment that is performed by a medic does not alone mean all treatments/sales/income are exempt from VAT. I have put together this basic pack to help non-clients understand the exemption ruling.” Event

ICAN Conference Report A report from the International College of Aesthetic Nurses (ICAN) digital conference On February 23 ICAN held its first ever conference on Zoom, designed as an introductory session for nurses that are new to aesthetic medicine. After an introduction from ICAN founder and nurse prescriber Amanda Wilson, the evening was kicked off by aesthetic practitioner Dr Nestor Demosthenous who gave a talk on consultation skills for beginners. Then, sales and marketing manager John Campbell discussed the benefits of the Allergan Spark Programme, and business development manager Hannah Vincent gave an overview of skincare brand PCA Skin. Nurse prescriber Lisa Whiting next gave a talk on starting out in aesthetics, and nurse prescriber Emma Davies discussed how to deal with aesthetic complications. On February 24 ICAN held its second session, directed at more advanced nurse practitioners. The first presentation was from aesthetic practitioner Dr John Curran who discussed medical VAT in aesthetics. Dr Demosthenous returned to speak about periorbital rejuvenation and ageing, followed by aesthetic nurse prescriber Patricia Goodwin who shared case studies using dermal filler Ellansé and discussed her techniques for a successful outcome. Davies again closed the conference with a talk on dealing with complications, followed by an opportunity for viewers to ask extra questions. On the event, Wilson commented, “The ICAN team was overwhelmed with the number of attendees over the two days. We welcomed over 200 of our members and had some really great feedback from the nursing community. We are currently working on our next conference and cannot wait to share details with you all soon.”

News in Brief Lynton announces new ambassador Laser and IPL manufacturer Lynton has appointed aesthetic nurse Rosy Boulton as a brand ambassador. In her role, Boulton will provide promotional, educational, and support materials in accordance with the Lynton 3JUVE device and the illumiFacial. Boulton stated, “I am honoured to be working with Lynton. As an advocate of their devices and treatments prior to becoming a brand ambassador, I aim to continue raising awareness of the brand, their technology and the results they achieve.” Fagron launches UV-C Air Steriliser Pharmaceutical company Fagron has developed a UV air steriliser to provide indoor air disinfection for clinics and other enclosed spaces. The FagronLab UV-C Air Steriliser uses long-life, C-band (wavelength 253.7 nm) ozone-free ultraviolet to improve microbial air safety against viruses, bacteria and fungi, according to the company. Dan Barton, marketing communication manager at Fagron, commented, “The FagronLab UV-C Air Steriliser is truly an ingenious device that’s simple to operate and maintain, whilst continuously disinfecting the air to keep you safe. It’s a great way to keep your workspace or office as clean and hygienic as possible.” Inflexion invests in Medik8 Mid-market private equity firm, Inflexion, has invested in Pangaea Laboratories, a global beauty business and owner of the British skincare brand Medik8. Founder of Medik8, Elliot Isaacs, commented, “In the last three years, the brand has experienced phenomenal growth as the skincare consumer has become more knowledgeable and moved towards science and ingredients. We are thrilled to be partnering with Inflexion who have the passion and expertise to help us accelerate the brand’s international ambitions.” FDA clears Tixel for skin resurfacing Skin device Tixel, manufactured by Novexel, has received clearance from the Food and Drug Administration (FDA) for dermatological procedures requiring ablation and resurfacing of the skin. Mr Evgeny Piven, CEO of Novoxel said, “To get the first FDA clearance for Tixel was one of our primary goals. This achievement is the result of hard work by Novoxel employees, assisted by our worldwide KOLs. We‘re very grateful that we can now offer this product to physicians in the US. Since launching Tixel in Europe and many other countries several years ago, we have seen a growing demand from physicians and patients for our unique products.”

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Increasing Patient Safety The JCCP calls for better industry regulation The Joint Council for Cosmetic Practitioners (JCCP) has released a 10-point plan designed to create a more regulated, monitored and safer environment of practise for non-surgical aesthetics and hair restoration. The plan considers mandated qualifications, premises criteria, insurance and many other steps relating to the sector and industry. The JCCP is calling for any responses to the plan by June 1, after which it will be shared with government and national bodies. Professor David Sines, chair of the JCCP, commented, “Our 10-point Plan sets out the key parameters that are required to address the multiple challenges that exist within the sector. It is our hope and aim that by adopting a concerted and unified approach to addressing the issues set out in our Plan it will result in the achievement of systemic and responsive change within the sector. The primary aims are improving service user safety and quality of experience, whilst in parallel promoting excellence and pride within the aesthetic profession itself.” Point one: statutory regulation The JCCP suggests there should be statutory regulation for the non-surgical aesthetics and hair restoration surgical sector. The council wishes to help create primary and secondary legislation to set standards, which should include registration of premises, practitioners and ensure that only safe products are used. The JCCP also wants to implement powers for environmental health practitioners/enforcement officers to enable them to immediately deal with non-compliant practitioners. In addition, the organisation proposes restricting access to treatments to those over 18, except in certain medical circumstances. Point two: mandatory education and training standards Ensuring government and education/training regulators in the UK mandate specific qualifications, education and training requirements for specific modalities is also suggested. The JCCP proposes all cosmetic practitioners join a relevant Professional Standards Authority-accredited register prior to being enabled to practise. The JCCP will work with the UK Government to inform the design, production and implementation of primary and secondary legislation in order to set standards for education and training provision. Point three: publication of clear, transparent information Aesthetic service providers should clearly display simple and informative guides on all their services, including risks, benefits, costs, qualifications and proof of insurance to members of the public, according to the JCCP. Point four: legal definition of medical and cosmetic treatments The JCCP will work with government agencies to clearly define in law what constitutes a ‘medical’, a ‘medically-related’ treatment and what is ‘cosmetic’. The plan proposes that the JCCP will work with representatives across the aesthetics industry to seek to better define this, as well as what determines whether treatments require evidence of a health-related benefit. Point five: safe and ethical prescribing The JCCP says it will implement robust standards and regulation for safe, ethical and professional prescribing within non-surgical aesthetics. The objective is to get the UK Government, the devolved National Parliaments/Assemblies and the professional regulatory bodies to enforce legislation that prevents the practice of unsafe prescribing. The JCCP will also campaign for the implementation of legislation to re-classify dermal fillers as prescription-only devices. Point six: more regulated advertising and social media The JCCP suggests tighter controls and penalties on exaggerated, inaccurate and misleading advertising and social media posts in relation to aesthetic treatments. The JCCP aims to encourage the Advertising Standards Authority (ASA) to take stronger action against poor advertising practice and to get government agencies to work with

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social media companies to restrict the publication of misleading and harmful social media posts. Point seven: national complications reporting The JCCP will introduce enhanced and coordinated processes for the reporting and analysis of adverse incidents. The aim is to construct a single national database for adverse incidents/complications with regard to prevalence, intervention requirements and patient outcomes, as well as publicise and promote the use of the MHRA mobile app for complications reporting. Point eight: adequate insurance cover The JCCP proposes implementing legislation for all health and nonhealthcare practitioners offering aesthetic and hair restoration procedures to hold robust and adequate medical indemnity insurance covering each service they provide. To gain insurance, the JCCP believes there should be a requirement for all practitioners to demonstrate relevant knowledge and competence in the provision of treatments. Point nine: licensing of premises, practitioners and treatments The JCCP proposes nationally agreed standards for licensing and regulating premises for procedures and individuals. This will help to create a system where there is adequate auditing for qualifications, the safe supply and use of products/medicines and safe ‘harm-free’ premises. Point 10: raising consumer awareness Raising public awareness of the risks and benefits associated with non-surgical treatments and hair restoration surgery is the final action suggested by the JCCP. The objective is to ensure that the media profile around patient/consumer safety issues is raised through official communication channels, such as NHS websites, and that patients are being directed to a specific online area that contains relevant information and can educate them about aesthetic treatments.

Have your say

You can read the full 10-point plan by going to the JCCP website and anyone that wishes to send responses or commentary on the plan should email info@jccp.org.uk by June 1.

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Dermal Fillers and COVID-19 Aesthetics explores new guidance on dermal filler delayed onset reactions following COVID-19 infection and vaccination It is well established that a patient can have delayed onset nodules (DONs) or delayed onset reactions (DORs) in the following weeks, months or years after receiving a dermal filler treatment.1 This is particularly evident when the immune system is challenged, with potential triggers of these reactions including bacterial infections, viral illnesses, and vaccinations.1 Since the worldwide rollout of COVID-19 vaccines in December 2020, adverse reactions in those with soft tissue fillers have been reported. In Moderna’s phase 3 trial of its NIAID vaccine, which included 30,000 subjects, the US Food and Drug Administration (FDA) advisory committee noted that three patients who had facial fillers experienced moderate swelling to their face after receiving the vaccine.2 Currently the Pfizer/BioNTech and AstraZeneca/Oxford vaccines have recorded no similar side effects,3 but the news caused concern amongst both aesthetic practitioners and patients.4 In response, the Aesthetic Complications Expert (ACE) Group World has released a six-page paper, titled ‘The Impact of SARS-CoV-2 Vaccination and Infection on Soft Tissue Fillers’, written by aesthetic practitioner and ACE Group World founder Dr Martyn King.3

New guidance In the Moderna trial, three patients who had previously received soft tissue fillers had mild facial swelling following the vaccine. This was on the day of vaccination in two patients and, in the other patient, two days after vaccination. Filler injection had been administered two weeks before the vaccine in one patient and six months previously in another (the third was not disclosed). Given the study population and the incidence of facial filler treatments, Dr King believes it is likely that a significant number of those involved would have had an aesthetic treatment within the last 12 months, and they did not suffer any reaction.3 In light of this information, the ACE Group has recommended that practitioners should not perform soft tissue filler treatments either two weeks before or three weeks after COVID-19 vaccination or infection.3 Dr King comments, “From studies on other vaccinations,5 it’s known that the first three weeks are pivotal when developing an antibody response, and this is when the immune system is most stimulated. The guidance we have created applies to all current COVID-19 vaccinations, and not just to the Moderna vaccine.” According to the ACE Group guidelines, patients who have had lip filler or tear trough treatments in the last six to 12

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months should be considered at a higher risk of developing a reaction than those with other facial fillers.3 Dr King explains, “Although the data is currently extremely limited, the provisional evidence would suggest that the tear trough, malar and perioral regions are most susceptible to DORs6 following COVID-19 infection or vaccination, but it is possible this just represents the greater frequency that these areas are treated.” While there is currently no evidence or reports that any COVID-19 vaccination or infection has caused side effects for people who have had other aesthetic procedures, for example botulinum toxin, the ACE Group recommends avoiding treatments for one week post vaccine. Dr King explains that this is due to some patients becoming unwell and experiencing flu-like symptoms following vaccination.

Treating adverse reactions The current evidence would suggest that acute DORs in patients with soft tissue fillers present as mild to moderate oedema, although cases of angioedema have also been reported.6 The ACE Group notes that these reactions often quickly subside without treatment.3 However, if the response is greater than expected or lasts more than a few days, the ACE Group guidelines suggest that administering a short course of corticosteroids should be able to manage the complication quickly.3 Dr King comments, “When treating a complication, the ACE Group recommends a dose of 4mg oral Prednisolone for a duration of five days. As an alternative, Dexamethasone 4mg orally for three days can be used.” The guidelines state that if the DON or DOR does not respond to treatment as expected, practitioners should follow the ACE Group guidelines for COVID-19 reaction to infection. While the ACE Group states that reaction to infection should initially be treated in the same way as vaccination, from the limited evidence available, it seems that patients who contract COVID-19 and develop a DON or DOR tend to have a more recalcitrant problem needing multiple interventions.3 “If there is minimal response to an initial course of oral corticosteroids, or the problem escalates, the ACE Group recommends a prescription of a tetracycline (such as Doxycycline 100mg BD or Minocycline 100mg BD),” says Dr King, “Depending on response, hyaluronidase should be considered for hyaluronic acid dermal fillers whilst remaining

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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on antibiotic cover. The dosage used will depend on the extent and size of nodules and the filler product used.”

Patient education While the incidence of side effects is currently very low, the ACE Group emphasises that it is important for all patients to be fully aware of any risks related to COVID-19 vaccination and soft tissue fillers. It is recommended that these should be included on the consent forms given in initial consultations.3 Dr King notes, “Before performing any soft tissue filler treatment, the practitioner must take a full medical history, including previous and recent COVID-19 infection and vaccination schedule. The consent form given to them should explicitly state that aesthetic patients should not undergo soft tissue filler procedures within two weeks of their planned vaccination date or within three weeks having received it, and that they should not attend for treatment if they have symptoms consistent with COVID-19 or are suffering from ongoing symptoms from previous infection.” The ACE Group also recommends that the consultation forms should state that if patients develop any reactions following their treatment, then they should contact their healthcare practitioner at the earliest opportunity.3

Encourage vaccinations The ACE Group guidelines emphasise that previous soft tissue filler treatments are not a contraindication to vaccination and that practitioners need to continue to encourage patients to be vaccinated. Dr King comments, “The bottom line is that we need to ensure people are still getting their vaccines. While there have previously only been three reports of adverse effects, the vaccine is getting a greater mass roll-out now than before and it is starting to go out to the age demographic of patients who typically get facial filler.” Similarly, Dr King adds that once we are out of lockdown, more people will be able to get filler administered. “This means that these side effects may become slightly more common, and we don’t want any aesthetic patients to turn the vaccine down simply because they’ve had filler or are considering getting filler,” he explains. Dr King says that practitioners have a responsibility to ensure good communication with their patients, and to be aware how to make it as safe as possible. He comments, “It is essential that all practitioners are mindful of the risk, consent their patients appropriately, risk assess their patients, carefully time their treatments around their expected vaccination date and are knowledgeable on how and when to intervene if a complication does occur.” He also emphasises the importance of reporting a reaction, concluding, “Currently, there is a distinct lack of reporting on complications in aesthetic practice. Due to the lack of evidence concerning the COVID-19 vaccine and infection, it is even more important that this reporting occurs. The ACE Group advocates that all practitioners should report complications to the manufacturers and the MHRA.” The ACE Group provides a reporting mechanism to facilitate this process via its website and app, and the MHRA has created a dedicated Coronavirus Yellow Card reporting site which practitioners can use.3 REFERENCES 1. Turkmani, M.G., De Boulle, K. and Philipp-Dormston, W.G, Delayed hypersensitivity reaction to hyaluronic acid dermal filler following influenza-like illness. Clinical, Cosmetic and Investigational Dermatology, 2019. 2. Claire Gillespie, Moderna’s COVID-19 Vaccine May Cause Side Effects in People With Facial Fillers, 2021, <https:// www.health.com/condition/infectious-diseases/coronavirus/moderna-vaccine-facial-filler> 3. Dr Martyn King, The Impact of SARS-CoV-2 Vaccination and Infection on Soft Tissue Fillers, 2021, <https:// uk.acegroup.online/blog/2021/03/06/covid-19-fillers/> 4. Jolene Edgar, 2021, Why you should still get the COVID-19 Vaccine, <https://www.allure.com/story/covid-19-vaccineside-effects-dermal-fillers-injectables> 5. BBC Science Focus Magazine, Pfizer vaccine: Single dose “90 per cent effective after 21 days”, 2021, <https://www. sciencefocus.com/news/pfizer-vaccine-single-dose-90-per-cent-effective-after-21-days> 6. Artzi, O., et al., Delayed Inflammatory Reactions to Hyaluronic Acid Fillers: A Literature Review and Proposed Treatment Algorithm, Clinical, Cosmetic and Investigational Dermatology, 2020.

Dr Dinko Bagatin, specialist of general and subspecialist of plastic, reconstructive and aesthetic surgery at Poliklinika Bagatin in Zagreb and Split What’s your main focus at Poliklinika Bagatin? We were originally founded in 1995 by Professor Marijo Bagatin and we are now one of the leading institutions for aesthetic surgery, dermatology and aesthetic medicine in South East Europe. We have a diverse range of treatment offerings, but a big drive has been in the fat loss/body sculpting market. One of our most popular treatments is the green lasers by Erchonia, FDA cleared for full body circumference up to 40 BMI. Tell us about Erchonia green lasers? We were the first in Europe to introduce the Emerald Laser in May 2020, after achieving vast success with its predecessor, Verju. This green laser technology by Erchonia has taken our success to another level. First, it represents a better patient experience and increased satisfaction; secondly, the superior results have led to higher sales in clinics. We also like the fact that it works in tandem with the patient’s body to also work on their health and wellness. In my opinion, it provides the best and most flexible all-round solution on the market today, and also enables us to treat bigger patients. How does the Emerald work? One of the things I like about the Erchonia green laser technology is that it is a hands-free approach which frees up my staff. It is truly painless and has no reported side effects or adverse reactions. The technology can draw fat out of the body without destroying the fat cell, keeping the endocrine function intact. It does this by using electromagnetic energy transfer to create a photochemical reaction to create a transitory pore in the membrane of the fat cell. This emulsifies the intracellular fat and allows it to extrude out of the cell into the interstitial space. The patient’s lymphatic system is then used to transport released fat out of the body. It can be used by itself or combined with other technologies that help lymphatic flow. This column is written and supported by

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

Advertorial BTL Aesthetics

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How to Get Your Patients Summer Ready Dr Selena Langdon shares her most popular pre-summer body treatment tips Dr Selena Langdon is the founder of Berkshire Aesthetics and has featured in the Tatler Cosmetic Surgery Guide as a Top Doctor for body treatments for three years running. Here, she shares her most popular presummer body treatment tips to help your aesthetic practice.

What treatments do patients look for in the run up to the summer? It is an ideal time during the winter and spring for patients to start preparing their summer body. Many of us have been indoors and exercising less than we were pre-lockdown. Taking the opportunity now to target certain areas of the body ready for possible summer holidays with treatments such as Emsculpt or Emtone could really give your patients a boost to see results in time. Patients are keen to address the buttock area, thighs, arms and abdomen, as we tend to expose them more during the summer months outdoors. Most want to feel confident when wearing shorts and beachwear rather than covering up in loungewear all the time. Commonly, cellulite is a major concern for lots of women and we are lucky to be able to offer an effective treatment that really improves the appearance. Men and women also want treatments that can tone their abdomens and firm their buttocks, especially after all those months we have been sat at our desks on Zoom!

Is there anything that can really help with cellulite? Cellulite has often been seen as a difficult condition to treat. The more invasive options involve downtime, bruising and possible scarring which many patients are not keen to try. With Emtone, the system allows us to perform a very effective treatment that targets all five components of cellulite with no downtime. Emtone is a non-invasive treatment for cellulite and loose skin that combines both monopolar radiofrequency with targeted pressure energy, making it the first and only energy-based device that simultaneously delivers thermal and mechanical energy. This enables us to treat the root causes of cellulite by improving blood flow, disrupting fibrous bands that cause dimples, eliminating fat cells, resulting in better lymphatic drainage and improving skin elasticity by increasing collagen and elastin. Patients report improvements even after a single treatment and results typically continue to improve over the next few months.

How does EMSCULPT differ from other muscle stimulation systems? Emsculpt really stands out as the clear market leader for me when it comes to combined muscle building and fat reduction. I know my patients are in safe hands with Emsculpt as it has been extensively peerreviewed with ongoing new research continuously published about the technology. Efficacy and safety are extremely important to me, and the system has been

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used worldwide for many years. Patients have fed back that the procedure feels so much more powerful with rapid results that other systems struggle to deliver. Emsculpt is FDA cleared to help patients build muscle and sculpt the body using high intensity focussed electromagnetic energy (HIFEM). The procedure causes thousands of muscle contractions which improve the tone and strength of your muscles, increasing muscle mass by an average of 16%. In addition, multiple clinical studies on Emsculpt show an average of 19% fat reduction. Emsculpt allows me to deliver real results to my patients with no downtime.

How do you combine body treatments for best results? The key to achieving optimal results for my patients is to combine treatment modalities. There is never a one size fits all approach. I encourage my patients to follow a healthy lifestyle with a sensible diet and exercise, and to combine this with a bespoke treatment programme that addresses their body concerns. I am lucky to have several BTL technologies in my clinic, some of which include Emtone, Emsculpt and Exilis Ultra. This means I can address not only muscle tone, cellulite and loose skin, but also stubborn pockets of fat. By targeting skin, muscle and fat, I can offer patients a complete package of treatment that gives a fully holistic approach.

How long do the results last? With any energy-based system, I always emphasise that ongoing lifestyle and maintenance treatments play an important role in achieving long-lasting results. I believe in setting realistic expectations and never promise permanent outcomes. Patients appreciate my honesty and know that we work with them in partnership to take care of them by setting out a maintenance schedule. I usually advise retreating with Emtone yearly for the best results. In terms of Emsculpt, patients may choose to top up every six months depending on the degree of muscle toning they are looking to achieve, and of course they can top up sooner if they wish to do so. This advertorial was written and supplied by

More info: www.btlaesthetics.com/en info@btlaesthetics.co.uk @btlaestheticsuk Tel: 01782 579 060

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Considering Post-Pregnancy Devices Summaries of the types of procedures you can add to your clinic offering to help boost the confidence of body-conscious mothers ‘Mummy Makeovers’ can be big business in aesthetics. Women who have experienced pregnancy and childbirth may have body hang-ups that exercise and healthy eating cannot address alone, which is where you can help. Many may be quick to assume that surgery is the only option to treat particular post-partum concerns, yet there are numerous technologies on the market that offer effective results for various indications with minimal downtime. So, if you’re considering adding a new treatment to your clinic, why not look into a device that could

appeal to so many of your patients? Here we detail three of the most common post-pregnancy concerns and some of the device-led options you can potentially offer for each. A number of the options outlined can be combined with other treatments for enhanced results, so bear this in mind and conduct further research before making up your mind. Each description has been adapted from articles specifically on each of these topics on the Aesthetics website.

Body contouring Concerns addressed: excess fat, loose skin

Cryolipolysis Adapted from: Body Contouring Using Cryolipolysis by Mr Geoffrey Mullan and Using Cryolipolysis to Treat Fat by Dr Galyna Selezneva1,2 How it works: cryolipolysis involves exposing fat cells to low temperatures. They are then triggered to undergo apoptosis, resulting in an inflammatory response and removal by phagocytes over 12 weeks. Clinical research suggests: in a 2013 study of 518 patients, 891 total areas were treated and analysed. These included the flanks (59%), abdomen (28%), back (12%), inner thighs and knees (1%), and buttocks (1%). The majority of sites were treated once (86.5%), although some areas were treated two (13%) or three (0.5%) times. The authors reported that 86% of patients showed improvement, 73% were satisfied and only six were dissatisfied after Before

initial treatment, which dropped to two (0.4%) after a second treatment. Risks: research has indicated that cryolipolysis does not produce any significant adverse complications; however, redness and bruising can be expected, which will generally resolve quickly. Late-onset pain may occur several weeks after treatment, but this usually resolves without intervention. Short-term changes in the function of peripheral sensory nerves may take place, but these return to normal within several weeks with no long-term damage to nerve fibres or skin. In rare cases, additional fat, known as paradoxical adipocyte hyperplasia, can grow at a treatment site, the incidence of which has been indicated as 1 in 20,000 patients. User insight: “In my experience cryolipolysis is a suitable, safe option for patients who do not wish to have the risks and downtime associated with surgery and my patients have shown a high level of satisfaction.” Mr Geoffrey Mullan

High-intensity focused ultrasound

After

Images show 37-year-old patient before and 14 weeks after treatment with CoolSculpting cryolipolysis. The mother had not been able to lose fat in the lower abdomen region and flanks.

Adapted from: An Overview of Non-surgical Body Contouring Treatments by Dr David Jack and An Introduction to Fat Reduction by Dr Tatiana Lapa and Mr Rishi Mandavia3,4 How it works: focused ultrasound is used to create deep areas of coagulative necrosis in the subcutaneous laser, which results in volume reduction and tightening, while not damaging the surrounding tissues. Clinical research suggests: response is usually evident within two weeks and complete within three months. One study in 2013 supported mean reductions in waist circumference ranging from 4.2-4.7cm, 12

weeks after the procedure. Another more recent study in 2020 found a reduction of 3.43cm in mean waist circumference and fat thickness after eight weeks. It should be noted both had small sample sizes. Risks: mild redness, swelling and tenderness can occur immediately but will generally not persist. In one study, pain was measured as 2.74 out of 10 immediately after treatment, which reduced to 1.10 after one week. User insight: “More than one treatment is usually required to provide optimal results. These treatments are suitable for all skin types and generally have a minimal side-effect profile.” Dr David Jack

Non-thermal low level laser therapy Adapted from: Treating the Body with Low Level Lasers by Robert Sullivan PhD5 How it works: non-thermal low level laser therapy (NTLLLT) has been indicated to effect body composition through inducing changes in adipocyte metabolism and changing the expression of the hormone involved in appetite, leptin. Clinical research suggests: in a study to examine the clinical effectiveness of a 635680 nm NTLLLT, results of 40 participants showed a statistically significant cumulative girth loss of 2.15cm after eight 30-minute treatments over four weeks. NTLLLT has also shown to provide further benefits, including a reduction in cholesterol and leptin levels. In a two-week trial of 22 patients, a 50% reduction after six treatments was demonstrated. Risks: believed to be minimal. One review reported 38% of 1,114 patients treated described swelling or erythema at the treated area, 32% had pain or tingling during, and

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

BELIEVE IN THE POWER OF SEEING. Ultherapy® is the only FDA cleared microfocused ultrasound technology that has real time visualisation (MFU-V).1,2 Real-time visualisation, enabling treatment customisation, precision targeting of tissues, and optimised patient outcomes 3 FDA-cleared and CE-marked so you can be confident of Ultherapy®’s good safety profile1

REAL-TIME VISUALISATION

The Gold Standard for non-surgical lifting and skin tightening, as determined by an expert consensus panel3

For more information visit Ultherapy.co.uk

@merzaesthetics.uki Merz Aesthetics UK & Ireland REFERENCES: 1. www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed September 2019 2. Ulthera release: Ultherapy® décolletage treatment now FDA-cleared. BioSpace website. https://www.biospace.com/ article/releases/ulthera-release-ultherapy-and-0174-d%C3%A9colletage-treatment-now-fda-cleared-/. Accessed January 21, 2020. 3. Fabi SG, Joseph J, Sevi J, Green JB, Peterson JD. Optimizing patient outcomes by customizing treatment with microfocused ultrasound with visualization: gold standard consensus guidelines from an expert panel. J Drugs Dermatol. 2019;18(5):426-432

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-anissue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

Refer to the Instructions for Use (IFU) for complete instructions on operating the Ultherapy® System The non-invasive Ultherapy® procedure is U.S. FDA-cleared to lift skin on the neck, on the eyebrow and under the chin as well as to improve lines and wrinkles on the décolleté. The CE Mark indications for use for the Ulthera® System include non-invasive dermatological sculpting and lifting of the dermis on the upper face, lower face, neck and décolleté. Reported adverse events from postmarketing surveillance are available in the Instructions for Use (IFU ). Please see the available IFU in your country for product and safety information, including a full list of these events. © 2018 Ulthera, Inc. The Merz Aesthetics logo is a registered trademark of Merz Pharma GmbH & Co. Ulthera, Ultherapy, DeepSEE, SEE THE BEAUTY OF SOUND and the Ultherapy logo are trademarks or registered trademarks of Ulthera, Inc., in the U .S. and /or certain foreign countries. Merz Pharma UK Ltd. 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire, WD6 3SR Tel: +44 (0) 333 200 4140 M-ULT-UKI-0914 Date of Preparation March 2021

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increased urination was also reported. User insight: “I frequently hear patients report feelings of more energy, improved health, less pain and better sleep patterns. It is plausible to conclude that NTLLLT improves cellular function and, as supported by the presented evidence, the ability to restore, reenergise and rejuvenate.” Dr Robert Sullivan PhD

Radiofrequency Adapted from: An Overview of Non-surgical Body Contouring Treatments by Dr David Jack and An Introduction to Fat Reduction by Dr Tatiana Lapa and Mr Rishi Mandavia3,4 How it works: radiofrequency (RF) treatment involves the heating of skin and deep tissue, resulting in vasodilation and inflammatory changes, with subsequent stimulation of dermal thickening, deeper connective tissue thickening and reorganisation.1 Clinical research suggests: heating the adipocyte layer to 43-45°C has been indicated to induce selective apoptosis in fat cells, with

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volume reduction three to eight weeks posttreatment, with up to 3cm reductions in waist circumference following 10 treatments. Risks: transient effects such as erythema are common and expected. While RF treatments are considered on the whole to be safe, these devices are operator dependent so complications such as burns do still occur. In addition, older monopolar RF devices have been associated with uneven depths of RF penetration, later unevenness of fat breakdown and associated surface contour abnormalities. Bipolar or multipolar Before

RF handpieces tend to be much more predictable, so the risk is less with these when compared to monopolar RF. User insight: “RF can present challenges in terms of pain management. Topical anaesthetics that numb the epidermis are not recommended as they may aggravate pain, whilst local anaesthetics may interfere with delivery of RF waves. Oral analgesics are the generally recommended agents for pain management.” Dr Tatiana Lapa and Mr Rishi Mandavia After

Figure 2: Before and after treatment in a post-partum woman with the Alma Accent, which combines radiofrequency and ultrasound. Images courtesy of Dr Jorge F. Ottini, Argentina.

Vaginal rejuvenation Concerns addressed: vaginal laxity, stress urinary incontinence, sexual dysfunction

Radiofrequency Adapted from: Vaginal Rejuvenation by Dr Mayoni Gooneratne and Rejuvenating the Vagina by Allie Anderson6,7 How it works: RF generates volumetric heat in the tissue, promoting collagen and elastin production. No anaesthesia is required, and patients report a tolerable sensation of warmth. Treatment takes 30 minutes or less to administer. Clinical research suggests: a 2015 study among 23 patients, who underwent three treatments at 30 minutes each, found that all experienced a tightening result, and significant improvement in urinary continence and sexual satisfaction. There were no adverse effects reported. A 2017 randomised, single-blinded and sham-controlled study of a different RF device found that a single treatment was associated with both improved vaginal laxity and improved sexual function. Risks: treatments that are based on the ablation of mucosal tissue have a longer recovery time than non-ablative techniques. A 2011 histological study looked at ovine tissue treated with ablative and nonablative low-energy RF. The study concluded that the non-ablative treatment delivers RF at levels insufficient to result in thermal cellular necrosis. Procedures should be delayed for at least six months’ postpregnancy to allow time for the restoration of hormonal levels and the resolution of anatomical changes caused by pregnancy. A woman should also have ceased breastfeeding at least three months prior to evaluation for any treatment. User insight: “Vaginal laxity is a common problem for women, especially after pregnancy and birth, and into menopause. However, due to embarrassment and lack of knowledge, it remains underdiagnosed. As women gain knowledge and confidence in this area, and seek effective treatments, we can expect continued development in the non-invasive energy-based devices. Initial studies suggest

that they can be effective treatments for vaginal laxity with mild to moderate symptoms, for women of all ages, both pre- and postmenopause.” Dr Mayoni Gooneratne

Laser Adapted from: Vaginal Rejuvenation by Dr Mayoni Gooneratne and Rejuvenating the Vagina by Allie Anderson6,7 How it works: CO2 and Erbium:YAG lasers are both used for vaginal rejuvenation. While they operate at different wavelengths, each uses fractional photothermolysis where light energy from the laser creates heat damage at multiple microscopic areas within the skin. The thermal necrosis then triggers a wound-healing response which results in the formation of new elastin and collagen fibres, thus firming and tightening the tissue. Treatment takes between 10 and 30 minutes, with no anaesthetic necessary. Clinical research suggests: a study in 2014 aimed to assess the efficacy and feasibility of fractional CO2 laser in the treatment of vulvovaginal atrophy in postmenopausal women. 50 women aged 54-66 years were assessed before and after three applications

Figure 3: Patient presenting before and after one treatment using the Votiva FormaV RF device for 15-20 minutes. The first treatment was vaginal, then the external and labia minora were treated for 10 minutes. Images courtesy of InMode UK.

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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of treatment. The study showed a significant improvement at 12 weeks’ post treatment. A separate study published in 2017 assessed fractional CO2 laser treatment in 21 perimenopausal women. At 12 weeks’ follow-up, 82% of patients showed a statistically significant improvement in vaginal health, 81% reported improvement in sexual gratification and 94% reported improvement in vaginal rejuvenation. Erbium:YAG lasers operate at a lower wavelength than CO2 lasers, but treatment works on the same principles. A comparative study found that there was improvement in vaginal tightening in both groups. A 2014 study into the use of Erbium:YAG for the treatment of vaginal relaxation looked at 30 post-partum females aged 33-56 years, who each received four sessions of treatment. No adverse events or side effects were recorded, and significant improvement in vaginal laxity was seen in all subjects at two months’ post procedure.

Risks: non-ablative laser treatments have been found to be well tolerated with no serious adverse effects. One study of ablative fractional CO2 laser treatment found that some patients experienced a burning sensation, which lasted up to five days’ post treatment. Patients treated with CO2 laser should refrain from sex for five to seven days, and with the Erbium:YAG laser, for three days. Side effects are limited to mild bleeding or spotting, and the procedure lasts around 20-25 minutes. As above, vaginal treatments should take place at least six months’ post-pregnancy and the woman should have ceased breast feeding for at least three months. User insight: “Laser treatment aims to improve the tone of the vaginal wall, thereby improving sexual function and pleasure. By treating the anterior wall of the vagina, it also has very significant effects in treating stress urinary incontinence.” Mr Christopher Inglefield

Scarring transformation Adapted from: An Overview of Microneedling by Chloé Gronow, Treating Striae Distensae by Dr Kieron Cooney and Scar Treatment by Dr Carolyn Berry8,9,10 Concerns addressed: scars, stretch marks

Microneedling How it works: when causing the right form of injury, the dermis reacts to the trauma by repairing itself, generating new collagen and elastin, resulting in a rejuvenated appearance. Pens and roller devices can be used. Longer needles are advised for scar treatments. Clinical research suggests: 30 women with striae rubra who were treated with three treatment sessions, six weeks apart showed a positive outcome. Researchers analysed microneedling alone versus microneedling with a TCA peel and showed improvement in both groups, albeit more so in the combined. Microneedling is more commonly used in combination with other treatments. Risks: generally not recommended for keloid scarring, active infection on a dark and unstable skin type. Side effects can include bleeding, slight bruising, redness, dryness and skin flakiness. User insight: “Microneedling is an option if someone cannot afford downtime or is on a tight budget.” Dr Harryono Judodihardjo

Laser How it works: treatment leads to epithelial damage with resultant re-epithelialisation, and stimulation of extracellular collagen synthesis and increased elastin production. There is remodelling of the tissue with a resulting improvement of surface appearance. Lasers that target the water chromophore in skin, such as the ablative 1060 nm CO2 laser, and the 2940 nm Erbium:YAG laser, are widely used in the treatment of acne scars. As such, these lasers are also being used for the treatment of stretch marks, which have similar

histological features as acne scar tissue. Other lasers can also be considered. Clinical research suggests: pulsed-dye lasers have been shown to have good results for striae rubra, as have 1064 nm Nd:YAG lasers. Ablative and non-ablative fractional lasers such as 1060 nm CO2 laser and the 2940 nm Erbium:YAG laser mentioned above, are more commonly used with successful results. Of note is a study evaluating the effectiveness of a RF device in combination with a pulsed dye laser, in which 89% of the patients showed good to very good overall improvement. Multiple treatments are recommended. Risks: as with other laser treatment, side effects can include redness, swelling and itching. Burns comprise more serious side effects. It’s also important to note that treatment will not completely eradicate stretch marks, just reduce their appearance. User insight: “I believe that the literature indicates that chronic striae alba (pale, atrophic, avascular lesions, similar in appearance to stretched, mature, scarred tissue) appears to be more resistant to laser treatment, though ablative and non-ablative fractionated laser devices do offer optimism.” Dr Kieron Cooney

buttocks, over three sessions at four weekly intervals. It was reported that there was improved appearance; assessed by a blinded photograph assessment, clinical observations and patient feedback. It was reported that RF may be more effective when combined with other modalities such as laser. There are also devices available that combine microneedling with RF, which can offer enhanced results. User insight: “Research into the use of RF in combination with PRP, microdermabrasion and microneedling is worthy of more consideration as few studies have looked at the benefits on the appearance of stretch marks in combination.” Dr Kieron Cooney

Consider wellbeing

Despite the business opportunities ‘mummy makeovers’ can bring, your patients’ mental health and general wellbeing should not be forgotten. According to a survey by the Mental Health Foundation, more than half of 1,572 women aged 25-34 felt more negative about their body image after pregnancy.11 Practitioners should not take advantage any vulnerabilities associated with this and must always offer an in-depth consultation and refer to an appropriate specialist if necessary.

Radiofrequency How it works: the technology works by passing an electric current through the tissues. Those tissues that have high resistance absorb the energy converted to heat and again elicit a collagenesis response. Clinical research suggests: in one study, nano-fractionated RF was applied to 33 women with striae alba on the abdomen or

VIEW THE REFERENCES ONLINE! AESTHETICSJOURNAL.COM

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

Advertorial CoolSculpting®

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The Elite Experience Meet your potential – the evolution of body contouring

The body is becoming the new face.1 With 79% of patients feeling as though they have excess fat in areas of their body or submental region,1 more and more will be seeking treatment so it’s a patient demand you simply can’t ignore.2 With top patient concerns being related to the abdomen, flanks and inner thighs,3 aesthetic practitioners need to find effective solutions that will give patients notable results in the areas that matter most, while also being the best fit for their business. CoolSculpting® is the world’s leading body contouring treatment designed to reduce stubborn fat,4 while preserving the skin and surrounding tissue.5 To date, over eight million treatment cycles have been completed across the globe.6 And now, after more than 10 years of successful results,7,8 Allergan Aesthetics has launched its next generation device – CoolSculpting® Elite – offering a whole new experience for patients and practitioners.9

A design made by YOU CoolSculpting® Elite was developed following an extensive user insight study, combined with Allergan Aesthetics’ 20 years of R&D experience.7,10 Jarred Evans, managing director of PDR, a design and innovation agency based in the UK, worked closely with the R&D teams at Allergan Aesthetics

in the US to help define and design the next generation of the CoolSculpting® system. Evans explains, “Allergan Aesthetics knew they needed to make the best even better.4 While there had been a continuation in developing a string of effective new applicators and with that new treatment areas, there was an opportunity to take a step back and develop a whole new technology platform and approach from the ground up.7,11 To do this, we visited clinics, worked alongside practitioners and interviewed patients and customers from around the world in depth. These insights and understandings led to us being able to develop a significant pipeline of new innovations and opportunities.”10 As such, the whole design philosophy behind the Elite system is ‘Designed by You’, says Evans, adding, “The Elite design programme has been something that right from its very conception, sought the views, perspectives and practical realities of real users and patients. The data we collected drove the specification for the new design, from its aesthetics to its user interface, and allowed design engineering work to stay focused on the customer and patient needs above all else.”10

Introducing the newest features According to Maria Pierides, Director, Body Contouring, Allergan Aesthetics, each individual innovation of the CoolSculpting®

How CoolSculpting® works Often called ‘fat freezing’ CoolSculpting® is a cryolipolysis treatment that cools subcutaneous fat cells to temperatures that trigger apoptosis, whilst maintaining the integrity of the surrounding tissue.5 Following treatment, the body’s immune system naturally

Elite is significant, but together they create a system that is far easier to store, clean, maintain and use.9 “Body contouring has evolved and as category creators, so have we.12 We have built on our established heritage and expertise in this area and added in new capabilities to create CoolSculpting® Elite.7 We have also listened to our customers and considered every detail of the new system to give every practice and their patients an improved experience.”10 Powered for duality: the Elite has been re-engineered with a more powerful chiller to deliver reliable cooling consistency, enabling simultaneous dual applicator treatment.9,13 Use of dual applicators provides the ability to conduct twice the number of treatments in the same amount of time.9,14 New applicator toolkit: the new C-shaped cups are engineered to complement the body’s natural curves, maximising your contouring capabilities, and to improve fit and comfort during tissue draw.9,15,16 Lightweight and detachable from the umbilical,9,15 the seven applicators have up to 18% larger cooling surfaces to treat a wide variety of body areas,15 and an improved cooling distribution to treat a greater percentage of targeted tissue.17 Streamlined workflow: the new universal smart card is simplified to work across the full applicator family, giving you more flexibility.9 The applicators have fewer parts for a faster set up12 and are designed for easier posttreatment applicator clean-up.9

processes the fat and removes the dead cells, and delivers a reduction of up to 27%.18,20 CoolSculpting® has been studied in the greatest number of patients, compared with other non-surgical fat reduction devices, and its efficacy is evidenced in more than 60 peer-reviewed publications to date.8

Aesthetics | April 2021

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Before

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Advertorial CoolSculpting®

After

Medical director of The Cosmetic Skin Clinic Dr Tracy Mountford says…

Results are shown 27 weeks after the first CoolSculpting® session. The patient received two treatment cycles using the CoolMini™ applicator on the submental region. There is no additional clinical information for treating the submental region in more than two sessions.* Before

After

Results are shown 17 weeks after the second CoolSculpting® session (27 weeks after the first CoolSculpting® session). The patient received a total of four treatment cycles using the CoolAdvantage™ applicator on the lower and mid abdomen, lower bra and flanks.* *Patients were treated using the original CoolSculpting® system

Modern interface: the easy-to-use interface provides an intuitive experience. It looks sharper and more contemporary, providing you with optimum usability.9 Slim and sophisticated: the contemporary design allows for seamless practice integration, keeping those with limited clinic space in mind. The Elite was created to be more compact, with thinner, lighter and more flexible handpieces that are detachable from the umbilicals for ease of movement and storage.9,12

Make the most of CoolSculpting® Allergan Aesthetics with CoolSculpting® Elite continue to provide a comprehensive level of support to patients and clinics as with the original device.9,12 Safety: the CoolSculpting® Elite system still utilises the patented Freeze Detect® and CoolControlTM to monitor tissue during cooling to optimise patient outcomes.9 Partnership: Allergan Aesthetics is committed to making CoolSculpting® a success for clinics and provide more than the system alone. To learn more about how CoolSculpting® Elite can benefit your practice, visit uk.coolsculpting.com/hcp REFERENCES 1. Allergan. Unpublished data. INT/0130/2018. CoolSculpting® consumer research (overall aesthetic concerns). March 2018. n=25,749 (total study population N=32,570). Data were obtained from market research undertaken in 2016/17 by online survey across 27 countries. 2. Allergan 360 Aesthetics Report. 3. Allergan. Data on file. INT/0118/2018. CoolSculpting® consumer research (areas of excess body fat). February 2018. 4. Allergan. Unpublished data. INT-CSC-1950062. CoolSculpting® market research. July 2019. Based on HCP tracking market research in the US, UK, Germany, Canada, Brazil, China, and Australia (N=526), and global market research of the overall body shaping and skin tightening market. 5. Zelickson B, et al. Dermatol Surg 2009;35(10):1462–70. 6. Allergan. Unpublished data. INT-CSC-2050157. Number of CoolSculpting® treatment cycles as of July 2019. March 2020. 7. Allergan Unpublished Data. INT/0586/2018. CoolSculpting® science and evolution. October 2018. 8. Allergan. Unpublished Data. INT-CSC-1950037. CoolSculpting® publications. As of June 2019. Additional publications may exist that are not captured by a PubMed search, for example conference abstracts or journals not indexed by PubMed. Off-label use of cryolipolysis devices was excluded. Includes English language publications only.

There is huge growth in the popularity of body contouring amongst patients and there’s a real thirst for nonsurgical solutions that work. They say that the ‘body is the new face’ and I think this is because people are now investing more in their body.1 As technology is becoming so effective, practitioners have the ability to refine and define the shape of the body nonsurgically.9,18 I’ve been using CoolSculpting® for almost nine years and I believe it is a non-surgical solution that is an alternative option to surgery, for those who want to sculpt and contour their shape,9 with less downtime.19 I think the newly evolved CoolSculpting® Elite holds great potential in enhancing both our patients’ needs and the benefits in our practice. The biggest benefit is that you no longer need two machines to treat two areas!9,14 The dual applicators enable twice the number of treatments in the same amount of time – and changing the applicator head is smoother and quicker – offering a better and more efficient treatment experience to even more of our patients.9,15,16 The fact that it’s a smaller, slicker, more streamlined piece of equipment with a beautiful aesthetic means it fits well within the clinic and will really benefit those with space restraints.9,12 The increased ease of use of CoolSculpting® within our clinic means we can service our patients in a more optimised way.9,12,14,15

9. 10. 11. 12. 13.

Allergan. CoolSculpting® system (CoolSculpting® ELITE) user manual. CS-UMCM3-04-EN-A. 2020. Allergan Unpublished Data. INT-CSC-2050239. PDR practice and patient insights. May 2020 Kilmer SL, et al. Lasers Surg Med 2017; 49(1):63-68 FDA. K193566. ZELTIQ® CoolSculpting® System. January 2020. Allergan. Unpublished data. INT-CSC-2050287. CoolSculpting® ELITE chiller specifications. July 2020. 14. Allergan. CoolSculpting® system user manual. BRZ-101-TUM-EN4-H. December 2016. 15. Allergan. Unpublished Data. CoolSculpting applicator dimensions, design information. INTCSC-2050029 16. Allergan Unpublished Data. INT-CSC-205028. CoolSculpting® clinical fit and function study of V003 cups. March 2020 17. Allergan Unpublished Data. INT-CSC-2050288. Applicator cooling and distribution dye test. August 2020. 18. Sasaki GH, et al. Aesthet Surgery J 2014;34:420-31. 27% refers specifically to the lower abdomen, average fat layer reduction as follow up was 21.5%. 19. Avram, M. M., & Harry, R. S. Lasers in Surgery and Medicine, 2009;41(10), 703–708. 20. Klein KB, et al. Surg Med 2009; 41:785-90

This article was produced and funded by Allergan Aesthetics, an AbbVie Company

For more information go to: uk.coolsculpting.com/hcp

Aesthetics | April 2021

UK-CSC-2150032 Date of preparation: February 2021

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The Physiology of Wound Healing Miss Priyanka Chadha, Miss Lara Watson and Dr Nihull Jakharia-Shah review methods to enhance wound healing and reduce scarring Wound management is an important consideration in surgical and non-surgical aesthetic practice. Effective wound healing is vital for optimising both functional and aesthetic outcomes. Poor wound healing can lead to contracture and loss of function of a muscle/ joint.1 Wounds with poor aesthetic outcomes can cause significant psychological distress and secondary psycho-social burden,2 while chronic wound management can carry a large economic drain.3 In aesthetic practice, wounds are an important consideration prior to any procedure as, although the underlying treatment may be effective, poor wound formation could lead to overall worse aesthetic outcome and patient dissatisfaction.

It is initially achieved through platelet aggregation, leading to clot formation and vasoconstriction of exposed vessels. The final product of this process is a fibrin mesh which provides structure to the wound site and traps cells necessary for later stages of wound healing.4

Increasing aesthetic standards and a deeper understanding of the physiology of wound healing have pushed for the development of novel wound management techniques which we will explore in this article. Whether from trauma, surgery or aesthetic practice, the principles of optimal wound management are shared, and the desired outcome is always minimal disruption of the structure and function of the treated area. Most of these techniques can be performed by any medical aesthetic practitioner, but a deep understanding of the process is needed for safe and effective use.

Stage 3: Proliferation Proliferation occurs via growth factor-stimulated mitosis of cells in the exposed wound surfaces, sealing the wound gap (re-epithelialisation). Growth factors and cytokines encourage migration and mitosis of fibroblasts across the wound. If the wound gap is small, this is sufficient to lead to closure. The proliferation phase is established by day five and lasts up to three weeks.4 Fibroblasts in the surrounding skin produce collagen in response to growth factors. This reinforces the adhesion of opposed wound surfaces and creates a new epithelial surface. Glycoproteins fill the spaces between the cells and the collagen fibres to maintain a biologically active environment.4 Angiogenesis, the formation of new blood vessels, is triggered via growth factors released from macrophages. This is vital to supply the site with nutrients and oxygen for new tissue to be formed. B-lymphocytes infiltrate the tissue and proliferate plasma cells to release antibodies to prevent infection. This collection of lymphocytes, plasma cells, macrophages, fibroblasts, collagen and glycoproteins is termed granulation tissue. Granulation tissue provides the optimal tools and environment for formation of new tissue.6,7 The blood clot formed during haemostasis is degraded via the enzyme plasmin, a product of the metabolism of plasminogen, which breaks down the fibrin in the mesh.8

Stages of wound healing The skin plays a vital role in maintaining homeostasis, protecting us from the external environment, and cosmetic effect. As such, our bodies have physiological mechanisms to repair the skin with the aim of restoring its inherent function. This process is carried out over four stages: haemostasis, inflammation, proliferation, and remodelling and maturation. Stage 1: Haemostasis Wounds that penetrate the dermis damage internal vessels, causing haemorrhage. Haemostasis occurs at the onset of injury to control blood loss and maintain an environment that can facilitate growth of new tissue. Hemostasis Blood clot

Figure 1: Stages of healing10

Inflammation

Stage 2: Inflammation Exposed wound sites are prime environments for bacterial growth. Cytokines and inflammatory mediators attract neutrophils and macrophages to engulf bacteria and necrotic tissue whilst releasing growth factors. This phase often lasts between four and six days and is characterised by erythema, pain, oedema and heat.5

Proliferation Phase

Tissue Remodelling

Scab

Fibroplasts

Macrophage

Fibroplasts proliferating

Subcutaneous fat

Freshly healed epidermis

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

Freshly healed dermis

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Stage 4: Remodelling and maturation Remodelling, also known as the ‘maturation phase’, consists of wound closure and remodelling from Type III collagen to Type I. The type III collagen structure produced during the proliferative phase is disorganised; during the remodelling phase this is replaced by Type I collagen, whose fibres align along tension lines and cross-link. The new structure has greater tensile strength and reduced scar thickness. Fibroblasts differentiate into myofibroblasts which contract and close the wound. Contact inhibition occurs when opposing epithelia of the wound unite and, by doing so, inhibit further growth. This stage typically starts around week three and can last over a year.9

Mechanisms of wound closure There are three mechanisms of wound closure: primary, secondary and tertiary intention. The clinical context will determine which mechanism is most appropriate; for example, within non-surgical aesthetic practice wound healing will occur via primary intention as the wound gap will be small. Primary intention wound closure This is used when opposing wound edges are within close proximity of each other to allow connection via collagen fibres and myofibroblasts alone. The wound space should be clean to prevent obstruction, infection or biochemical changes that disrupt optimal healing physiology. This mechanism can be augmented through the use of glue, steristrips, staples or sutures. On occasion, primary closure can be considered to be ‘delayed’ when the wound is left open for a period of time to ensure no contamination and a clean base before further closure by specific means.11 Secondary intention wound closure This occurs when there is a larger wound gap, non-linear wound edges or wound contamination. It carries a greater risk of infection and suboptimal closure. Use of dressings is important in secondary intention healing in order to keep the wound clean and keep opposing surfaces in close proximity. Skill is required during dressing and subsequent dressing changes to ensure minimal disruption to the granulation tissue and prevention of contamination. If there is considerable tissue loss, the wound may not be able to close at opposing surfaces, meaning the wound must be kept open and heal from the base upwards. This process takes considerably longer than primary intention.11 Tertiary intention closure This is also known as ‘delayed primary healing’. It is used when there is reason to delay definitive closure, for example, to allow treatment of infection or debridement of necrotic tissue. Anaerobic bacteria colonisation may be particularly troublesome as these bacteria can grow within re-epithelialised tissue, leading to chronic infection and abscess formation. Once the wound is ready for closure, initial steps include skin grafts, flaps and sutures. The ultimate healing process includes a combination of primary and secondary intention.11

Scar assessment A scar is the remnants of regeneration tissue and fibrosis from wound healing. Regenerated tissue is the collection of new cells formed by mitosis of exposed epithelial cells and fibrosis of the organised collagen (Type I), which occurs at higher levels compared with normal tissue. Genetic, epigenetic factors and environmental factors affect wound

healing and, eventually, scar formation. There are three main types of scars: keloid, hypertrophic and contracture scars.12 • Keloid scarring describes a scar which is larger than the initial wound and usually occurs through defects in contact inhibition. The margin of the scar will extend beyond the margin of the wound. • Hypertrophic scars are raised but contained within the boundaries of the initial wound. • Contracture scarring is the development of a rigid scar which results in reduction/loss of mechanical function of the affected area. The Vancouver scale is used to quantify scar appearance and is commonly used for assessing burn scars. It has four measurables – vascularity, height, pliability and pigmentation – and is scored out of 13. Vascularity is a measurement of the blood supply to the scar. Height is measured in millimetres of depression/elevation from adjacent ‘normal’ skin. Pliability is the structural integrity of the scar and is related to elasticity and the amount of collagen present. Pigmentation is scored via comparison of pigmentation of scar tissue to surrounding ‘normal’ skin.13 The Manchester Scar Scale is an alternative scar assessment technique that includes subjective scores. It contains the following criteria: vascularity, pigmentation, acceptability, observer comfort, contour, skin texture, relationship to surrounding skin, texture, margins, size.14 This scale is applicable to a wider range of scars than the Vancouver scale and is reported to be more effective at evaluating post-operative scars. However, the Vancouver scale is more commonly cited in literature, likely due to its relative objectivity and simplicity compared to other scoring systems.

Sutures for wound healing There are a number of suture techniques that can be utilised to close a wound; these will in turn have an impact on the functional and aesthetic quality of the scar. Although primarily used in surgical procedures it is important for any aesthetic practitioner to understand the basic principles of surgical practice as this will enable them to provide better advice to patients on their treatment options. Barbed sutures have barbs along the surface of the suture which lock into the tissue, preventing the need for knots to tie the suture in place. These enable faster operating times but are reported to have lower aesthetic outcomes.15 Mattress stitching is a technique that produces deep and superficial closure, whilst also optimising the alignment of wound edges. This can produce better aesthetic outcomes through the eversion of wound edges, but care must be taken not to strangulate skin at the wound margin as this can lead to necrosis and scars (cross-hatch, railroad or Frankenstein marks). Cosmetic outcomes can be enhanced with bolstering techniques; these include the use of gauze, cardboard or tubing (plastic). These methods prevent excessive pressure being applied to the surrounding skin, preventing the sutures from being embedded whilst allowing them to pull wound edges together.16 Often, the sutures that are used and techniques employed are individual to the operating surgeon and based on a number of factors, including advice from departmental culture, personal experience and location of the wound.

Wound-healing techniques in the literature A number of novel techniques exist to augment wound healing and improve aesthetic outcomes. We have touched on a few next but

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the list is by no means exhaustive as literature is sparse for many of these techniques. It should be noted that the listed techniques can be implemented by any practitioner, without additional qualification, though an understanding of the mechanism is important to ensure safe and effective use. Laser-assisted skin healing Laser-assisted skin healing (LASH) is a technique that involves using lasers on the sutured incision. A study of 40 women by D Casanova et al. in 2017 found that the use of a 1210 nm laser diode was effective in reducing the time taken for an incision on breast tissue to heal.17 This double-blinded randomised controlled trial involved a single treatment after suturing the wound. The average laser treatment lasted for 6.9 minutes with a standard deviation of 2.5 minutes. Alexandre Capon et al. found that 810 nm diode laser treatment can have a positive effect on scar formation of 30 participants, however laser strength is key to determining the level of healing within the scar.18 Rui Jin et al. found that there is minimal evidence for the use of laser therapy in treatment of keloid scars.19 The above literature strongly suggests that laser treatment in patients with lower Fitzpatrick skin scores produces more noticeable benefits. However, there is debate over which wavelength and what treatment regime produces optimum results. Silicone dressing Silicone dressings contain a layer of silicone gel on the surface in contact with the skin and have a robust reputation in the augmentation of scar formation. They are generally placed on a scar after the sutures have been removed. In Jan Sam Kim et al. dressings were kept on the wound of one patient’s foot for 12 weeks. In this study, scars at four and 12 weeks were better than the control scars when measured on the Vancouver scale.20 It is hypothesised that the improved results are due to the silicone dressing aiding in reapproximating skin margins and delaying primary closure. This results in a smaller scar.21 Non-silicone dressings Non-silicone dressings include, but are not limited to: acellular bilaminate, salinomycin and carboxymethylcellulose. Acellular bilaminate primary dressings limit scar formation, by preventing differentiation of myofibroblasts and inflammatory mediator production from macrophages.22 Dressings coated with the antibiotic salinomycin aid healing by preventing infection. Carboxymethylcellulose dressings have been found to be ineffective in aiding cell adhesion and proliferation of the cells. This was present in both the porous and homogenous forms of the wound dressing. However, in combination with fibrin, a study has shown the potential for improved aesthetic outcomes and faster wound healing.23 Microneedling Microneedling, done using a device such as a dermaroller, is used to instigate cosmetic enhancement of healing tissue. This occurs via electrical signals stimulating proliferation of cells. A systematic review of microneedling for facial scars concluded that there was an improvement in aesthetic outcomes, however further studies are required to establish treatment protocols.24 A different study by Vijaya Lakshmi et al. recorded that pain was not an issue with patients. The depressed and elevated scars flattened with the surrounding skin while pigmentation became similar to the surrounding tissue.25 This was only performed on 14 patients, so reliability is limited by the sample size.

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Stem cell therapy Stem cell therapies have increasingly featured in the media for wound healing and antiageing purposes. There is limited conclusive literature on this, in part due to the range of cells that can be used. Autologous stem cells have a favourable immune profile but may be limited in efficacy as the cells have less potential for differentiation.26 Omni/ pluri-potent stem cells, such as embryonic or mesenchymal cells, carry a strong theoretical capacity for wound healing enhancement but have ethical limitations to research and widespread use for aesthetic purposes.27 Despite the limitations, studies that have investigated stem cell therapy suggest it has the potential to result in improved outcomes. Though it should be noted that these studies primarily investigate chronic wounds.28

Understand the wound-healing process The physiology of wound healing is consistent for all wounds and should be understood by clinicians in order to produce optimal scars. Any practitioner providing surgical or non-surgical aesthetic treatments should consider wound formation as part of the consent and decision-making process prior to performing a procedure. Poorly managed wounds from even non-surgical procedures can result in worse aesthetic outcomes and patient dissatisfaction. In extreme cases wounds can limit function of surrounding tissue or form chronic wounds with a significant psycho-social burden. A number of techniques exist for wound closure and wound healing that can manipulate the natural healing process in order to achieve aesthetically and functionally superior outcomes. A majority of the wound-healing interventions are novel, meaning literature is limited. Most of these techniques can be performed by any practitioner. Further evidence is required in order to create a verified, standardised treatment regime; however, practitioners should be aware of and understand the options, perform them safely and contribute to the development of knowledge within this field where possible.

Aesthetics Clinical Advisory Board Lead Mr Dalvi Humzah says… Wound healing remains a fundamental issue in both medical and surgical practice. Many aesthetic procedures involve a planned ‘wound’ of the skin and the subsequent healing process, if not adequately supported, can lead to chronic problems such as contracture and abnormal scarring. This CPD article is a synopsis of the current state of understanding with regards to wound healing. All practitioners should understand these fundamentals as this will allow them to ensure that wounds heal in the appropriate environment. We have come a long way from the early studies in the 1960s on moist wound healing, prior to which dry healing was advocated. The use of new materials described in this paper draws on the moist healing concepts and manipulation of the cellular dynamics of wound healing to bring things up to date. The final goal is to manipulate the process of wound healing to make it efficient and produce a scarless wound. Apart from foetal healing, we have yet to achieve this, however, the current concepts of LASH and use of novel biomaterials discussed in this paper will provide practitioners with an understanding on aspects of wound healing that they can apply to their patients.

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Test your knowledge!

Miss Priyanka Chadha currently works as a plastic surgery registrar in London and is co-director of Acquisition Aesthetics training academy. Her academic CV comprises national and international prizes and presentations, as well as higher degrees in surgical education and training. Miss Chadha is a key opinion leader for Galderma. Qual: MBBS(Lond), BSc(Hons), DPMSA(Lond), MRCS(Eng), MSc(Lond)

Questions

Miss Lara Watson is dual-qualified in medicine and dentistry and works as a registrar in oral and maxillofacial surgery. She is a faculty member for Galderma and is also a co-founding director of Acquisition Aesthetics with a strong background in anatomy and scientific research. Qual: BM, BMedSci, BSc, MRCS(Eng), BDS(Hons)

2. Which of the following is NOT

Dr Nihull Jakharia-Shah is an internal medicine trainee with an interest in dermatology. He has an academic background having published in dermatology, plastic surgery and aesthetic journals. Dr Jakharia-Shah has presented his work at international conferences with prizes awarded. He held a senior position at Acquisition Aesthetics training academy for three years, gaining exposure to clinical aesthetic practice. Qual: MBBS, BSc(Hons)

Complete the multiple-choice questions below and go online to receive your CPD certificate!

Possible Answers

What are the four stages of wound healing?

a component of granulation tissue?

3. Which scar type grows beyond the margins of the wound?

4. Which parameter is NOT

included in the Vancouver scar scale?

5. Which dressing type functions

by preventing differentiation of myofibroblasts and inflammatory mediator production from macrophages?

a. Haemostasis, infection, granulation, remodelling b. Haemorrhage, coagulation, platelet aggregation, fibrinolysis c. Haemostasis, inflammation, proliferation, remodelling d. Haemostasis, proliferation, remodelling, contracture a. b. c. d.

Silicone Collagen Fibroblasts Glycoproteins

a. b. c. d.

Acne scar Contracture scar Hypertrophic scar Keloid scar

a. b. c. d.

Type of scar Pigmentation Vascularity Height

a. b. c. d.

Silicone Acellular bilaminate Salinomycin Carboxymethylcellulose

Answers: 1. c, 2. a, 3. d, 4. a, 5. b Torbac advertorial.pdf

16/03/2021

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www.tor-generics.com TOR-BAC EAN CODE: 5060219260072 Tel: 01923-825379 Available at Select Aesthetic Wholesalers, Boots Alcura & AAH Pharmacueticals

REFERENCE: 1. Centre for Disease Control, ‘Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injections’ < https://www.cdc.gov/ injectionsafety/providers/provider_faqs_multivials.html> Last accessed: 19 March 2018.

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generally equal in size with a wider nasal base. This emphasises that lip treatment aims and outcomes should differ between cultural groups.11,12 Furthermore, Asiatic lips tend to be fuller on top,13,14 whilst African lips are generally larger in all dimensions including protrusion, due partly to greater soft tissue mass.15 Dividing the lower face into thirds helps to give a clear comparison of lip to chin size during lip augmentation planning, allowing for successful treatment of middle-aged patients of all races.10,16 The rule of Phi is not universal and lower face aesthetics should take a holistic, individualised approach, combining both art and science.9,10,12 In all cultural assessments, restoration of aesthetic quality requires correction of disproportionate relationships in the lower face, achieved by appropriate changes in the measurements.17,12

Perioral ageing

Augmenting Thin Lips Aesthetic nurse Emma Coleman describes her method for treating thin and ageing lips in 40 to 50-year-old women Globally, lip augmentation treatment spend is forecast to reach US $4.4 billion over the next seven years. Hyaluronic acid (HA) fillers will remain the most popular treatment choice, with the UK predicted to have the fourth highest spend globally by 2027.1 These figures suggest that aesthetic practitioners will be busier than ever with lip treatments using dermal fillers. Yet having spoken to many practitioners, there seems to be a unanimous agreement that treatment of thinning, ageing lips in the older age group can be challenging. This article will discuss lip treatment popularity, how lips age, the ‘normal’ and ‘attractive’ lip ratios and how this varies between ethnic groups. Treatment journey plans, managing patient expectations and treating the patient holistically will also be covered, with two female case studies presented.

Lip attractiveness and assessment Lips play an important role in female attractiveness; full lips impart a sense of youthfulness and health, whilst thinner, flatter lips may imply fragility and senility.2 One cross-cultural study recruited cosmetic surgeons from around the globe (n=1,011), to highlight that desirable lip proportions

are commonly dependent on a person’s geographic, cultural and ethnic background.3 Another trial (n=150) analysed lip dimension most attractive to Caucasian women, providing evidence that an increase in 53.5% surface area on original lip size represented the most attractive.4 Conversely, a US study analysed and compared the contribution of lip augmentation to facial attractiveness in 197 Chinese, Caucasian and Korean individuals. Both Asian groups naturally possessed very different lip projection and parameters compared to the Caucasian group, whilst lips in all groups were shown to be of less significance in attractiveness than previously considered.5 The golden ratio, (or Phi), has been traditionally used as a way of maintaining upper to lower lip ratio at 1:1.6.6,7 This calculation has also been used in studies to help highlight racial differences in overall facial measurements, an important consideration when augmenting lips.8,9 One review provided evidence that to achieve optimum attractiveness, Caucasian lips should be approximately 40% of the lower face width with greater vermillion border protrusion in females,10 whilst East Asian individuals’ mid and lower facial thirds are

As we age, the face experiences fat displacement leading to a scalloped anterior jawline and straight, angular lips.6,18,19 The chin, nose and lip protrusion can be assessed from the side using the Steiner Line method, where a ruler may be held between the subnasion and pogonion. This can also be used post treatment to revisit nose, lip and chin protrusion ratio,7 which can be helpful to patients in assessing outcomes rather than simply looking at images. One image-based Chinese study (n=180) provided evidence that chin correction positively impacted aesthetic lip treatment results, suggesting the chin may be a good place to start prior to injecting the lips.18 I personally tend to address surrounding facial areas at the second treatment appointment to allow time for the initial swelling to subside, giving me a clear picture on what treatment area(s) to address next. Lip size and volume can be accurately assessed using the validated five-point scale called the Medici Lip Fullness Scale (MLFS) which is demonstrated in (Figure 1).20,21 The lips age due to a combination of physiological and anatomical changes. The skin of the lips is thin, made of just three to five layers of squamous epithelium cells, versus 16 layers on other areas of the face, making it fragile.8,13,14,22 Sun damage accelerates lip ageing. Individuals with Fitzpatrick skin types IV and above have high levels of melanin in their skin and although they are more likely to experience perioral hypo- and hyperpigmentation, people with darker skin tones are less prone to lip solar elastosis compared with Fitzpatrick types I to III.14,17

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1 – Very thin

2 – Thin

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3 – Medium

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4 – Full

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5 – Very full

Figure 1: The Medici Lip Fullness Scale20,21

Age-related oral changes can be observed in soft tissues through stratified squamous epithelium depletion which becomes thinner, loses elasticity, and atrophies with age. Hard tissues – observed through bone depletion – are thought to be due, in part, to reduced levels of cyclooxygenase, an important enzyme in bone repair.6,22 As age progresses, fat depletion and atrophy of the alveolar bone leads to loss of facial height and repositioning of the mandible.6,22 There is also evidence to suggest that ageing of skin on the lower face is genderdependent; one study (n=30) compared perioral skin wrinkling on fresh male and female cadavers. Skin analysis provided evidence that the female specimens displayed a significantly higher number of deeper wrinkles, thought to be due to a lower number of skin appendages including sebaceous and sweat glands in the female bodies, compared to the males.23 This can also cause the lips to thin, with a ‘rolled in’ effect as plumpness and tubercle definition are lost.6,22 One 2019 study (n=200) highlighted metric changes in perioral soft tissue in male and female subjects, providing evidence that upper lip thickness and volume reduced with age, as did alar nasolabial fold thickness.19 In my own experience, nasolabial fold treatment adds volume and lift to the upper lip and therefore has a strong case for treatment inclusion.

Consultation Successful treatment outcome must combine in-depth initial consultation to assess the patient’s needs and expectations, discussion of realistic projected outcomes and treatment plan over several weeks or months, pricing structure, correct product choice with appropriate injection technique, aftercare education and support. The treatment itself should be tailored to each patient and their age, with the practitioner taking a multi-skilled approach, drawing on knowledge of a range of techniques, whilst using their artistic eye to attain a beautiful result befitting to the patients’ entire face.

In my experience, it is important to remember that the needs of a 25-year-old patient differ hugely to those of a 49-yearold. At initial appointment with older female patients falling into the ‘very thin’ lip category, we use the mirror to assess goals and what is achievable together. This is important as it gives patients the opportunity for treatment autonomy and input. Some patients have seen a particular social media image they aspire to; many come to me asking me to put 0.5ml of HA filler into the top lip only, which I never advocate because HA filler immediately changes the whole lip appearance and should therefore be distributed to both upper and lower lips. I assess the entire mid and lower face for loss of volume and elasticity before deciding the best technique. Patient education at this stage is important so that they clearly understand the treatment journey, cost and possible risks.

Treatment Once treatment aims have been established, possible complications discussed, and paperwork signed, I select a soft filler – usually Belotero Balance or Lips Contour due to their low HA concentration of 22.5mg/ml and I find that they are less likely to cause lumpiness. Of course, other brands are available. If the patient has experienced notable skin laxity and loss of volume to the mid-face, chin and jawline, I suggest an initial dose of 0.5/0.6ml using a retrograde thread technique to give a natural result. My preference is a 30 gauge or 27 gauge needle rather than a cannula to allow specific product placement and avoid an unsculpted ‘tyre’ look. I first inject the vermillion border with linear threads, sometimes using a fanning technique and depositing a small bolus into the cupid’s bow tip to add lift, then following the same retrograde technique along the vermillion wet-dry border with aspiration. I then address the oral commissures, according to the pre-agreed look (elevated or straight). I may opt for a tenting technique 1-2mm above the vermillion border to give a more rolled out,

plump lip, depending on surrounding fat pad and skin elasticity maintenance. It is important when using this technique to maintain deep injection to avoid visible lumps, whilst maintaining shallow enough needle insertion to prevent occlusion.20 I will bring the patient back three to four weeks later to assess and treat with additional HA should they need it. At this point – provided the patient has tolerated the softer filler well – I will often select a more concentrated filler of 24-25.5mg/ml such as Juvéderm Ultra 3 or Belotero Lips Shape/ Belotero Intense. I also assess nasolabial lines and chin together at this stage, and look to treat if necessary.14,18

Case studies 49-year-old patient A single and dating 49-year-old lady presented wanting to have more of a visible top lip in photos. She had previous lip treatment with another practitioner two years ago. Upon assessment I measured that her closed top lip had a MLFS score of 1. It was 1.5-2mm, with the thinnest area arising below the cupid’s bow dip. The lower lip measured 5mm at the widest point and had a MLFS score of 2. Her tubercles, vermillion border definition and chin fat pad were depleted, the latter highlighted using Steiner Line assessment, but she had good cheek volume. She was experiencing early menopause symptoms including hot flushes, mood swings and poor sleep pattern. To help maintain her bone density I recommended she take calcium and vitamin D supplements.11,24 The treatment objectives were to increase her upper lip depth by 100%, reinstate a clean cupid’s bow and tubercles, define the vermillion border, lift commissures, and define the lower lip, increasing depth by 20%. We agreed to start with 0.6ml of Belotero Balance, returning in two weeks to add another 0.6ml of Belotero Intense, including chin rejuvenation. The top lip initially was a little larger than the bottom, which I addressed during the subsequent

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Before

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After

Figure 2: 49-year-old before and immediately after two lip filler treatments with a 14-day interval between treatments. Before

After

Figure 3: 44-year-old patient before and immediately after two lip filler treatments, carried out six months apart.

appointment, and included 0.15ml injection into the chin anteriorly, plus a 0.02ml thread at the upper and lower commissure points to add lift. After two treatments, the top lip measured 4mm at the cupid’s bow, 2mm laterally the bottom lip was 5.5-6mm. The patient’s tubercle rejuvenation was evident and her MLFS scores for both lips were now 3 (Figure 2). The patient was very happy with her results and will return in several months for a jowl and further lip treatment. 44-year-old patient A 44-year-old lady with no history of cosmetic procedures presented with a significantly thinner top lip compared to lower, asking for size equality (Figure 3). She had no obvious pre- or peri-menopausal symptoms. Her closed upper lip MLFS score was 1. This varied between 1mm to 2.5mm in depth. The lower lip MLFS score was 4 and measured 7mm at its widest point. Minimal upper vermillion border definition was evident, although tubercles were maintained. The patient possessed strong chin and cheek volume, her nasolabial lines were soft, and her skin displayed good elasticity. The treatment objectives were to increase her upper lip depth by 75-100%, lower lip by 50%, and to enhance her tubercles. To attain this, I suggested that 0.45ml be injected into the upper lip, while 0.15ml was injected into the bottom using 0.6ml Belotero Balance. I opted for a tenting technique to the upper lip, applying filler at vertical retrograde points into

the sub-mucosa, aiming to significantly lift and roll out, which I believed would sit well with her skin and facial structure. I injected linear threads into the wet dry border on the lower lip and a little into the vermillion border to balance size and shape. The patient returned again six months later, at which time, having assessed her for product tolerance, I repeated the treatment using the same techniques with Belotero Intense to provide more noticeable, longer-lasting results. After her two treatments, her top lip measurements varied between 3.5-5mm and her lower lip measured 8mm. The upper and lower MLFS scores at this stage were 3 and 4 respectively. Initially she wanted to go bigger in size and seemed disappointed with her result, so I explained that the resulting lip protrusions and ratios were suited to her face, which she agreed with. She will return to clinic twice yearly to maintain this result.

Summary Successful fine lip augmentation of women in the 40 to 50 age group using HA filler requires a sound knowledge of the ageing processes in and around the lips, how this differs between individuals, and an ability to adapt to different patients’ needs with a variety of techniques. Budget and patient expectations must always be managed as, in most cases, treatment must be ongoing to maintain optimal lip depth and protrusion long term.

Emma Coleman is a dermatology and advanced aesthetic nurse practitioner. She trained in aesthetics in London in 2015 and gained a distinction in Clinical Dermatology Diploma with the University of South Wales in 2019. Coleman is a member of the British Dermatological Nursing Group (BDNG) and clinical director at the four Emma Coleman Skin clinics across Kent and London. Qual: RGN, DipDerm REFERENCES 1. Sherry J, Lip Augmentation Market Size Worth $4.4 Billion by 2027, CAGR: 9.5%: Grand View Research, Inc. (USA: prnewswire.co.uk,2020). <https://www.prnewswire.co.uk/newsreleases/lip-augmentation-market-size-worth-4-4-billion-by2027-cagr-9-5-grand-view-research-inc--897798329.html> 2. Maloney, BP, ‘Cosmetic Surgery of the Lips’ Facial Plast Surg 12 (1996), p265-278 <https://www.thieme-connect.com/products/ ejournals/abstract/10.1055/s-0028-1082417> 3. Heidekrueger, P et al., ‘Lip attractiveness: a Cross-Cultural Analysis’ Aesthetic Surgery Journal 37(7) (2017) p828-836. 4. Popenko, N et al., ‘A Quantitative Approach to Determining the Ideal Female Lip Aesthetic and Its Effect on Facial Attractiveness’ JAMA Facial Plastic Surgery 19(4) (2017) p261-267. 5. Wong, W, et al., ‘Contribution of Lip Proportions to Facial Aesthetics in Different Ethnicities: A Three-Dimensional Analysis’ Journal Plast, Recon & Aesth Surg 63(2010) p2032-2039. 6. Coleman, S, & Grover, R, ‘The Anatomy of the Aging Face: Volume Loss and Changes in 3-Dimensional Topography’, Aesth Surg Journ, 26(2006) p:S4-S9 Journal 7(2020). 7. Kar, M et al., Is it Possible to Define the Ideal Lips?’ Acta Otorhino Ital, 38 (2018) p.69. 8. National Human Genome Research Institute Anatomy of the Lips, Mouth and Oral Region (USA: Genome.gov, 2020) <https:// elementsofmorphology.nih.gov/anatomy-oral.shtml> 9. Holland, E, ‘Marquardt’s Phi Mask: Pitfalls of Relying on Fashion Models and the Golden Ratio to Describe a Beautiful Face’ Aesthetic Plastic Surgery, 32,(2008) p.200-208. 10. Anic-Melosovic, S, et al., ‘Proportions in the Upper Lip– Lower Lip–Chin Area of the Lower Face as Determined by Photogrammetric Method’ Journ Cran-Maxillo-Fac Surg 38(2010) p.90-95. 11. Jinkelstein, J, et al., ‘Bone Mineral Density Changes during the Menopause Transition in a Multiethnic Cohort of Women,’ JCEM, 93(2007), p.861-868. 12. Anand, S, et al., ‘Vertical and Horizontal Proportions of the Face and Their Correlation to Phi Among Indians in Moradabad Population: A Survey’ Journ Indian Prosthodontoc Soc 15(2015) p:125-13 13. Carey JC, et al. Elements of morphology: standard terminology for the lips, mouth, and oral region. Am J Med Genet A 2009;149A:77-92 14. Demosthenous, N, ‘Lip Augmentation’, PMFA JOURNAL, 4 (2017). 15. Joe Niamtu III, Cosmetic Facial Surgery, 2nd edition (California:Elsevier, 2017) p.639-655. 16. Prendergast, P et al., Advanced Surgical and Facial Rejuvenation. (Berlin Heidelberg: Springer-Verlag, 2012) p.15-22. 17. Farkas, LG & and Kolar JC, ‘Anthropometrics and Art in the Aesthetics of Women’s Faces’ Clin Plast Surg, 14(1987), p.599616. 18. Ying-Ying-Su, et al., ‘Influence of Chin Prominence on AnteriorPosterior Lip Positions of Facial Profile’ Shanghai Kou Qiang Yi Xue. 17, (2008) p.598-602. 19. Ramaut, L et al., ‘Aging of the Upper Lip: Part I: A Retrospective Analysis of Metric Changes in Soft Tissue on Magnetic Resonance Imaging’ Plastic and Reconstructive Surg 143 (2019) p440-446. 20. Yazdanparast, T et al., ‘Assessment of the Efficacy and Safety of Hyaluronic Acid Gel Injection in the Restoration of Fullness of the Upper Lips’ J Cutan Aesthetic Surg 10 (2017), p101-105. 21. Kane, M et al., ‘Validation of a Lip Fullness Scale for Assessment of Lip Augmentation’ Plast Reconstructive Surg 130 (2012), p822e-828e. 22. Mckenna, G et al., ‘Age-Related Oral Changes’ Gerodontology 37 (2010) p519-523. 23. Paes E et al., ‘Perioral Wrinkles: Histologic Differences Between Men and Women’ Aesthetic Surgery Journal 29 (2009) p467472. 24. Nicola di Daniele, et al., ‘Effect of Supplementation of Calcium and Vitamin D on Bone Mineral Density and Bone Mineral Content in Peri- and Post-Menopause Women: A Double-Blind, Randomized, Controlled Trial’ Pharmacological Research 50(2004) p:637-641.

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Sculptra – an exciting new era in collegentic technology Galderma explains how this collagen-stimulator can help your patients A common skin concern in patients of the 39-45 year old bracket is matching the way they look with the way they feel. Place the control back into the hands of your patients to manage the effects of skin ageing. Naturally restore the skin’s foundation with

Sculptra for a sustained and progressive result, day after day. As skin ages, the natural loss of collagen leads to thinner and structurally weakened skin.1,2 Sculptra activates the body’s natural ability to produce collagen, restoring the skin’s structure and

A qualified GP for over 25 years and 16 years of practising in aesthetic medicine, Dr Kathryn Taylor-Barnes is passionate about providing nonsurgical cosmetic procedures such as wrinkle-relaxing treatments, dermal fillers, lip enhancements, wrinkle smoothing, cheek enhancements, sweat reduction, hand rejuvenation and skin tag removal in a safe, comfortable environment – always putting the client and their safety at the heart of everything she does. She says, ‘’My ethos has always been to make the most of what nature gave you without looking like you’ve had help and Sculptra is wonderful to have in the clinic’s treatment offerings to do precisely this. Sculptra is hugely popular amongst our patients who are aiming to slow down the ageing process in their late thirties to mid-fifties. We offer so many solutions to help the look and feel of the skin and Sculptra is unique in that it provides a great boost of natural collagen production to revitalise the dermis and create a gentle, yet noticeable, refreshed look and ‘Sculptra Glow’. Sculptra can be used as the key foundation to an antiageing treatment plan and with a bit of commitment produces truly fantastic results.” Dr Kathryn Taylor-Barnes, Clinical Director, Real You Clinic 38

renewing its natural firmness.3-7 When choosing treatment, patients find long-lasting results more important than how quickly they appear.8 The subtle skin improvement over time appeals to those looking for a natural solution to ageing.

Providing beautifully subtle results for her patients at one of the most prestigious clinics in the world, The Harrods Wellness Clinic, Dr Marwa Ali is a sought-after, highly experienced aesthetic doctor specialising in advanced cosmetic non-surgical procedures. With an enviable following on social media and regular inclusion in titles such as Vogue and Harper’s Bazaar, and Finalist in the 2021 Aesthetics Awards, it is no wonder Dr Ali hails a new era in aesthetics. Commenting on her experience of Sculptra, Dr Ali has this to say: “I have been using Sculptra on my patients for years and I find that they return again and again for it specifically. The results are exceptional – I get some amazing outcomes. Collagen is 75% of the dry weight of skin so when I see a patient concerned with ageing, it’s usual for collagen-boosting to be one of the first things we discuss before any of the other more superficial and less-lasting options I can provide. Sculptra offers an impressive rate and volume of collagen production and in the correct hands can really make magic happen.” Dr Marwa Ali, Cosmetic Doctor, Harrods Wellness Clinic

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Mode of Action and Efficacy Sculptra restores volume by revitalising collagen production to improve the skin’s inner structure.3,4,6 Key Benefits • Long-lasting – Sculptra renews the skin by volume by revitalising collagen production to restoring volume and smoothing wrinkles up improve the skin’s inner structure.3,4,6 6,9-11 to 25 months after the last treatments. • Creating patient delight – 96.6% of patients • Collagen stimulation – Sculptra restores rated Sculptra good to excellent.12 Before

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Sculptra training as part of the Galderma Aesthetic Injector Network (GAIN) will host online and face to face injection technique coaching plus on-going support; how to use the product effectively, advice on specific cases and how to add the treatment to the clinic portfolio. In addition, GAIN will also provide branded social

media materials such as Instagram-ready images, plus point of sale promotional tools, to help practitioners increase engagement and generate sales. The Sculptra GAIN programme is available by invitation only for advanced injectors and, with successful completion of the training programme, clinics have an

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REFERENCES 1. Farage MA et al. AdvWoundCare, NewRochelle, 2013;2(1):5-10. 2. Quan T and Fisher GJ. Gerontology, 2015;61(5):427-34. 3. Stein P et al. J Dermatol Sci, 2015;78(1):26-33.9. 4. Goldberg D et al. Dermatol Surg, 2013;39(6):915-22.

5. 6. 7. 8.

Vleggaar D et al. J Drugs Dermatol, 2014;13 (4 suppl):s29-31. Moyle GJ et al. HIV Med, 2004;5(2):82-7. Bohnert K et al. Plast Reconstr Surg, 2019;127(4):1684-92.C2. Weinkle S and Lupo M. J Clin Aesthetic Dermatol, 2010;3(9):30-33.

Aesthetics | April 2021

9. Narins RS et al. J Am Acad Dermatol, 2010;62(3):448-62. 10. Brandt FS et al. Aesthet Surg J, 2011;31(5):521-8. 11. Nelson L and Stewart KJ. J Plast Reconstr Aesthet Surg, 2012;65(4):439-47. 12. Brown SA et al. Plast Reconstr Surg, 2011;127(4):1684-1692.

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As we prepare to come out of lockdown and start returning to normality, Merz Aesthetics UK and Ireland has developed its own roadmap to support clinics through until June with a new series of webinars. From clinical and business sessions to the new health and wellbeing series, the spring programme offers prepare to come out oftolockdown and Healthcare start returning to a broad rangeAs ofwe inspiring education help steer As we prepare to come out of lockdown and normality, Merz Aesthetics UK and Ireland has developed its Practitioners back into practice.

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From assessment, • Ultherapy® Signature Treatments patient management to product choice, marketing expert and brand strategist Joining forces with Combination international treatment planningtreatment and ongoing • Full face Ravichandran. From assessment, BELOTERO® the knowledge they need to make their Wednesday, April 14, 8pm-9pm anatomytoand Adam Haroun Merz • Ultherapy® Signature Treatments marketing(Branding.MD), expert and brand strategist patientand management product choice, minjection techniques planning and ongoing patient management Treatments Ultherapy® treatment offering a success. physiology, thisinjection two-part webinarand willanatomy and brings you the Business Webinar Merz Series, Wednesday, April 14, 8pm-9pm Adam Haroun (Branding.MD), techniques brings you14, the Business Webinar Series, physiology, this two-partwith webinar willdesigned to follow product choice, injection techniques Monday June 7.30pm-9pm Webinars include: HEALTH AND WELLBEING SERIES the journeys of two patients to help healthcare practitioners WELLBEING SERIES designed to help healthcare practitioners HEALTH follow the journeys of two patients with and anatomy and physiology, thisto two-part AimedAND at helping practitioners cope practical tips and take-aways enhance and clinic owners navigate times of Aimed at helping practitioners cope and clinic owners navigate times of practical tips and take-aways to enhance tegist and remain focused over the coming your own clinical practice and help you uncertainty and change to better position webinar will follow the journeys of two • Ultherapy® Signature Treatments coming uncertainty and change to better position and remain focused over the your own clinical practice and help you Merz months, the Health and Wellbeing achieve optimal patient outcomes with their businesses for the future. months, the Health and Wellbeing their businesses for the future. achieve optimal patient outcomes with patients with practical tips and take-aways BUSINESS SERIES Wednesday, April 14, 8pm-9pm r Series, series in partnership with “Raise the BELOTERO® for the brows, series in partnership withthe “Raise the BELOTERO® range forpractice therange brows, ctitioners to the enhance your own clinical and Joining forces with international marketing Bar” willwill seesee speakers from the fields The Marketing 101 series aimstotocover cover temples, cheeks, sub and labial zone andThe Marketing Bar” speakers from the fields temples, cheeks, sub labial zone 101 series aims of help you achieve optimal patient outcomes expert and brand strategist Adam Haroun of psychotherapy, psychology and everything healthcare practitioners need chin. Join them for: r position of psychotherapy, psychology and chin. Join them for: everything healthcare practitioners need physiology explore a range of topics. SERIES to get Merz startedbrings on theiryou marketing with the BELOTERO® range. (Branding.MD), the journey. HEALTH AND WELLBEING physiology a range to get started oninclude: their marketing journey. Hosted by MIPs explore sessions will include:of topics. Topics will • The Patient Journey Join them for: Business Webinar Series, designed to help Aimed at helping practitioners cope Hosted by MIPs sessions will include: Monday, March 29, 7.30pm-9pm Topics will include: • The Patient Journey healthcare practitioners and clinic owners and remainafocused over the coming o cover • Creating happier, healthier • The Do’s and Don’ts of Aesthetic • BELOTERO® Combination Monday, March 29, 7.30pm-9pm ers mind with psychotherapist and Marketing Treatments Treatmentsneed • • BELOTERO® BELOTERO® Combination navigate times of uncertainty and change months, the Health and Wellbeing series •author Creating a happier, healthier • The Do’s and Don’ts of Aesthetic Combination journey . Owen O’Kane, hosted by Wednesday, March 24, 8pm-9pm Monday, April 19, 7.30pm-9pm to better position Monday, April 19, 7.30pm-9pm their businesses for the in partnership with ‘Raise the Bar’ will with psychotherapist andsee Marketing Treatments Mrmind Dalvi Humzah, • How to Create Powerful Content Topics will include: speakers from the25, fields of psychotherapy, author Owen O’Kane, hosted by Wednesday, March 24, 8pm-9pm Thursday, March 8pm-9pm and Listen clinical series hosted by future. Monday, AprilThe 19,next 7.30pm-9pm • Sleep better, live better with explore a April 7, 8pm-9pm Mr Dalvi Humzah will focus on the • How toWednesday, psychology and physiology etic Mr Dalvi Humzah, Create Powerful Content sleep physiologist Guy Meadows, • Don’t Forget Measurement: Test temples and full face combination Thursday, andDo’s Listen The next clinical series hosted The next clinical series hosted by by • The and Don’ts of Marketing range of topics.March 25, 8pm-9pm hosted by Drs Emma the Effectiveness of your Work treatments. Mr Humzah and the MIPs will pm • Sleep better, live better with Wednesday, April 7, 8pm-9pm Dalvi Humzah will focus on the MrMr Dalvi Humzah will focus on the temples Wednesday, March 24, 8pm-9pm Hosted by MIPs, sessions will include: and Simon Ravichandran, Wednesday, April 21, 8pm-9pm guide you to improve your knowledge ent sleep physiologist Guy Meadows, Don’t Test temples fulland face combination Thursday, April 8, 8pm-9pm appreciation of topographical and full faceand combination treatments. Mr • • How toForget Create Measurement: Powerful Content and • Building resilience and a strong The Marketing Masterclass series is anatomy with anthe in-depth look at the the Effectiveness hosted by Drs of your Work treatments. MrMIPs Humzah and and the will guide you MIPs to will Listendesigned Wednesday, April 7, 8pm-9pm • mindset Sleep better, liveEmma better with sleep m Humzah with Paralympian Claire Lomas to help 21, practitioners become anatomyyour of theknowledge temple, how the ageingWednesday, and Simon Ravichandran, April 8pm-9pm guide you to improve est improve your knowledge and appreciation • Don’t Forget Measurement: Test the physiologist Guy Meadows, MBE, hosted by Dr Kim Booysen, hosted by more strategic and focused with their process impacts the bony and soft tissue Thursday, April 8, 8pm-9pm and appreciation of topographical k Monday, Apriland 26, 8pm-9pm marketingof and communicate more dimensions, assess different Effectiveness of topographical anatomy withhow an to in-depth your Work Drs Emma Simon Ravichandran, pm Building and a your strong series is anatomy with anpatient in-depth the •• Triumph overresilience adversity and find effectivelyMasterclass with their customers. types look and aat demonstration ofThe Marketing look at the anatomy of the temple, how Wednesday, April 21, 8pm-9pm Thursday, April 8, 8pm-9pm motivation health Claire Lomas Webinars willpractitioners include: treatment approaches with mindsetwith withmental Paralympian designed to help become anatomy of the appropriate temple, how the ageing ageing processneedle impacts bony and • speaker Building resilience and a strong s the is advocate Ben Smith, andthe cannula using BELOTERO®. MBE,and hosted by Dr Kim Booysen, more strategic and focused with their process impacts the bony and soft tissue hosted by Dr KateParalympian Goldie, ecome soft tissue dimensions, how to assess The Marketing Masterclass is designed to mindset with Claire Monday, April 26, 8pm-9pm marketing and communicate more dimensions, how to assess different Wednesday, May 12, 8pm-9pm their different patient types and a demonstration help practitioners become more strategic and Lomas MBE, hosted by Dr Kim Triumph over adversity andBooysen, find your effectively with their customers. patient types and a demonstration •• Positive Psychology with teacher, They will then share theirofexpertise and or e Visit of appropriate appropriate treatment approaches with focused with their marketing and communicate Monday, 26, 8pm-9pm motivation with mental health Webinars will include: treatment approaches with author and April happiness expert insight into the treatment of the full face Cope,over hosted by Dr Kate Goldie, with the BELOTERO® range. speaker andadversity advocate Ben Smith, needle and cannula using BELOTERO®. needle and cannula using BELOTERO®. more effectively with their customers. • Andy Triumph and find your merzwebinars.com Monday, June 7, 8pm-9pm Join them for: hosted bywith Dr Kate Goldie, motivation mental health speaker or scan the QR code to register for any Wednesday, MaySmith, 12, 8pm-9pm and advocate Ben hosted by of the upcoming Merz Aesthetics Webinars • Dr Positive Psychology with May teacher, They will then share their expertise and Kate Goldie, Wednesday, 12, author and happiness expert insight into the treatment of the full face Visit 8pm-9pm M-MA-UKI-1329 Date of Preparation March 2021 Andy Cope, hosted by Dr Kate Goldie, with the BELOTERO® range. merzwebinars.com • Positive Psychology with teacher, Monday, June 7, 8pm-9pm Join them for: author and happiness expert Andy or scan the QR code to register for any Cope, hosted by Dr Kate Goldie, of the upcoming Merz Aesthetics Webinars Monday, June 7, 8pm-9pm M-BEL-UKI-1057 Date of Preparation March 2021 2021 M-MA-UKI-1329 Date of Preparation March

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Treating the Neck

pregnant or breastfeeding, those with a known sensitivity to BoNT-A and/or have neuromuscular disorders.8

Dr Jemma Gewargis explores the Nefertiti Neck Lift technique

Managing expectations

The lower third of the face often shows the most undesirable ageing signs, such as deep oral commissures, loss of definition of the mandibular arch and pronounced platysmal bands.1 In my experience, the Nefertiti Neck Lift provides a good treatment option to target these signs of ageing. The technique was first described by dermatologist Dr Phillip Levy in 2007, named after Queen Nefertiti of ancient Egypt.2 Nefertiti translates to ‘the beautiful woman has come’, with relevance to elegant lines of the jaw and neck. The procedure involves injecting botulinum toxin A (BoNT-A) primarily into the platysmal neckbands, the depressor anguli oris (DAO) muscle, and the skin of the jawline to produce a more youthful, smoother, and contoured appearance without surgery. It tightens the skin of the jawline, softens neck jowls and improves skin laxity, providing a visual effect of a ‘mini-lift’.2,3 Patient satisfaction is extremely high with this technique, and the specificity of dosing has led to a low incidence of adverse effects.2,4,5

fat (deep and posterior to the muscle).1,5 Patients with mild/moderate submental fullness with the platysma covering the entire submental region will respond almost entirely to BoNT-A treatment, as relaxation of the protruded anterior bands will tighten the muscular fibres overlying the fat pad and push it back into place.1,5

Aetiology In addition to skin ageing through reduced collagen deposition and environmental factors, the skin of the face and neck consequently becomes lax and drapes in the lower face, over the mandibular border, overhanging and blunting the cervicofacial angle.6,8 The downward pull of the platysma contributes to the formation of jowls and multiple rhytides, as well as loss of definition of the chin and jawline. Gravity also contributes to the changing appearance of the thin, lax and less elastic skin of the aged neck, accentuating the neck lines and, coupled with fat volume depletion, leads to noticeable ageing of the neck.2

Anatomy

Patient selection

The platysma muscle of the neck varies considerably in thickness and extent between people. It is composed of two separate broad, thin sheets of muscle running up the front and lateral neck from the upper chest to the mandible, fusing and blending its fibres with the superficial muscular aponeurotic system (SMAS) superiorly in the face.6 The fibres of the platysma perform a number of depressive actions. The anterior portion and thickest fibres of the platysma blend with the perioral muscles and so can pull the lower lip and corners of the mouth downward and laterally.2,6 The pars labialis fibres continue within the tissue of the lateral half of the lower lip – they interdigitate into the muscles around the angle of the mouth (orbicularis and risorius), the chin (mentalis), and the depressors of the lower lip (depressor labii inferioris and especially the DAO).6,7 Active fibres of the upper platysma (pars mandibularis) can blunt the jawline.1 There are two distinct fat deposits that play an important role in the ageing of the neck – the submental fat pad (anterior to the platysma muscle) and subplatysmal

Patients who contract the platysmal bands habitually when speaking respond best to this treatment.8 They are usually slim build patients aged between 30-60 with pronounced bands, and do not present with any significant complex asymmetries during animation as there is a greater risk of complications.1,2,3 They have early signs of jowling and loss of skin elasticity around the mandibular region, forming the visible so-called ‘turkey neck’. The presence of excessive fat on the mandibular border can reduce the efficacy of the treatment.1,2,4 Asking the patient to pull down hard on the platysmal muscle by protruding the lower jaw and observing the disappearance of the mandibular border provides another good indication for successful treatment.2,6,8 The Nefertiti Neck Lift treatment is contraindicated in patients with a history of neck injury or where the neck platysmal muscle has hypertrophied to support a weak neck, as the risk of weakening the neck further here would be detrimental. In addition, as with other BoNT-A treatments, they are not suitable for those who are

It is important to manage expectations to ensure the patient understands that the Nefertiti Neck Lift has minimal improvement on the horizontal neck lines. For this, other rejuvenation means can be used, such as soft hyaluronic acid fillers, mesotherapy or ablative procedures.1 A combination approach can be utilised to tackle multiple concerns of the neck, with the Nefertiti Neck Lift as an additional procedure to improve the aged appearance. For those with excessive skin laxity and hypertrophied platysmal bands, a referral for a surgical opinion should be considered. It’s also important to make patients aware of the longevity of the treatment. Compared to treatment using BoNT-A in other areas of the face, several studies have shown better longevity of the Nefertiti Neck Lift result at an average of four to six months duration, depending on the precision of the injections, strength of the platysma, as well as the frequency and intensity of the patient’s neck movements.2,4,5

Treatment The use of BoNT-A to perform the Nefertiti Neck Lift is an advanced off-label treatment, making it important for practitioners to be fully trained on the technique and for patients to be informed during the consent process. The treatment can be performed using abobotulinumtoxin A (Azzalure/Dysport) that has a conversion of 2.5 units for every 1 unit of onabotulinumtoxin A (Botox/Bocouture), the latter of which will be referred to in this article. A dilution of 1.25ml bacteriostatic saline per 50 units with a resulting dose of 4 units per 1ml will be discussed. In addition to thoroughly documenting the exact dosages and photographing the areas treated, I recommend taking photos of the pre-injection markings to improve reproducibility with repeat treatments. Use of a cosmetic marker to demarcate the injection points improves precision and reduces the risk of asymmetry, in my experience. During the procedure, the patient should be in a sitting or semi-reclined position which is both comfortable for them and practitioner.2 This allows the patient to contract the platysmal bands and the DAO actively through grimacing or protruding the lower jaw.1,2,3 Following a full consultation, clinical photography and a detailed consent process,

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the youthful expression of the lower face. Further to this, treating the DAO with BoNT-A following dermal filler placement in this region works synergistically to prolong the filler longevity due to the reduction of strength of muscular movement.1 An improvement at the mandibular arch can be Figure 1: Demarcated injection points at the mandibular border obtained by blocking the and contracted upper platysmal band fibres. lateral platysma bands the skin can be disinfected thoroughly, and beginning with the very upper fibres that an aseptic technique maintained throughout. interdigitate with the facial muscular fibres.1,4 Pre-treatment with topical aesthetics (e.g. Injections should be placed posteriorly to a EMLA) is discouraged, as they can inactivate line drawn as a continuation of the nasolabial the activity of the platysmal bands, producing fold that is posterior to the lateral border an inaccurate assessment of where to inject.1 of the DAO and anterior to the belly of the To demarcate the sternocleidomastoid sternocleidomastoid.1,6 muscle, ask the patient to turn their head The success of the Nefertiti Neck Lift is laterally either side. Ensure injection points due to the ‘facial lifting’ technique which are not placed here as to not prevent involves manipulating the opposing effects difficulty with neck movements and head of the platysma depressor muscles to allow positioning. In my experience, patient elevator muscles to predominate to lift the comfort can be improved by grasping face, with the long-term aim to strengthen each platysmal band individually between them over time.1,6 the thumb and index finger with the nonInjecting with BoNT-A releases the dominant hand. 2U of BoNT-A should downward tension on the jawline, alleviating be injected intradermally (at a 15-degree the depressor effect and enhancing the angle) at each point along the vertical band, unimpeded elevator muscles lifting action.4 starting approximately 2cm below the This sharpens and redefines the mandibular inferior border of the mandible centrally in border whilst also elevating the corners of the submental area, and approximately 1cm the mouth, in addition to relaxing the upper below the inferior border of the mandible, platysma, producing the Nefertiti Neck Lift.2 6 lateral to the origin of the DAO. With patients aged over 50, it is beneficial to Repeat injections at intervals of 1.5-2cm from treat regularly at four to six month intervals each other, descending down the neck to avoid depressor muscles recovering (and towards the border of the clavicle. Raising allow muscular atrophy) so the elevators to a small visible wheal indicates the correct strengthen over time, causing a long-term superficial placement of the BoNT-A, which lifting effect.1,5 The Nefertiti Lift can also be will reduce the risks associated with deeper used to correct jowl and platysmal band injections such as diffusion into adjacent asymmetry after suboptimal rhytidectomy, musculature.1,6,8 Throughout treatment, the though care should be taken due to the midline portion of the neck around the changes in anatomy following surgical laryngeal area is avoided to minimise the risks intervention.5 associated with inadvertent deeper injections in this region.2 Dosages Most patients will require around three to The dosage of BoNT-A for the Nefertiti Lift five injection points per platysmal band for varies depending on the severity of ageing, adequate treatment. It is advised that only two strength and number of the platysmal bands, bands per side of the neck should be treated as well as the length of the neck.3 A standard 6 in the first instance. Any other platysmal maximum dosage of 40U is recommended bands should be treated two to four weeks for the Nefertiti Lift in one sitting with 20U later, especially when 40U of BoNT-A has distributed evenly each side of the neck.1,4,8 already been injected (dosages explained There is scope for refinements with further later).2 The DAOs are also targeted in the BoNT-A at the two-week recall period to Nefertiti Neck Lift where indicated, to help correct any asymmetry or lack of response raise the corners of the mouth, improving from a particular platysmal band. This

ensures a more predictable and reproducible treatment with minimised complications.2,4 More significant dosages between 40-50U for the Nefertiti Neck Lift can be introduced in a gradual manner on patients who have been previously treated, but this comes with a greater risk of complication due to increased potential for migration into the surrounding muscles.1,8

Risks and complications Treatment of the vertical bands of the neck and lower face with the Nefertiti Lift is usually safe, and there is low incidence of complications.2 When they do occur, this is usually as a result of either improper technique or excessive dosing.2,4 Though infrequent, bruising can occur1,5 and mild and transient neck discomfort or weakness can be noticed two to five days after treatment.2,5,6 In rare cases, dysphagia and dystonia have been reported.1,2,5,8 Other rare complications include an asymmetric smile, disruption of lip competence causing incontinence of food and liquids, dysarthria and dysphonia.1,6

Consider adding the Nefertiti Neck Lift to your offering Rejuvenation of the neck using the Nefertiti Neck Lift technique is a minimally invasive, safe, and effective treatment with a very high patient satisfaction rate.4,5,7,8 It can act as a stand-alone procedure or in conjunction with lower face dermal filler augmentation to further improve treatment success. The Nefertiti Lift is an excellent approach to incorporate into treatment plans and a useful skill to have in the armamentarium of aesthetic practitioners who have undergone the necessary advanced training to perform this procedure. Dr Jemma Gewargis is an aesthetic practitioner and cosmetic dentist, splitting her time between two private dental practices and multiple aesthetic clinics in West London, as well as being the lead clinical trainer at the Aesthetic Foundation Academy on Harley Street. Qual: BDS (Hons)

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1. TEOSYAL® PureSense Redensity 2 – instructions for use — 2. Berguiga M, Galatoire O. Tear trough rejuvenation: a safety evaluation of the treatment by a semi-crosslinked Hyaluronic Acid filler. Orbit, 2017; 36 (1):22-26. — 3. Teoxane Post Marketing Surveillance from 2016 to 2020-Q3 — 4. Data on File. Torsion and compression tests assessed on a rheometer. The measurement of the rheological parameter Delta index represents the balance between gel viscosity and elasticity. Physical analysis of HA fillers intended for infraorbital uses. RDRE 2023. — 5. TEOXANE Post Marketing Surveillance Survey. September 2020. 1504 respondents — 6. Teoxane internal data source. TEOSYAL® PureSense Redensity 2 deliveries from 2012 to 2020: 1’011’774 boxes. TEOSYAL® PureSense Redensity 2 is a trademark of the firm TEOXANE SA. This product is a gel that contains hyaluronic acid, and 0.3% by weight of lidocaine hydrochloride (local anesthetic can induce a positive reaction to anti-doping tests). In the case of known hypersensitivity to lidocaine and/or amide local anaesthetic agents, we recommend not use lidocaine-containing products and please refer to products without lidocaine. TEOSYAL® PureSense Redensity 2 is a class III medical device and is regulated health product bearing the CE marking (CE2797) under this regulation. For professional use only. Please refer to instructions for use. This product availability depends on registration, please contact your local distributor. Please inform the manufacturer TEOXANE of any side effects or any complaint as soon as possible to the following address: medical@teoxane.com.

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tuberosity. The gluteus maximus, which is the largest and most superficial of the gluteal muscles, is the muscle most responsible for the shape of the buttocks. The gluteus maximus originates from the posterior surface of the ilium, sacrum, and coccyx and extends across the buttock at a 45-degree angle. This muscle forms most of the bulk of the buttock. It inserts into the iliotibial tract and gluteal tuberosity of the femur. The gluteus maximus is a powerful muscle that extends the hip joint and is used for forced extension in activities such as running, climbing, and rising from a seated position.6 It is not important posturally, is relaxed standing and is used minimally in walking. It is innervated by the inferior gluteal nerve.6 The gluteus medius lies between the gluteus maximus and the gluteus minimus. It is a fan-shaped muscle whose muscle fibres are oriented vertically, arising from the ilium Mr Deniz Kanliada provides an introduction to and inserting into the greater trochanter. using hyaluronic acid-based dermal filler products This muscle can only be palpated in the superolateral portion of each buttock. Its for buttock augmentation action is abduction of the hip and lateral Buttock augmentation is one of the most popular aesthetic rotation of the thigh. It is innervated by the superior gluteal nerve.6 treatment trends of the last decade.1 The Brazilian Butt Lift (BBL) The smallest of the gluteal muscles is the gluteus minimus, situated is a common procedure for augmentation and aims to shape the beneath the gluteus medius muscle. It originates from the ilium and buttocks by obtaining fat from other areas of the body through inserts into the greater trochanter and works in concert with the liposuction and reinjecting it into the lower back and loins.1 gluteus medius to prevent adduction of the thigh and to stabilise However, it has become a controversial treatment due to significant the hip. It is innervated by the superior gluteal nerve.6 The piriformis complication rates with the highest reported death rate of all muscle is an important anatomical landmark dividing the gluteal region cosmetic surgery procedures.2,3 into a superior and inferior part. The superior gluteal artery and nerves For patients seeking an alternative to the BBL, dermal fillers can be emerge superiorly to the piriformis, while the inferior gluteal artery and a suitable treatment to consider. The poly-L-lactic acid dermal filler nerve emerge into the gluteal region inferiorly to the piriformis.6 Sculptra gained approval from the US Food and Drug Administration for use in human immunodeficiency virus-related facial lipoatrophy The sciatic nerve is the longest and widest nerve in the body. It in 2004, leading to its use in buttock augmentation.4,5 However, the arises from the lumbar and sacral plexus L4 to S3 and exits the pelvis search for alternative methods has recently led to hyaluronic acid through the greater sciatic foramen, inferior to the piriformis muscle, (HA) products also being used, and products that are specifically although variations in its exit have been described.7 It then travels designed for buttock enhancement have emerged. beneath the gluteus maximus down the posterior thigh. It does not innervate the gluteal muscles.6

Enhancing the Buttocks Using HA

Anatomy As with any injectable treatment, knowing the anatomical area inside and out will help to ensure successful results and minimise the risk of complications. The gluteal region is the transitional area between the trunk and the lower extremity. It is composed of two rounded prominences or buttocks located posterior to the hips formed by subcutaneous fat and the gluteal muscles.6 This region extends in the vertical axis from the iliac crests superiorly to the infragluteal folds inferiorly. The width of the gluteal region includes the area between the depression of the greater trochanter of each lateral thigh at the iliotibial tract and is separated in the middle by the gluteal cleft.6 While the gluteal region is anatomically part of the trunk, it is functionally part of the lower extremity. Important external landmarks include the iliac crest, posterior-superior iliac spine (PSIS), sacrum, coccyx, and ischial

The gluteal arteries arise from the internal iliac artery. The superior gluteal artery is the largest branch of the internal iliac artery and exits the pelvis above the border of the piriformis muscle. It accompanies the superior gluteal nerve beneath the gluteus maximus and divides into branches that supply that gluteal musculature. The inferior gluteal artery exits beneath the piriformis and accompanies the inferior gluteal nerve beneath the gluteus maximus to supply the gluteus maximus, piriformis, and thigh. The gluteal veins accompany the gluteal arteries and drain into the internal iliac vein.6 In a study of 150 male subjects and 148 female subjects, analysis revealed a significant difference in gluteal region fat thickness between male and female subjects. The average gluteal fat thickness for female subjects was 33.2mm, while the average for male subjects was 23.1mm.8

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Inverted ‘V’ shape

Square ‘H’ shape

Heart/pear ‘A’ shape

Figure 1: Types of buttock shapes

Buttock shapes In my experience, there are several different buttock shapes that patients are likely to present with (Figure 1). The square and ‘V’ shape is more masculine, and the rounder and heart shape are more feminine.9 From my experience, the heart shape is more desired amongst slimmer patients and the round shape is more desirable amongst larger-sized patients. Men prefer more projection than an hourglass figure, so heart shape or round shape needs to be adjusted according to the body type and goals. I find that these trends are similar across different ethnicities. • The inverted ‘V’ shape: The ‘V’ shape becomes more common as we age because lower oestrogen levels change the place of fat storage from the butt to the midsection. It gives the look of the bottom of the butt being less full than the top, resulting in a ‘V’ shape. • The square ‘H’ shape: This shape is the result of prominent hip bones (the structure of the pelvis) and distribution of fat in the hips (also known as love handles), giving the more vertical look on the sides of the glutes. • The heart/pear ‘A’ shape: This type of butt results from fat distribution around the lower portion of the butt and thighs, leading to an increase in widening from the waist down to the legs. • The round ‘O’ shape: Also known as ‘the bubble butt’. This type is the result of fat distribution around the whole butt cheek.

Patient selection When considering a patient for buttock enhancement using HA fillers, it is important to identify any contraindications.10 These are the same as dermal filler placement in other areas and include: • • • • • •

Severe skin laxity, especially in the lower portion in elderly patients Ptosis of lower third of the gluteal area Pregnancy and breastfeeding Infections in the area Allergy to lidocaine or hyaluronic acid Patients with high blood pressure or cardiac problems due to high sodium amount in the product

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Round ‘O’ shape

Practitioners must therefore proceed with caution because there will likely be scarring and fibrotic attachments in the area which will make the injections harder. It will also be more difficult to spread the product equally and there is risk that the blood supply may be further decreased because of high volume of fillers compressing the blood vessels against the implants. If practitioners are to go ahead with treatment, I recommend that products should be injected slowly and carefully.

Product selection Poly-L-lactic acid injections are often used by practitioners to augment the buttocks and the literature suggests they are an effective treatment for patients seeking non-invasive gluteal enhancement with minimal downtime, improving gluteal firmness, shape, proportion, and projection.5 However, if the main goal of the treatment is volume replacement, enhancement or contouring, then HA injections are preferred.11 Because of their biochemical nature, HA fillers are viscoelastic and absorb water and expand further for better volume replacement.12 There is only one HA-based filler on the market indicated for restoring loss of volume and contouring body surfaces such as the buttocks, which is the product I choose for my patients. Like other biphasic hyaluronic acid-based products, the reabsorption rate is around 18-24 months. The lifestyle of the patient, such as their occupation if they sit more or wear tight clothing, as well as exercise, can affect the lasting time of this product.13

Treatment Body fillers are best indicated for enhancement of the upper and middle thirds of the buttocks and the lateral trochanteric depressions. I recommend not to inject into the lower part of the buttock because it will make the area heavier and cause a saggy appearance. As mentioned, all important arteries, veins and nerves run beneath the gluteus maximus muscle, so all injections need to be made above to avoid complications.14 The deepest points and Before

After

I find that the most ideal patients are young individuals with or trochanteric depressions – colloquially known as hip dips, these are the inward depression along the side of the body, just below the hip bone – who do not have excess fat and cellulite around the butt area. There are many patients who have had buttock implants or fat transfer who want to improve their shape or believe they need more volume. Fillers can be a good option to correct irregularities or increase the projection and the size even more; however, there is currently a lack of research in treating patients who have previously had fat transfer or implants with HA fillers in this area.

Figure 2: 29-year-old patient before and immediately after dermal injections to the buttock. 200ml of Genefill Contour HA dermal filler was used.

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After

green teas, ibuprofen, or multivitamins for three days. The gym should also be avoided for a week and butt exercises should be avoided for six weeks. If the patient desires more volume in the area, I would look to retreat in three to four weeks because this is when expansion of the product should be expected.

Side effects and complications

Figure 3: 35-year-old patient before and two months after dermal injections to the buttock. 350ml of Genefill Contour HA dermal filler was used.

borders of injection should be marked while the patient is standing. Gluteal skin and fat thickness are important to consider when planning the treatment because it indicates the correct cannula length and injection depth for each patient. Buttock injections are done with blunt cannulas and usually an 18-19 gauge 100mm cannula is recommended by the product manufacturers. 14 gauge and 16 gauge cannulas are not indicated because of leakage risk and a high quantity of product injected in a single layer can create lumps. After cleaning the area with alcohol or another antiseptic solution, I choose to inject anaesthetic (2% lidocaine 5ml mixed with 10ml isotonic solution). I will inject 0.3ml of 1% lidocaine using a 30 gauge needle for the cannula entry points. For a blunt cannula of 19-20 gauge, I will usually create the entry points using an 18 gauge sharp needle. Note that a large volume of local anaesthetic may alter the shape of the defects to be corrected, which may alter your results. Injections into the buttocks will start from lateral to medial and from deeper layers, with larger boluses, to superficial layers, with smaller boluses. As mentioned, it’s vital that filler is placed above the muscles. To be able to enhance the volume smoothly and equally, 3D multilayer injections (subdermal, into the fat, under the fat layer) are needed. My technique usually involves inserting multiple macro droplets of around 3mls each and I find this gets the best results. After volume restoration, to be able to create nice contouring for the waist and legs, more superficial injections can be used; the fanning technique is my recommendation. The fanning technique may also be needed while injecting the depressions in the lower portion of the buttock or sides closer to the skin. Injection should continue until all the marked areas have been treated. The amount of product required for this procedure is vast compared to other areas. For example, for hip dip corrections, 50-70mls each side is usually needed and if patients need both hip dip correction and buttocks lift, then around 100-120mls each side is needed. I do not recommend that practitioners inject more than 300mls in the first session and multiple sessions may be required. Following the treatment, I advise patients to avoid hot showers,

Complications of buttock fillers are similar to other filler treatments like pain, bruising, swelling, redness, allergic reactions, itching and a feeling of pressure.7 In my experience, pain in the buttocks or back is expected to occur in the first two to three days. Due to swelling in the area, sitting, walking, or running will also be painful during this period, but this can be decreased by taking paracetamol. Because of toilet and bathroom use, antibiotics should be considered for three to five days if high volumes have been injected (200-300mls) or if the patient has had fat transfer or butt implants before. There is a lack of evidence and research into the risk of vascular compromise in the buttocks. The vessels are large in the buttock and it is not a complication I have ever seen. As with other dermal filler treatment areas, practitioners should be well-versed and trained in recognising complications and management protocols.

Conclusion Buttock augmentation, enhancement, lifting and contouring is getting more popular and popular every day. Patients are requesting quick, safe, and effective treatment to increase volume in the buttocks or to create a rounder and more lifted look. When considering butt lift and enhancement options, it’s important to note that fat transfer is easier than surgery and results last many years, but general anaesthesia is needed and complications can be life threatening.15,16 HA-based filler is a good alternative to surgery and fat transfer in my experience, as it has similar results, good longevity of up to 18-24 months and the treatment can be done in the clinic under local anaesthesia. Complications are less common and life-threatening complications are extremely rare. Like all other advanced treatments, buttock enhancement and body contouring using dermal filler requires a high amount of experience, advanced training and skills, and must be done by an experienced specialist.

Mr Deniz Kanliada is a consultant ENT and facial plastic surgeon based in Harley Street. He has been practising in aesthetics for more than 14 years and has completed more than 2,000 surgical procedures in Istanbul, the UK and Cyprus. Mr Kanliada is the founder of educational software provider Virtual Surgery Training Ltd, which develops Virtual Aesthetic Doctor training. He is also a key opinion leader for Genefill Contour. Qual: Istanbul University, Faculty of Medicine, ENT Head and Neck Surgery Department

VIEW THE REFERENCES ONLINE! WWW.AESTHETICSJOURNAL.COM

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Recognising the Key Tear Trough Ligaments

Targeting this ligament will normally take one of two forms. In my experience, at a deeper level, a small amount of hyaluronic acid filler can minimise groove appearance caused by the ligament. A more superficial, subcision-like technique, on the other hand, can further improve the medial infraorbital region without the need to add volume. While subcision refers to a slightly different technique used to treat acne scars; the premise here is similar: using a blunt cannula in the subcutaneous layer can reduce the tethering of the skin to the ligament by breaking some of those attachments.

Dr Uche Aniagwu details the anatomy of the ligaments in the under-eye region

Orbital-retaining ligament

P-OOM: Palpebral segment of orbicularis oculi muscle

The orbital-retaining ligament is a continuation of the tear trough ligament and splits into two parts. It starts at the mid-pupillary line and extends roughly 15mm laterally.3 The ligament mainly serves to attach the orbicularis oculi muscle to the orbital rim and also forms the superior border of the suborbicularis orbital fat pad (SOOF).4 There is a common misconception that this ligament is the sole anatomical foundation of the palpebromalar groove; however, the origin of this groove is mainly thought to be due to atrophy of subcutaneous fat in the region coupled with fixation by the orbitalretaining ligament.5 From a clinical perspective, this ligament is of concern to patients exhibiting a prominent palpebromalar groove. Treatment of this region requires far more caution than the tear trough region for a few reasons. Primarily, the added component of superficial fat loss means that managing the actual problem requires some volume augmentation in the subcutaneous plane, which comes with inherent cosmetic risks of lumps and Tyndall effect when performed in the infraorbital region.2 Additionally, just beneath this ligament is an area known as the prezygomatic space, which notoriously can lead to malar mounds if mismanaged with dermal fillers.6 It’s for this reason that in my advanced tear trough filler course I stress not filling between the midline and the lateral canthus; in my opinion, all enhancements in this region should come from treating the cheeks, either in the zygoma region or below the zygomatic ligament.

O-OOM: Orbital segment of orbicularis oculi muscle

Zygomatic ligament

As the clinical lead for hyaluronic acid filler augmentation trainings on my courses, I always, no matter the experience level of my students, begin each session with an anatomical review of the tear trough region. Though it may seem redundant to some of the more experienced students, I still do so to stress just how critical anatomical understanding is for mastering tear trough treatments, perhaps more important than in any other non-surgical facial treatment. Mastery of this region’s anatomy can not only prevent complications and improve patient outcomes, but it can also expand a practitioner’s patient pool and build injection confidence. Of course, such lessons should focus on the structures that most-influence a practitioner’s results as an injector. Here is a brief introduction to the key infraorbital ligaments and their significance for under-eye treatments involving hyaluronic acid filler. Key TTL: Tear trough ligament ORL: Orbital-retaining ligament splits into upper lamellae (UL) and lower lamellae (LL)

SOOF: Suborbicularis orbital fat pad splits into medial (MS) and lateral (LS) ZL: Zygomatic ligament DLCF: Deep medial cheek fat pad – lateral segment Figure 1: Diagram demonstrating the anatomical features of the tear trough

Tear trough ligament The tear trough ligament is the superstar of the region and should be the number one focus when managing infraorbital complaints. Like most ligaments in the region, this ligament is osteocutaneous,1 meaning it originates from bone and attaches to the skin, which results in the infraorbital region’s characteristic medial groove. The majority of complaints from patients will involve this ligament, and it will feature prominently in cases of under-eye hollows or often in framing infraorbital bags.2 The ligament’s main function is to tether the orbicularis oculi muscle and malar fat pads to the maxilla (cheekbone). It is important to clarify that contrary to popular misconception, the ligament is only about 5-7mm in length and extends from the medial canthus to the midpupillary line, at which point it becomes the orbital-retaining ligament.

The zygomatic ligament originates laterally at McGregor’s Patch and forms the inferior border of the prezygomatic space.6 It appears continuous with the tear trough ligament, though it is not. Once again, this ligament is osteocutaneous and manifests in patients as an apparent mid-cheek groove. Typically, this presentation will appear in conjunction with a pronounced tear trough groove.7 PMG It’s important to recognise TT that the strength of these ligaments from bone to skin relies heavily on genetics, so these patients may present at MCG NJG any age.7 The ageing process can certainly exaggerate these attachments, however, a skilled Figure 2: Image of patient demonstrating the locations of the nasojugal groove practitioner must be (NJG), the tear trough (TT) groove, the able to manage these palpebromalar groove (PMG) and the midcheek groove (MCG). concerns when treating

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young patients, for whom adding volume may be inappropriate as they do not demonstrate any volume loss. In the case where there is clear volume loss of the cheek accompanied with infraorbital concerns, it would then be sensible to add volume on the bone of this region using a needle and bolus technique. Any decision to inject above the zygomatic ligament should be made with caution, as the pre-zygomatic space is prone to post-treatment complications and often manifests in malar mounds.8 If your best clinical judgment indicates that you treat the cheeks above the zygomatic ligament, then injections directly onto bone are likely to be the least complication prone. In patients where cheek augmentation is not indicated, you may want to consider subcision-like techniques using a cannula in the region. Similar to the tear trough region, in my experience, using a cannula in the superficial planes to add some separation between the ligament and skin can improve the results of a mid-cheek groove. For many patients, using very small microdroplets of filler along the line of the ligament (less than 0.1ml total) can also be used in the superficial planes to further enhance any subcision performed.

Enhance your knowledge Mastering anatomical knowledge of these ligaments and the broader infraorbital region – including fat pads, bone, and skin – is of paramount importance for anyone looking to become an expert under-eye injector. With this knowledge, practitioners can expect to create far more robust and effective treatment plans, provide

better results while reducing post-treatment complications, and vastly expand their patient pool. Having said all that, I offer these words of advice: while the anatomy is often similar, each patient’s needs are different. Do not compromise spending time understanding the patient’s needs and collaborating with the patient to form a treatment plan. After all, no two faces are the same. Dr Uche Aniagwu is the founder and clinical lead of the Dr Uche Tear Trough Training Academy. He is also a resident injector at Beyond Medispa, Harvey Nichols and has authored the Essential Eye Beauty Guide, which was published in 2019. Dr Aniagwu studied medicine at St Bart’s and has an MSc in Radiation Biology from the University of Oxford. Qual: MBBS, MSc REFERENCES 1. Wong CH, Hsieh MK, Mendelson B. The Tear Trough Ligament: Anatomical Basis For The Tear Trough Deformity. Plastic Reconstruction Surgery, 129: 1392, 2012. 2. Stutman RL, Codner MA. Tear Trough Deformity: Review of anatomy and treatment options. Aesthetic Surgery Journal, 32(4): 426, 2012. 3. Haddock NT, Saadeh PB, Boutros S, et al. The Tear Trough and Lid/Cheek Junction: Anatomy and Implications for Surgical Correction. Plastic Reconstruction Surgery 123: 11332, 2009. 4. Haddock NT, Saadeh PB, Boutros S, et al. The Tear Trough and Lid/Cheek Junction: Anatomy and Implications for Surgical Correction. Plastic Reconstruction Surgery, 123: 11332, 2009 5. Doubt G, Garb BB, Rampazzo A, et al. Surgical Anatomy Relevant To The Transpalpebral Subperiosteal Elevation Of The Midface. Aesthetic Surgery Journal. 35(4):353, 2015. 6. Mendelson BC, Jacobson ST. Surgical Anatomy Of The Midcheek: Facial Layers, Spaces, and The Midcheek Segments. Colin Plastic Surgery, 35:395, 2008. 7. Huang YL, Chang SL, Ma L et al. Clinical Analysis and Classification of The Dark Eye Circle. International Journal of Dermatology, 53(2): 164, 2014. 8. Kpodzo DS, Nahai F, McCord CD, et al. Malar Mounds and Festoons: Review of Current Management. Aesthetic Surgery Journal, 34(2): 235, 2014.

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how long we could expect results to last. Lipolytic effects can be long-lasting, provided the patient does not have a significant weight gain, whilst treatment sessions depend on the degree of skin laxity and adiposity to address. In this patient’s case, she was told of the possibility of requiring a second top-up treatment between six to nine months to confer a greater skin tightening advantage, and that results are expected to last between one to two years. The patient had no contraindications to treatment, so we were ready to proceed.

Treatment

Case Study: Treating the Lower Face Dr Priya Verma details her approach to treating laxity and jowling with laser-assisted lipolysis Presentation A 60-year-old Caucasian female presented to my clinic with concerns about jowl development and laxity under her chin and in the neck. She was seeking a treatment which would confer skin tightening across the jawline, chin and the neck, without the need for surgery. The patient had never had any cosmetic treatments to these particular areas in the past. On examination, there was marked laxity in the submental area, anterior neck with static wrinkles and formation of jowls disrupting the contour of the jawline. The main issue here was loss of tensile strength and elasticity due to chronological ageing.

Consultation During the consultation, it was apparent that a key factor for this patient was to obtain an ageappropriate yet natural result. She had no relevant past medical history of note. We discussed the different treatment options available to her, which included high-intensity focused ultrasound (HIFU) and surgical facelift. After outlining details for both, we agreed that HIFU would not have provided a significant enough result for a long enough period as desired by the patient, while a surgical facelift would carry too high a risk of complications with much more noticeable downtime, which the patient did not want to experience. I had also outlined the use of a minimally-invasive laser-based skin tightening procedure called Endolift. Given the patient’s request for minimal downtime, natural results, and a sufficient outcome longevity, this was deemed as the preferred choice. The patient opted for a threearea treatment to include the lower face (including mandibular border), submental area and anterior neck. This treatment is performed using the LASEmaR 1500 device, which is FDA-approved for laser-assisted liposuction. It is a 1470 nm diode laser which acts by remodelling the hypodermis of the skin, causing skin tightening and where necessary, reduction of excessive fat through lipolysis.1 Endolift uses a specially designed micro-optical fibre, as thin as a human hair, to deliver the laser energy. The laser creates microchannels of trauma in the hypodermis, which stimulates retraction of the connective septum, and within the extracellular matrix causes upregulation of fibroblasts, thereby stimulating neocollagenesis.2 The patient had the correct clinical indications for treatment: significant skin laxity and a degree of localised adiposity. She asked about the number of sessions that would be required and

Prior to treatment, the skin was sterilised using NatraSan antiseptic spray. The skin was then marked up to demarcate safe zones for treatment and high-risk areas to avoid, such as the thyroid tissue and the territory of the marginal mandibular branch of the facial nerve. To ensure the patient’s comfort during the procedure, a percutaneous local anaesthetic was used. The preferred choice was 2% lidocaine, reconstituted into 0.9% sodium chloride, injected in a fan-like manner into the three treatment areas using a 22 gauge blunt cannula. The local anaesthetic is used to provide numbing, not complete loss of sensation, so the patient can provide some tactile feedback if highly innervated areas are being adversely affected. The quantity of anaesthetic used is also restricted to avoid excess liquid, which can cause dispersion of the photothermal effect of the laser.3 A laser-protective eye shield was applied to the patient prior to the treatment, in compliance with non-surgical laser standards.4 After allowing five to 10 minutes for the local anaesthetic to be effective, I began the procedure. There are two types of fibre that can be used for Endolift: linear (also known as bare-tip) or radial. The laser beam in a linear fibre is emitted in a forward direction, whereas the radial fibre provides a more circumferential laser beam. The fibres come in different sizes, ranging from 200 to 600 microns, which are indicated for different areas of the face and body. For this patient I used a 300-micron linear fibre as there was a degree of lipolysis to achieve and this linearity theoretically provides a relatively stronger irradiance compared with the radial variant, given what we know from endovenous laser ablation studies comparing fibre tips.5 I began at the left lower face, inserting the fibre under the skin approximately 2cm anterior to the tragus by temporarily pulsing

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After

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Patient before and one month after one treatment using Endolift to address laxity in the submental area, static wrinkles on anterior neck and formation of jowls, disrupting the contour of the jawline.

the laser, creating a micro-burn in the skin marking the entry point. I advanced the fibre stopping short of the corners of the mouth, then pulsed the laser continuously during retrograde movement towards my entry point. I continued to treat the lower face area using this technique in a fan-like manner. We know that the marginal mandibular nerve is most susceptible to injury where it courses over the facial artery in the region of the mandible,6 so this area was treated with caution. Once the clinical endpoint was reached, i.e. a noticeable retraction in the skin and discernible firmness, I moved on to the next area. In the neck the entry point used was 1cm below the angle of the mandible, staying anterior to the border of sternocleidomastoid, and under the chin at the submental crease extending to the region of the hyoid bone. Since we know that the thyroid gland contains photosensitive tissue, and as one study has demonstrated, even the use of lowlevel infrared laser irradiation results in thyroid hormone profiling changes,7 the fibre did not traverse the thyroid tissue at any point during the procedure. Throughout the treatment a Zimmer cooling device was used to provide more comfort for the patient, but also to cool the tissue from the heat generated by the laser. In some areas there was more marked adiposity, such as the submental region, so here I found that reducing the speed of fibre retraction when pulsing the laser was more effective at lysing fat cells. The extent of fat melting that occurs is clinically apparent by a specific ‘crackling’ noise heard during treatment. The more lipolysis occurring, the more apparent that noise becomes. In areas where skin laxity was the main concern (i.e. lower face and neck) I found that speeding up fibre retraction and pulsing the laser during anterograde movement enhanced the retraction of the tissue, achieving the endpoint faster. I encountered no issues with the procedure, the tissue responded very well with no bruising or haematomas from the fibre penetration and the patient was very comfortable throughout. Where there were areas of higher resistance, I manually manipulated the skin to guide my fibre through the tissue.

Post procedure Immediately following the procedure there was a visible improvement in skin laxity, particularly to the neck area. Post procedure the patient had mild erythema, very mild swelling and slight paraesthesia in the lower face (as expected), however no motor deficit to any of the branches of the facial nerve were noted. She denied any pain following the treatment.

The laser creates microchannels of trauma in the hypodermis, which stimulates retraction of the connective septum The patient was advised to stay out of direct sunlight for 48 hours following treatment, to avoid touching, rubbing or applying anything to the skin for 24 hours to reduce the risk of infection, and to wear a compressive lower face/neck garment where possible in the 4872 hours following treatment to help reduce swelling, bruising and continue to help shape the final result. Although the patient chose not to on this occasion, I usually recommend a skin bioremodelling product such as Profhilo after this procedure as it helps to stimulate four different collagen proteins and elastin in the extracellular matrix,8 allowing the two treatments to work in harmony. I scheduled a follow-up appointment with the patient four weeks post treatment, as this is usually sufficient time to allow any swelling and/ or bruising to settle. As well as this, the lysed adipose cells have been cleared through the lymphatic drainage and procollagen formation is in progress. At the patient’s four-week review, she reported that the erythema subsided within 24 hours, the swelling had resolved within five days, and the paraesthesia lasted two to three weeks. She had marked improvement in the laxity to her neck and jawline, while the submental adiposity had significantly reduced. The patient was extremely pleased with the results. She could see a visible difference to all three areas and I was pleased to inform her that this result would continue to improve over the coming six to nine months as collagen matures.

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

Side effects/complications Patients undergoing Endolift treatment should be fully informed and consented on the possible risks and side effects relating to the procedure. These include pain, bruising, haematoma formation, erythema, swelling or oedema, micro-burns to the skin, hyper/hypopigmentation, paraesthesia/dysaesthesia/ hyperaesthesia/anaesthesia, nerve injury/neurapraxia, giving rise to altered facial expressions (usually temporary lasting up to a few months), and optical fibre breakage under the skin.9

Conclusion Endolift is a safe and effective procedure for skin tightening, offering the added benefit of laser-assisted lipolysis. Patients nowadays are seeking minimally-invasive procedures to achieve their desired aesthetic,10 making this treatment perfectly positioned in the aesthetics arena to deliver results without the need for surgery and with very little downtime. Although many patients undergoing treatment will see an immediate improvement, the final result can be appreciated six to nine months post procedure. The key to a successful result using the device is adequate patient assessment, consideration of the degree of skin laxity, skin thickness and extent of adiposity to determine not only the parameters for use, but also the approach to treatment. For severe laxity the patient should expect to need two sessions, ideally six months apart, and for severe adiposity they should be pre-warned they may not be suitable. Disclosure: Dr Priya Verma is a key opinion leader and trainer for Endolift Dr Priya Verma is an aesthetic practitioner and NHS academic clinical fellow in general practice at King’s College London. She studied medicine at Warwick Medical School, before completing training in aesthetics in both London and Milan. Dr Verma is currently completing her post-graduate certificate in skin ageing and aesthetic medicine, while practising from Nova Aesthetic Clinic in London. Qual: MBChB; BSc (Hons); DRCOG; DFSRH; MRCGP (in prog); PGCert Skin Ageing & Aesthetic Medicine (in prog) REFERENCES 1. Eufoton S.R.L (2018). Endolift. Eufoton Medical Lasers. <https://www.eufoton.com/en/treatments/ aesthetics/endolift> 2. Eufoton S.R.L (2018). Endolift. Eufoton Medical Lasers. <https://www.endolift.com/en/> 3. Brown, E. (2020). Fundamentals of Lasers and Light Devices in Dermatology. In: V. Madan, ed., Practical Introduction To Laser Dermatology, 1st ed. Manchester: Springer International Publishing, 35-36. 4. British Medical Laser Association (2017). Essential Standards Regarding Class 3B and Class 4 Lasers and Intense Light Sources in Non-surgical Applications. p.8. <https://www.bmla.co.uk/ wp-content/uploads/BMLA%20Essential%20Standards%20May%202017.pdf> 5. Stokbroekx, T., De Boer, A., Verdaasdonk, R., Vuylsteke, M., & Mordon, S. (2013). Commonly used fiber tips in endovenous laser ablation (EVLA): an analysis of technical differences. Lasers in Medical Science, 28(6), 501-7. 6. Hazani, R., Chowdhry, S., Mowlavi, A., & Wilhelmi, B. (2010). Bony Anatomic Landmarks to Avoid Injury to the Marginal Mandibular Nerve. Facial Surgery, 31(3), 286-89. 7. Azevedo, L., Aranha, A., Stolf, S., Eduardo, C., & Vieira, M. (2005). Evaluation of low intensity laser effects on the thyroid gland of male mice. Photomedicine and Laser Surgery, 23(6), 567-70. 8. HA-Derma (2016). What is Profhilo? HA-Derma. <https://ha-derma.co.uk/products/profhilo/> 9. Scrimali, L & Lomeo, G. (2015). Endolaser soft lift: from theory to practice. Aesthetic Medicine, 1(1), 27-29. 10. Matarasso, A., Nikfarjam, J., & Abramowitz, L. (2016). Incorporating Minimally Invasive Procedures into an Aesthetic Surgery Practice. Clinics in Plastic Surgery, 43(3), 449-57.

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Lifting the Breast with Radiofrequency Mr Massimiliano Cariati and Mr Rishi Mandavia present their non-surgical approach to breast lifting The breasts are a uniquely important part of the female body, with both physiological and psychosocial roles. In many works of art throughout history, breasts have been portrayed prominently, and with many symbolic associations, most frequently with fertility. Views of their importance and acceptance have metamorphosed through time and have reflected upon the views of women of the period and society in general. It therefore comes as no surprise that aesthetic surgery of the breast is one of the most common procedures performed by plastic surgeons today, as a proportionately developed breast continues to be an important feminine feature.1

Breast ptosis Breast droop, or ptosis, is an extremely common occurrence, following weight loss, pregnancy, breastfeeding, and more generally as a consequence of normal ageing. The result is a loss of youthful shape and contour, frequently associated with a change in the position and orientation of the nipple and areola complex.2 This results in aesthetic detriment and deviation from the broadly accepted ‘ideal’ breast shape,3 described as a 45:55 ratio between the upper and lower pole of the breast, with an upward pointing nipple at an angle between 10-20 degrees, and with a straight or gently concave upper slope and a convex lower slope.2 Breast ptosis can be classified using the Regnault classification system, which describes the degree of droop by the relative position of the nipple areola complex and the inframammary fold (Figure 1).4 The pathophysiology of breast ptosis centres around the effect of gravity, parenchymal loss, loss of elasticity, decreased integrity of fascial support and of Cooper’s ligaments, and the thinning and stretching out of skin. As a result, breast position is lower on the chest wall, breast contour changes, and upper pole fullness is lost.2

Normal

Grade 1 Minor Ptosis: Nipple is at the level of the inframammary fold

Grade 2 Moderate Ptosis: Nipples drop below breast crease, but higher than most of the breast mound

Breast restoration with radiofrequency

Mastopexy is a surgical procedure that seeks to restore a more youthful shape and contour of the breast, restoring texture, repositioning the nipple areola complex within the breast mound, and tightening the skin envelope. Traditionally this can be achieved through a variety of surgical approaches, which vary in indications depending on breast features, but all share some common drawbacks. Scarring and the need for general anaesthetic are frequent reasons why women who have experienced ptosis frequently choose to defer or opt out from addressing their cosmetic concern. It is in this context that non-surgical interventions may be considered. In our clinic, we use radiofrequency assisted lipocoagulation (RFAL) combined with radiofrequency (RF) microneedling. This is a ‘scarless’ procedure that can be performed under tumescent local anaesthetic in the clinic – with minimal risks and post-procedural downtime. In the appropriate patient, it is capable of producing a desirable degree of lift and contouring of the breast without any of the downsides of a surgical mastopexy. The practitioner performing the procedure should be a General Medical Council registered doctor with full licence to practice. The use of the device requires CQC registration. RF is a form of electromagnetic current that can be delivered to a variety of tissue types to generate thermal energy.5 When RF is applied to skin and underlying soft tissue, it generates contraction through two mechanisms. The first is shortening and thickening of collagen fibres and the second is initiation of a wound-healing cascade to trigger neoangiogenesis, neocollagenesis, and elastin reorganisation over the following three to four months.6 This explains why some results are noticed early on following the procedure but, in our experience, the more dramatic results manifest at three to six months post procedure. In our practice, we use BreastTite, which is part of the BodyTite platform. This is a bipolar device where electromagnetic energy is transmitted from a generator to the tissue between the two electrodes of a directional handpiece (Figure 2). It has controlled energy, which flows between the tips of internal and external sensors. We believe it’s important to use a device that has real-time internal and external temperature monitoring. This is so that when a pre-set temperature is reached, energy delivery stops so it does not overheat and cause injury to skin and surrounding tissue.7

Grade 3 Advanced Ptosis: Nipples drop below the inframammary fold and just at the level of maximum breast projection

Pseudoptosis: Lower breast sagging

Figure 1: Degrees of breast ptosis as per the Regnault classification system.3

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

Parenchymal Maldistribution: Unusual shape

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considered not suitable for this procedure and should generally be discouraged from pursuing cosmetic surgery of the breast in view of the increased risk of complications. Standard measurements are taken with particular attention to the sternal notch-to-nipple distance, nipple-to-inframammary fold distance, breast base and breast height on both sides (Figure 3), and clinical photography is taken to document breast position and shape.

Treatment protocol Figure 2: The radiofrequency handpieces that are inserted into the breast

Consultation As is the case with all cosmetic and aesthetic work, the pre-procedural consultation is essential to assess the patient, determine their needs and expectations, and select the most appropriate approach. It is essential to understand the patient’s specific concerns about their breasts, and to foster discussion and realistic expectations. Goals with regards to shape, size and fullness must be established. It is essential to manage these and to be transparent with regards to the potential of the technique. Whilst RFAL will likely produce a degree of tissue tightening and contouring for the majority of patients, it would be an inadequate choice for patients with grade 3 ptosis or with moderately large or large breasts. These patients are better candidates for surgery. Furthermore, patients seeking volume increase, particularly at the upper pole of the breast, will be unlikely to be satisfied with the results of RFAL, and should instead be counselled towards augmentation mastopexy and referred onwards as appropriate. The ideal patient for this procedure is someone with grade 1 or grade 2 ptosis (Figure 1), with small to moderately-sized breasts, typically not larger than C cup. In our experience, satisfactory results with noticeable contouring can be achieved in larger breasts also, but these should constitute the exception rather than the rule. At the time of the initial consultation, it is essential to assess breast health, and ensure that a full history with regards to previous or current breast symptoms and family history of breast disease is determined. A standard breast examination should be routinely carried out and any symptoms or findings should be investigated as per clinical guidelines prior to committing the patient to the procedure. In our practice, women aged 40 and above – even if asymptomatic and with no significant personal or family history – are referred for mammography prior to being considered for RFAL. Risks, such as pain, swelling, bruising, seroma, burns, scarring (at the entry port), failure to achieve lift or development of asymmetry, and benefits are discussed with the patient. Patients with a history of breast cancer, diabetes, poorly controlled cardiovascular disease, coagulopathy, steroid use for the management of autoimmune conditions, and smokers, are

SSN:N

The procedure is ideally performed under tumescent local anaesthesia and excellent levels of pain control allow the procedure to be safely performed in combination with 5mg diazepam, 30mg dyhidrocodeine and 1g paracetamol orally 30 minutes prior to the beginning of the procedure. This method of local anaesthetic is commonly employed in liposuction,8 and creates adequate space in the relatively avascular fascial layer of the breast separating the skin from the breast gland, to allow the internal cannula of the device to travel, and optimises conductivity for the RF between the internal and external electrode.8 This avoids bad coupling and reduces the risk of thermal injury. In our practice, tumescent anaesthesia is established infiltrating approximately 125ml of an isotonic solution of normal saline containing 10ml of 2% Xylocaine with 1:200,000 adrenaline for each breast. This results in a well-tolerated procedure with a short recovery phase and ideal safety profile. Standard clinical photography and paperwork are carried out, ensuring informed consent. The patient is placed in the supine position on the table, the skin is prepared with chlorhexidine solution and the field is draped with sterile drapes. Small volumes of 2% Xylocaine are administered at the chosen entry points, typically: 1. At the border of the areola at the 12 o’clock position 2. Towards the axillary tail of the breast 3. Medially along the inframammary fold 4. At the lateral aspect of the breast just above the inframammary fold Entry ports are created with the tip of an 18 gauge needle, and then extended to 2-3mm in size using the tip of a size 11 scalpel blade. The tumescent anaesthetic solution is infiltrated using a cannula and across the entire surface of the breast (sparing the nipple and areola complex) to the circumferential edge of the breast footprint. The device is set up and prepared by an assistant, and the handpiece is connected. Standard settings include external temperature cut-off at 38°C, internal cut-off at 60°C, treatment time of 120 seconds. Following infiltration of the tumescent, the internal cannula of the handpiece is introduced through the periareolar port and allowed to glide to the edge of the breast. Lubricating gel is applied to the skin

SSN:N

BW BH N:IMF

IMD

Figure 3: Standard breast measurements

Figure 4: Insertion of the internal cannula of the handpiece

Figure 5: Treatment using radiofrequency microneedling following RFAL

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Figure 6: 38-year-old patient before and three months after BodyTite and Morpheus8 radiofrequency treatment.

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Figure 7: 26-year-old patient before and three months after BodyTite and Morpheus8 radiofrequency treatment.

surface over the area to be treated to improve conductivity. Energy is then delivered on slow withdrawal to allow the heating of the treated tissue to the desired temperature cut-off (Figure 4). Typically, energy is delivered one breast quadrant at a time, to allow even distribution of treatment. A total of 10-15kJ are delivered to each breast, with some variability between cases dictated by breast size and degree of correction required. The contralateral breast is then treated following the same principles. At the end of the procedure, following further skin preparation, we will treat both breasts with a RF microneedling handpiece (we use Morpheus8), over the entire surface of the breast, at 3mm of depth, with energy setting 45 and overlap of 50% (Figure 5). Entry ports are closed with either a single 5/0 nylon suture, or with Steri-Strips. The wounds are then protected with padded waterproof dressings. The whole procedure takes two-to-three hours and is only carried out once. The patient is discharged with a one-week course of prophylactic antibiotic and regular analgesia. Follow-up appointments are scheduled at one week (to remove sutures if any were placed) then one, three and six months to assess the development of post-procedure results.

Post treatment In our experience, derived from management of post-surgical breast patients, it is essential that the patient is instructed to wear a supportive post-surgical bra 24 hours a day for four weeks, and then during the daytime for a further four weeks. Patients are allowed to return to normal activity from the following day, but are advised to avoid particularly strenuous exercise and sporting activity for two to four weeks. The expectation from the procedure is that at the time of the three-month review, noticeable results in terms of lift and improved contouring will have begun to consolidate. All patients treated describe the procedure as having rejuvenated and firmed their breasts, with the majority having noticed a good degree of lift, an improvement in breast shape and a noticeable improvement in skin quality, with reduction in pores and improvement in skin tone. In our experience, assuming adequate patient selection, RFAL can achieve between 1.5cm and 3.5cm of lift when measured as nippleareola complex repositioning (Figures 6 & 7). Furthermore, improved contouring with a rounder fuller appearance is achieved in all patients we have treated. The technique is also adept at correcting mild to moderate asymmetry in breast position and results are expected to last five years (Figure 8).

Figure 8: 38-year-old patient before and three months after BodyTite and Morpheus8 radiofrequency treatment.

Conclusion Breast ptosis is one of the most common concerns women experience from an aesthetic standpoint. Whilst surgical mastopexy is an extremely effective way of addressing this concern, many patients defer or rule out engaging with it because of their concerns particularly surrounding general anaesthetic and conspicuous scarring. RFAL is a minimally invasive, non-surgical, virtually scarless approach that can be safely and comfortably carried out under local anaesthetic in the outpatient setting with minimal risks. It is ideal for patients with small-to-moderately sized breasts and grade 1 or 2 ptosis, for whom it consistently achieves improved contour as well as a 1.5-3.5cm lift in nipple areola complex position, with satisfactory enhancement of breast cosmesis without the drawbacks of surgery. Mr Massimiliano Cariati is a consultant oncoplastic and reconstructive breast surgeon. He is the clinical lead for breast services at University College London Hospital and is honorary associate professor with the Institute of Women’s Health, University College London. Mr Cariati holds a PhD in surgical oncology from the University of Cambridge and has published and presented his research widely nationally and internationally. Qual: MBBS, PhD, FRCS Mr Rishi Mandavia is an ENT surgical doctor and managing director of the Dr Tatiana Aesthetic Clinic. He holds an MSc in health policy, is carrying out a Ph.D. at University College London and has published and presented his research widely. Mr Mandavia is a member of the Royal College of Surgeons and also works as a NICE specialist advisor, a consultant to the Lancet Commission, and an advisor to the World Health Organization. Qual: MBBS, MSc, MRCS REFERENCES 1. Khan UD. An overview of aesthetic surgery of the breast. Plast Aesthet Res 2016;3:1-2. 2. Rinker B, Veneracion M, Walsh CP. Breast ptosis: causes and cure. Ann Plast Surg. 2010 May; 64 (5):579-84. 3. Mallucci P, Branford OA. Concepts in aesthetic breast dimensions: analysis of the ideal breast. J Plast Reconstr Aesthet Surg. 2012 Jan; 65(1):8-16. 4. Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg. 1976; 3:193-203. 5. Greene RM, Greene JB. Skin tightening technologies. Facial Plast Surg. 2014 Feb; 30(1): 62-67. 6. Zelickson BD et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based non-ablative dermal remodelling device. Arch Dermatol. 2004 Feb; 140(2): 204-209. 7. Theodorou S et al. Soft tissue contraction in body contouring with radiofrequency-assisted liposuction: a treatment gap solution. Aesthet Surg J. 2018 Jun; 38(2): S74-S83. 8. Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr Surg. 1993; 92(6):1085–1098.

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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How to Perfect Flat Blanching in Fine Lines using BELOTERO® Balance1 Dr Kim Booysen shares a case study on how fine line correction with BELOTERO® Balance1 is one of her most popular clinic treatments. Perhaps it’s the longevity of up to a year or perhaps it’s the natural feel of the filler, but most likely it’s the ability to almost instantly give an airbrushed appearance, giving patients a refreshed and rejuvenated appearance. I started using this product in patients who had allergies or aversions to other wrinkle treatments and I haven’t looked back. Patients will now request this treatment for fine lines, ahead of other traditional wrinkle treatment modalities. In this article I will explain why I use BELOTERO® Balance1 and what techniques I employ to get the best results for my patients.

An ideal fine line filler? An optimal intradermal filler should be resilient, inject easily, restore structure, induce neocollagenesis and has no reports of Tyndall2 effect. I have found that BELOTERO® Balance1 meets all these requirements. Filler resilience can be clearly demonstrated using a stretch test. Simply inject a small thread of BELOTERO® Balance1 onto a surface and stretch the filler, you will see how far you can pull the thread and how well it stays together. This is due to the Cohesive Polydensified Matrix (CPM®) technology that gives the product cohesivity, that ability to stick together.2 This property also reduces the risk of Tyndall effect when injected superficially.2 The CPM® technology has also shown to produce minimal inflammatory response.2 Once injected the 22.5mg of hyaluronic acid’s hydrophillic nature and support of the surrounding collagen and elastin, results in a lifting effect in the tissue. BELOTERO® Balance1 has a low viscosity and injects easily through a 30G needle, making intradermal injection very comfortable and easy to perform.

technique, the aim is to place the product in the superficial reticular dermis. This is a bit harder than you initially think. To inject into the superficial reticular dermis in the average patient, the target tissue depth is 0.2mm. Personally, I try and ensure just the bevel length of the needle is in the skin. To be able to inject this superficially, an injection angle of less than 12 degrees, holding the needle almost parallel to the skin is advised. The bevel up is my preferred method, but placing the bevel down can help prevent loss of product through pores or along a previous injection point. A light depression of the plunger with enough product expelled to cause a small cream or white appearance to the skin, without raising a bleb is the ideal end point. The cream/white appearance of the skin is known as blanching and is the result of pressure placed on the loop arterioles in this superficial skin. This may take a little practice to get right in the beginning. Massage may help reduce any excessive placement of the filler. Slight tenting of the skin can also help prevent over treatment.

Product quantities

Injection angle

Blanching during treatment

BELOTERO® Balance1 comes as a 1ml syringe but is also rebranded as BELOTERO® Lips3 Contour and comes as a 0.6ml, giving you flexibility to choose the correct amount of product for each individual patient. It also allows you to regularly maintain this treatment using a smaller amount of product if the lines return over time. On average I find that deep lines in the periorbital region requires two treatments, two weeks apart and I utilise a 1ml - 1.6mls at the initial injection session followed by a 0.6mls - 1ml repeat treatment at the two-week review. If treating less pronounced folds in the crow’s feet then a single one millilitre syringe may be required for the first session and 0.6mls for the second session. The perioral region may require between 1 and 2mls of filler depending on the extent and number of the fold lines in this region. A repeat treatment is also required in this region to ensure optimal treatment outcomes. Be sure to advise your patients on the need for repeat treatments and include this in the treatment plan and costings.

Flat blanching technique When treating fine lines, we need to remember we are injecting intradermally and when using the flat blanching 58

Aesthetics | April 2021

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She holds degrees in Medicine, Eastreally London.Drrestored She degrees in Medicine, Law, International “The treatment has my self confidence, I love it!” Kimholds Booysen is an independent aesthetic clinic owner REGISTER NOW for our 2021 Clinical Law, International Health Management andinBusiness in South East SheManagement. holds degrees Medicine, ds in Health Management andLondon. Business Her special for our 2021 Clinical Dr Kim Booysen is an independent aesthetic clinic owner Management. Her special interests are medico-legal Law, International Health Management and Business e Education SeriesNOW Webinars REGISTER interests are medico-legal aesthetics and aesthetic Her red Management. Her special interests areWebinars medico-legal the confidence to be in South East London. She holds degrees in education. Medicine, Education Series Webinars aesthetics and aesthetic education. Her spare time REGISTER NOW for our 2021Clinical Education Series at is atfor merzwebinars.com for and aesthetic education. spare time is on spare time isaesthetics spent travelling with her husband and working our 2021 Clinical Law, International Health Management and Business spent travelling with her husband andHer working on local at merzwebinars.com spent travelling with her husband and working on local merzwebinars.com local environmental causes. environmental causes. Management. Her special interests are medico-legal environmental causes. Education Series Webinars aesthetics and aesthetic education. Her spare time is at merzwebinars.com References Adverse events should be reported. Reporting forms information for United spent travelling with her husband and working onandlocal 1 IFU BELOTERO® Volume Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and 2 IFU BELOTERO® Intense merz-aesthetics.co.uk information for Republic of Ireland can be found at https://www.hpra.ie/homepage/ @merzaesthetics.uki Merz Aesthetics UK & Ireland environmental causes. 3 IFU BELOTERO® Balance about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz merz-aesthetics.co.uk @merzaesthetics.uki Merz Aesthetics UK & Ireland 3

the confidence to be

4 Tran C. et al., In vivo bio-integration of three hyaluronic acid fillers in human skin: a histological study – Dermatology, 2014, 228:47-54

Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

References 1 IFU BELOTERO® Lido Balance. 2 February Micheels. P., Sarazin, D., Besse, S., Sundaram, H. &Flynn, T.C. (2013) A blanching References M-BEL-UKI-0982 Date of Preparation 2021 1 IFU BELOTERO® Lidotechnique Balance.for intradermal injection of the hyaluronic acid BELOTERO®. Plast Reconstr Surg. 132(4:2)59S-68S. doi: 10.1097/PRS.0b013e31829a02fb. PMID: 24077012. 2 Micheels. P., Sarazin, S., Sundaram, 3 D., IFUBesse, BELOTERO® Lips Contour.H. &Flynn, T.C. (2013) A blanching

This article has been sponsored by Merz Aesthetics UK & Ireland.

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Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting and M-BEL-UKI-1056 Date of forms Preparation March 2021

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informationevents for Republic of Ireland can be foundReporting at https://www.hpra.ie/homepage/ Adverse should be reported. forms and information for United about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Kingdom canby email be found at www.mhra.gov.uk/yellowcard. Reporting forms and Pharma UK Ltd to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. information for Republic of Ireland can be found at https://www.hpra.ie/homepage/ technique for intradermal injection of the hyaluronic acid BELOTERO®. Plast Reconstr about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz REFERENCES Surg. 132(4:2)59S-68S. doi: 10.1097/PRS.0b013e31829a02fb. PMID: 24077012. Pharma Ltd by to UKdrugsafety@merz.com or on for +44United (0) 333 200 4143. 1. IFU BELOTERO® Lido Balance. Adverse eventsUK should beemail reported. Reporting forms and information Kingdom can be This article has been sponsored by Merz Aesthetics UK & Ireland. 3 IFU Lips Contour. References 2. BELOTERO® Micheels. P., Sarazin, D., Besse, S., Sundaram, H. &Flynn, T.C. (2013) A foundAdverse at www.mhra.gov.uk/yellowcard. forms and information Republic of Irelandfor can be events should be Reporting reported. Reporting forms for and information United confidence g treatment M-BEL-UKI-1043 Date of Preparation March 2021 1 IFU BELOTERO® Lido Balance. blanchingtechnique for intradermal injection of the hyaluronic acid BELOTERO®. Plast foundKingdom at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. AdverseReporting events should alsoand can be found at www.mhra.gov.uk/yellowcard. forms 2 Micheels. P., Sarazin, Besse, S., Sundaram, H. &Flynn, T.C. (2013) A blanching Reconstr Surg.D., 132(4:2)59S-68S. doi: 10.1097/PRS.0b013e31829a02fb. PMID: 24077012. be reported to MerzPharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. for Republic of Ireland can be found at https://www.hpra.ie/homepage/ This has been sponsored by Merz Aesthetics & Ireland. information technique intradermal injection of the hyaluronic acid BELOTERO®. PlastUK Reconstr 3. article IFUfor BELOTERO® Lips Contour. about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Surg. 132(4:2)59S-68S. doi: 10.1097/PRS.0b013e31829a02fb. PMID: 24077012. Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. M-BEL-UKI-1043 Date of Preparation March 2021 3 IFU BELOTERO® Lips Contour.

Aesthetics | April 2021

This article has been sponsored by Merz Aesthetics UK & Ireland. M-BEL-UKI-1043 Date of Preparation March 2021

17/03/2021 15:18

to be

Advertorial Thermage FLX®

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Treating the Periorbital Area with Radiofrequency As lockdown lifts patients will request noninvasive procedures without downtime With increasing emphasis on maintaining a youthful appearance whilst upholding a busy social and work calendar, there is a growing demand for safe yet effective treatments that offer minimal discomfort or downtime. In fact, there has been a 30% increase in minimally invasive procedures since 2014.1,2 The periorbital area is a particularly popular zone for treatment, being the third highest ranking area for cosmetic surgery worldwide in 2019.2 However, it presents a number of difficulties and safety concerns and Before often, surgical intervention with blepharoplasty at a late stage is required as opposed to being able to manage patient’s concerns early on. “The Thermage FLX® system offers an effective3 and well-tolerated4 rejuvenation of the eye area thanks to its technology based on monopolar radiofrequency (RF),” says Milena Naydenov, head After aesthetician at 111 Harley St. She adds, “Indeed, in addition to successfully accomplishing noninvasive skin tightening of the face, and the body, Thermage® treats the lower and upper eyelids and is the only non-invasive RF device present in the UK which is FDA-cleared (in the US) for the treatment of the eye area.”

Risks associated with eye treatment The periorbital area is one of the first places to show signs of ageing and to present skin laxity, fine lines and wrinkles,” Milena Naydenov says. “Unfortunately, treatment options are limited due to the numerous safety concerns related to the proximity of the eyeball and indeed the delicate nature of the skin in this area,” she explains. Dr Yannis Alexandrides, plastic surgeon and founder of 111 Harley St, adds, “While blepharoplasty offers the gold standard for anti-ageing of the upper and lower eyelid, it is not an option

Thermage FLX® advanced features: 25% faster treatments* compared to the previous Thermage CPT® version: the new Total Tip 4.0 provides greater surface area coverage than the Total Tip 3.0. AccuREP™ Technology: automatic calibration allows for optimised energy delivery, to provide consistent output. Patient comfort:8 The system also features a multi-directional vibrating hand-piece** to help enhance patient comfort4 for body and face, making the treatment much more comfortable than the previous version. Single handpiece: consistent treatment from head to toe without the need to interchange any handpieces. Touchscreen navigation: updated interface brings a modern look and functionality.

Aesthetics | April 2021

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for many patients due to the risks associated with general anesthesia, the risks of scarring and the postoperative recovery period, especially given that the world will soon be returning to work.”

Other treatment options “Non-surgical options such as botulinum toxin and dermal fillers can be effective in the right hands, but also do still come with inherent risks,” says Dr Alexandrides, “Dermal fillers can lead to infection at the injection site as well as nodule formation or a bluish discoloration beneath the skin (the Tyndall phenomenon) due to superficial injection technique.5 Complications of injecting botulinum toxin include dry eye syndrome, which if unidentified has been shown to lead to eyelid swelling, epiphora (excessive tear production) and scleral show,”6 he adds.

Why Thermage FLX®? Milena Naydenov comments that the Thermage FLX® represents a complete innovation in skin tightening and allows him to offer an effective3 and well-tolerated5 treatment for patients wishing to address anti-ageing of the periorbital area. She says, “Thermage FLX® has been found to be effective4 in the delivery of energy into the skin, independently of skin colour. Resistance encountered by the RF energy flow causes a build-up of heat, which induces an immediate contraction of the collagen (an ‘instant lift’) and stimulates a natural wound-healing response, production of new skin cells and collagen.7 When focused in the dermis and hypodermis, RF treatment can lead to improvements in the skin structure and tightening of lax and sagging skin.” REFERENCES 1. International Survey on Aesthetic/Cosmetic - 2014 ISAPS. 2. International Survey on Aesthetic/Cosmetic - 2019 ISAPS. 3. R. Fitzpatrick et al. Multicenter study of non-invasive radiofrequency for periorbital tissue tightening. Lasers Surg Med. 2003;33(4):232-42. 4. M. Fritz and al. Radiofrequency treatment for middle and lower face. Arch Facial Plast Surg. Nov-Dec 2004;6(6):370-3. 5. Fillers: Contraindications, Side Effects and Precautions. Lafaille & Benedetto. J Cutan Aesthet Surg. 2010 Jan-Apr; 3(1): 16-19. 6. Dry Eye Syndrome Due to Botulinum Toxin Type-A Injection: Guideline for Prevention. Ozgur, Murariu, Parsa & Don Parsa. Hawaii J Med Public Health. May 2012; 71(5): 120-123. 7. Zelickson, et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based non-ablative dermal remodelling device: a pilot study. Arch Dermatol. 2004 Feb;140(2):204-9. 8. Solta Medical, 2009. Report on Gazelle Clinical Study 09-100- GA-T ‘Validation of the Thermage 3.0 cm2 STC and DC Frame Tips, Comfort Software and Vibration Handpiece on the Face and Thighs’ (#09019ER). Bothell. * R&D Report ** The vibrating function is not available when using the Eye Tip 0.25 cm2.

This advertorial was written and supplied by Thermage FLX®

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A summary of the latest clinical studies Title: Quality of Life and Concurrent Procedures in Truncal Body Contouring Patients: A Single-Center Retrospective Study Authors: Elfanagely O, et al. Published: Aesthetic Plastic Surgery, March 2021 Keywords: Concurrent Procedures, Truncal Body Contouring Abstract: Body contouring procedures provide patients with a meaningful improvement in health-related quality of life (QoL). We aim to compare the difference between the QoL in patients undergoing a single post-bariatric abdominal body contouring procedure (BCP) and those undergoing two or more concurrent procedures. Patients evaluated for post-bariatric BCP were identified and administered the BODY-Q. Patient demographics, clinical and operative characteristics, surgical outcomes, cost data, and absolute change in QoL scores were analyzed, chisquare, and Mann-Whitney U-test, between patients who underwent single (SP), double (DP), or triple (TP) concurrent procedures. A total of 45 patients were included. The median age was 52 years old. The majority were female (71.1%) and AfricanAmerican (55.5%). The most common single procedure was panniculectomy (75%). Surgical site occurrences, readmissions, and the complication composite outcome did not differ between groups. No difference was seen between SP and DP QoL score. The DP had a statistically lower net QoL score compared with TP cohort in four domains. The SP had a statistically lower net QoL score compared with the TP in three domains. Average total cost for patients receiving an SP was $8,048.44, $19,063.94 for DP, and $19,765.02 for TP.

Title: Characteristics of Patients Seeking and Proceeding with NonSurgical Facial Aesthetic Procedures Authors: Ramirez S, et al. Published: Clinical, Cosmetic and Investigational Dermatology, March 2021 Keywords: Ethnicity, Non-Invasive, Race, Rejuvenation Abstract: Identifying predictors for patients’ readiness to receive non-surgical facial aesthetic treatments facilitates the physician’s understanding of the patient’s goals and expectations. This paper aims to identify clinical and demographic characteristics of patients who proceed with non-surgical facial aesthetic procedures in Singapore. Using data from electronic patient health records, authors examined clinical and demographic characteristics of 624 Asian and Caucasian patients who sought treatment in a 12-month period and who had minimum follow-up of 1 year. Variables examined included age, race/ ethnicity, gender, prior treatment, and attitudes and motivation for seeking treatment. Univariate and multivariate analyses of factors associated with proceeding with the treatment plan were evaluated. Approximately 88% of patients who sought consultation proceeded with treatment. The majority were older than 40 years of age, were female and received prior treatments. Notable is the high frequency of rejuvenation rather than correction as the clinical outcome goal. There were slightly more Caucasians than Chinese patients, but the racial distribution allowed the identification of differences between the two groups. Chinese patients were younger and more likely to seek correction or more obvious changes as compared to Caucasian patients.

Title: A New Therapeutic Protocol for the Treatment of Keloid Scars: A Retrospective Study Authors: Boccara D, et al. Published: Journal of Wound Care, March 2021 Keywords: Corticotherapy, Extralesional Excision, Keloid Abstract: There are few means to treat large keloid scars, as exeresis – even if partial – impedes direct closure without tension in the absence of a flap or a skin graft. This study evaluates the efficacy, indications for use and limitations of a new therapeutic protocol, combining an extralesional keloid excision left to heal by secondary intention with a paraffin dressing and glucocorticoid ointment, followed by monthly intrascar injections of corticosteroids upon full re-epithelialisation. Scars were categorised as either healed or recurring. Their recurrence was scored according to the changes in functional signs and the scar volume. A total of 36 scars were studied. The mean follow-up was 14.1 months. Healing occurred in a mean of 6.8 weeks. Healing rate was 30.5%. Scar volume was improved in 60% of recurrent cases and functional signs in 56%. For patients in the ‘adherent’ group, the healing rate was 40%, and scar volume was improved in 75% of recurrent cases and the functional signs in 83% of cases. Excision-healing by secondary intention could therefore be offered to patients for whom adherence is uncertain. This study offers a straightforward, fast, accessible solution that does not appear to entail any risk of additional keloids.

Title: Corrective Strategies for Poor Appearance after Tissue Expansion for Temporal and Sideburn Cicatricial Alopecia Authors: Jiang W, et al. Published: Journal of Cosmetic Dermatology, March 2021 Keywords: FUE, Tissue Expansion, Local Flap Modification Abstract: The expanded scalps are usually used to repair the scalp defects. However, hair growth direction and hair density of the expanded scalps may be inconsistent with those of the defective sites, resulting in unsatisfactory results. The aim of this study is to assess the effect of local flap modification and follicular unit extraction (FUE) on the repair of poor appearance of temporal and sideburn after unsatisfactory tissue expansion. In our study, 19 patients with problems of hair growth direction or hair density after surgery were treated with following four methods: single local flap modification; removal of hair follicles by FUE to reduce follicle density; removal of disordered hair follicles by FUE and ectopic transplantation simultaneously; removal of hair follicles by FUE and ectopic transplantation after local flap modification. The follow-up periods of 19 patients varied from 6 months to 30 months. All incisions healed by first intention and all flaps survived well. The scars involved in the removal of FUE hair follicles were not obvious. Our results revealed that the ideal and cosmetic results can be obtained by flexible using of local flap modification, single FUE method, and FUE ectopic hair transplantation to repair the dissatisfied postoperative outcomes of temporal and sideburn cicatricial alopecia after tissue expansion.

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

The newly developed Level 7 Diploma in Clinical Aesthetic Injectable Treatments brought to you by VTCT The VTCT (ITEC) Level 7 Diploma in Clinical Aesthetic Injectable Treatments, is designed for regulated professionals who are registered with a healthcare statutory regulatory body. The development of the qualification has been undertaken with support from Harley Academy, who have been instrumental in helping shape aspects of both content and delivery in order to ensure the highest standards are maintained across the sector of non-surgical aesthetics. For more information, visit www.vtct.org.uk/level7-aesthetics

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Treatment styles – work out what machine will be busy all the time based on your patients’ current treatment styles. For my clinic, I wanted to offer advanced facials, which the HydraFacial does amazingly well, but I knew that I was missing out on not offering the more invasive treatments, so I invested in a fractional radiofrequency device as well. This had the added benefit of enabling me to offer skin-tightening packages and more specialist treatments. However, be aware – it’s foolish to think that by investing in a device you will attract a whole new clutch of patients. You may attract a few, but in my experience it’s better to please the patients you have and grow your database organically.

Onboarding a New Device Nurse prescriber Sara Cheeney shares her five steps for introducing a machine to your clinic Every clinic wants to offer their patients the best treatments and having the latest, ‘must have’ devices can achieve this. However, it can also spell the end of profitability for the clinic. With our patients demanding more perfect results, and jumping onto treatment fads and trends, the temptation to buy becomes strong. It’s also the reason that the aesthetics market is swamped with a mind-blowing choice of different machines and sometimes pushy salespeople trying to get their device into your clinic. Unfortunately, as a business coach I’ve seen the painful effects of clinic owners overstretching themselves to pay for a treatment device that was never going to cover its costs. By not doing their sums, they have placed a noose around their business’s neck. But it need not be like that.

Benefits of a new device There are plenty of positive reasons for investing in a treatment machine. They enhance your offering, they improve the patient journey, and they can give you an edge over competitors. The right device can take a patient’s treatment results from good to outstanding and the better the results, the more kudos and recognition your clinic will receive. Not only that, but your revenue will increase with the right machine. With each machine I’ve introduced to my clinic we have seen an increase in revenue and customer satisfaction, as our treatment offering has improved. To ensure you choose the best device for your clinic and patients, follow my five simple steps…

Step one: assess demand Demand is more than just what you perceive to be the favourite machine because that’s what the glossy mags tell you and your patients. It is about your patient demand and what will work for your clinic patient base. Consider asking your patients what treatments they’d like to see you offer, doing patient surveys via email and social media, and working out what will enhance your current offering. I believe a holistic approach to your patient’s journey offers the best results and happiest patient, so how will the chosen device complement your offering? What gaps do you need to fill? You should consider:

Average treatment cost – if your current average treatment cost is £100, there may be no point bringing in a machine where the treatments cost £500 as it won’t be what your patients are used to or can perhaps afford. As above, satisfying your existing patients should be your priority.

Step two: do your research If you are thinking about investing in a machine, then it’s time to take a step back and make an informed choice not a rushed decision, based on safety and clinical evidence based practice, market research, demand, economics and your clinic ethos. First of all, you should think about space. It sounds simple, but have you thought about where will you home the machine? Have you got space? Is it mobile, and can you move it between treatment rooms? You should be planning that the machine will be in full-time use, so how can you capitalise on this? At the heart of the decision is the reputation of the device; will it deliver the results in a safe, clinically-proven and effective way? What is its safety rating? Is it approved by the FDA or is it CE marked? You want peace of mind that the treatment device you choose is going to complement the tools in your toolbox, not create problems with shoddy results and negative patient feedback. Select a machine that will fit your needs, your patients’ needs and has excellent support from the suppliers. There is no point investing in a device with poor back-up support as, invariably, anything electrical and mechanical will have faults, but you want to know that these faults won’t result in something that can’t be used as the parts are ‘not available’. Every salesperson will tell you why their device

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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At the heart of the decision is the reputation of the device; will it deliver the results in a safe, clinically-proven and effective way?

is the best, so don’t take their word for it – speak to clinics who have already installed the machine you are interested in, search online for reviews and do your homework by looking at both clinical and case studies. Other things to consider about the company you may ultimately purchase from are, what do they offer by way of staff training, product deals and incentives, and marketing? Do they want their machine in every clinic on every high street, or are they selective about where they put their devices? The last thing you want is the clinic next door getting the same machine and undercutting your offering.

Step three: consider the financials Doing the sums is a must, but its not everyone’s strong point. Having a husband as an accountant taught me long ago that no matter how much I ‘needed’ the latest device, if the sums did not add up then it wasn’t coming through the door. In my experience, a treatment machine needs to generate four times its value in income, to cover overheads, labour, marketing, and any other associated costs. There’s the question of how you’ll pay for the machine. Offsetting your tax burden by buying an expensive machine outright could make great financial sense, but if you don’t have the available cash then the other option is leasing. You’ll need to take into account the additional lease costs and overheads. For example, if you are operating on a 40% profit margin, an additional £5,000 worth of sales would be needed to cover the £2,000 costs. You need to ask yourself ‘how quickly can this device make a return’? If it’s not busy, it’s not generating an income, therefore it’s a drain on the clinic.

Step four: get your staff involved It’s essential to consider what happens when your new device arrives in your clinic. Do your staff feel as passionately about this new member of the team that they must work with? Did you take them with you on the journey of deciding which machine to go with – were they involved with the decision making? Or are you thrusting something onto them that scares them and that they’ll do everything in their power to not use? When I have introduced new devices into my clinic, I’ve encouraged my staff to embrace their new ‘team mate’ with free treatments, and a commission structure that encourages up-selling of the treatments offered via the device. If your staff are reluctant, then you will need to turn this around with staff training and motivational tactics, as without them onboard you could end up with the device becoming an elephant in the room. This is where your research into good after-sales support and training will pay dividends! If your staff are onboard, then they’ll promote the benefits and thus improve the sales.

Step five: market appropriately Before your new device arrives, you should be shouting about it so the appointments are already in the diary for when it does. This is where that great after-service from a reputable supplier comes into play. How much support will you be given to promote your new investment? Are they helping to organise demonstrations, provide you with literature, images and incentives? The thing about marketing is it must be continual, so ensure that you have changed your plan to include the ongoing promotion of your new machine.

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Have you updated your social media plan to let people know? Do you have an e-newsletter where you can shout about it? Taking advantage of the device manufacturer’s own content will help prior to the device arriving on site. Most companies will have before and after photographs which showcase the amazing results of their machine, so make the most of these. Great content can be found from celebrities who have had effective results from a particular device, look at the buzz around Morpheus8 after Judy Murray had her treatment recently. A great way to advertise a new device is to have an open event with demonstrations. You won’t be able to fit all your patients into the clinic, so aim this at your VIPs or big spenders. You also won’t be able to offer everyone a treatment at the event, so chose your patients well; consider who’ll shout the loudest about their results? Offering free treatments to the patients you know will post on social media or within their friends group is free marketing, so make the most of it. For more advice on planning an event in these difficult times read PR consultant Jenny Pabila’s article on Hosting an Event During the COVID-19 Pandemic on the Aesthetics website.1

Careful consideration The way treatments are being delivered are involving more elaborate and expensive devices, and the marketing that these suppliers are doing makes it more tempting to put your business into huge debt to buy. My advice is don’t make the leap without reviewing all the options and enter any investment or lease with your eyes wide open and having done all your homework. If your investment doesn’t work out, there’s no point blaming the pushy salesperson! Sara Cheeney is an awardwinning nurse prescriber and owner of Pure Perfection Clinic in Rossett, North Wales. She has practised aesthetics for more than 14 years, acting as a trainer for ZO Skin Health, as well as a key opinion leader for HydraFacial and InMode. In 2020 Cheeney set up Clinic Success, a consultancy aimed at helping clinic owners steer their own businesses through the challenges of running a clinic without hitting pitfalls she has experienced. Qual: RN, NIP REFERENCES 1. Jenny Pabila, Hosting an Event During the COVID-19 Pandemic (UK: Aesthetics, 2021) <https://aestheticsjournal.com/feature/ hosting-an-event-during-the-covid-19-pandemic?authed>

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Advertorial GetHarley

Building Passive Income with GetHarley Aesthetic practitioner Dr Uma Jeyanathan explains how she benefits from the digital skincare platform Why did you join GetHarley? I was already thinking, how could skincare sales be made easier and more efficient? And that’s where team GetHarley come in, they take away the headache of selling skincare products. I was first attracted to GetHarley because a few industry KOLs were already using the platform and I thought if they were on board and benefitting from GetHarley then it must be good. Enough people were recommending it to me to make me realise I should join. GetHarley delivers great patient care. I could not work with a team who didn’t care, we align well.

How has working with GetHarley helped your business? Skincare sales only became profitable when I joined GetHarley because, before then, I hadn’t prioritised them. Skincare was always something that was important to me for my business and my patients, but I was solely focused on my treatment sales and because I was making a nice amount from those, I didn’t consider how much extra I could make from skincare sales. I now make approximately £90K annually in skincare sales and this is building.

How does it work? The team help organise your online or in-clinic skin consultations, and then you can create a bespoke medical-grade skincare plan easily on the platform, and it only takes a minute. GetHarley then takes everything else away from you – the sales side of it, the tech side of it, the logistics – deliveries, inventory and replenishments.

This means you can just focus on the consultation and product selection, and leave the rest to GetHarley. I am not techy; GetHarley organises everything and makes it so easy.

Do patients replenish their skincare? Yes. If patients have a bespoke, medicalgrade skincare plan that is right for their skin, that they have to be consistent with to get excellent results, then they will keep replenishing. You get the profits for every plan they re-buy, so it becomes a key part of your business. It’s long-term gain and builds over time. The skincare sales through GetHarley is a key part of my business.

Which skincare products can you retail through GetHarley and how do you sell well? It’s up to you what products you want to sell. I don’t know of any restrictions and I can’t imagine why any brand would not want to sell through GetHarley as it is simply helping practitioners sell more products. My tip would be to make sure you are really well-trained in the brands that you do sell, as your in-depth knowledge will help promote the regime. I never stop learning. I am constantly joining new training sessions to make sure I offer my customers the best advice and the best products. You can add new products to your GetHarley digital shelf at any time, so you have the freedom to explore and curate your offering.

What do you typically ask the patient in an online consultation? I always start with medical history, as you can get so many clues about their skin from that. Knowing about their lifestyle and diet Aesthetics | April 2021

is hugely important too, as are their sleep patterns. Once you have this information you should have a really good idea of what to advise. The next step is finding out the patient’s habits. Are they likely to use lots of products and want lots of steps, or is a capsule range much better for them? What is their budget? There is no need to really push a big sale at the start, you can always start small. GetHarley will do their job of increasing it for you by including samples and up-selling at a later date, so you can graduate to selling the full regime. It is often uncomfortable, as a medical professional, to feel like you are a salesperson, so GetHarley takes that away.

Does GetHarley help with in-clinic treatment bookings? Absolutely. I find many of my customers organically graduate to booking in for aesthetic treatments following skincare, and GetHarley helps facilitate these bookings. We are all getting older and this usually means we have additional needs as we age. Once we hit our forties, most people want more than just good skincare, they want to have in-clinic tweakments too. There are many added benefits when joining GetHarley, not just getting passive income from skincare sales, but building your clinic business too. I am nearly fully booked for the near future, just from doing online consultations!

This advertorial was written and supported by GetHarley.

Book your FOC virtual demo: practitioners@getharley.com www.getharley.com IG @getharley

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The beauty of the moment

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Utilising Facebook Groups Digital consultant Rick O’Neill explains the benefits of Facebook groups for growing your practice There can be little doubt that social media is a powerful tool for engaging patients and growing a medical aesthetic practice. But while you may have ‘followers’ on standard Instagram and Facebook pages, do you really have a community? It’s this subtle but important difference that means the ‘closed’ nature of Facebook groups can bring a different dimension to your online engagement and bring your patients and potential patients together into a community, leading to deeper and often more meaningful interactions. In this article, I’ll explore the differences between pages and groups, and look at the ways groups can be used to grow your practice.

The difference between pages and groups Facebook and Instagram pages are your public-facing presence and are your platforms for broadcasting to your patients and to the public. They are essential if you want to run advertising campaigns and are also indexed by search engines, allowing anyone to follow and engage with your business. Content on these pages tends towards being curated, branded, and considered. Facebook groups, used by 1.4 billion people every month,1 are a semi-closed (depending on the type of group, you often have to apply to join) place where your patients and potential patients can gather around your brand for deeper discussion, to ask the questions they may not be comfortable asking in a more public place. This allows them to get to know you much more, as well as each other. Essentially, Facebook pages are for broadcast whereas Facebook groups are for discussion.

What are the benefits? 1. Groups offer a ‘direct line’ to your patients and potential patients. Those that join groups have often had to apply to do so, and sometimes they’ll need to have answered a few questions or agreed to some rules before joining. They are there with purpose, so are likely your most engaged customers. This presents you with the opportunity to really learn and gather insights from these people that know your business best, and then implement those insights into your future content and engagement plans. 2. You will enjoy increased reach. Facebook’s algorithm is designed to feature content from groups with high engagement.2 The more you and your group members are posting and interacting with one another, the more your content will feature in their News Feed, increasing your natural reach way beyond that of a standard Facebook page (with Facebook pages having an average natural reach of just 5.2% of your total audience, and still declining).3 3. Benefit from having a forum for discussion. Facebook groups are not just for you as the group/business owner and can be just as beneficial for the group members. Members benefit from the ability to post questions, talk to other patients, discuss pros and cons of treatments in an environment that provides not only the technical ability to do so, but the feeling of sufficient privacy. This in turn positions you and your practice as the facilitator and expert on-hand, and

could lead to increased enquiries as a result. To avoid your patients getting overfamiliar, it’s important to set clear rules, moderate the page, and work on the tone of your responses, to ensure you continue to be seen as the professional in the room. 4. Groups can grow by referral. Unlike a standard Facebook or Instagram page, groups have a simple mechanism enabling any member to invite a friend or contact to join (pending acceptance from the group admin). This can lead to organic growth of the group and brings new potential patients into your community. 5. Establish your credibility. In groups, you have the opportunity to lead the community and demonstrate your expertise and credibility in deeper and more meaningful ways than you might be able to achieve on public-facing pages. For example, you can run Facebook Lives to your group members, and answer questions in real time utilising the real-time comment facility. You are also the moderator, so you set the rules, decide what members can or can’t post, and this allows you to create an empowering environment in which your patients feel comfortable and protected. 6. Facebook Lives in groups offer a new level of engagement. Facebook Lives, on average, get 10 times more comments than a pre-recorded video.4 A Facebook Live is a feature that uses the camera on a computer or mobile device to broadcast a real-time video to the platform. Broadcasting through Facebook Live within a group means you not only have an increased level of engagement, but within a community that you can reach much more readily than on a page (thanks to the algorithm favouring group content), and to a group of your most engaged patients or potential patients. Broadcasting at a regular weekly time is good practise and allows your members to add the viewing to their diaries. Instagram Live can still be good for your outward/public social media efforts, but those interacting on Facebook and within a closed group are, in my experience, likely to feel more comfortable in asking questions, and providing more details, than they might on Instagram. Some good examples of well-established Facebook groups within the aesthetics industry include The Aesthetic Entrepreneurs, the AlumierMD Professionals Forum, Champions Under Construction (by The Wonder Clinic, Bristol), Skin Deep West Mids and Staffs (by Sally Wagstaff), and The Lynton Lasers Customer Forum.

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Types of group Public groups With a public Facebook group, anyone can see what members post or share. If they have a Facebook account, they can also see a list of members, admins and moderators. The benefit of a public group is that you’ll be visible to all potential group members and customers, and there’s no barrier to join. There’s also no need for the admin to manually admit every single new member to the group. However, the downside to this is that with literally anyone being able to join, you have no real control over the community and content can spiral out of control and be difficult to moderate. Groups are affiliated with your business, so it’s important to consider the potential reputational damage that could occur from having a large, difficult to moderate, public group. Private visible groups Private Facebook groups can appear in searches, but those wishing to join must be manually accepted by the group admins. Only accepted members can see who else is on the member list, as well as what they’re posting and sharing. This means the group is accessible, but exclusive private visible groups are a good option for aesthetics practices as they are findable, but still controlled. Private and hidden (secret) Private and hidden Facebook groups (also known as secret groups) do not appear in searches. Secret Facebook groups have the same privacy settings as private visible groups (only current members can see posts and the membership list), but they are hidden to the general public. So, the only way to join is by being personally invited by the group admin. This type of group can be more effort to grow, but can work well if you want to create an exclusive community.

Creating a group Creating your Facebook group is a simple process. In the latest version of Facebook, on a laptop, you will see a ‘+’ button towards the top right of the screen. Clicking that will show a list of features that you can choose from, one of which is ‘group’. From there you will be walked through the process to establish your group, including choosing your group type, from the options highlighted above. Once you’ve done this, it is good practise to then take the additional step of adding your Facebook page as a second administrator of the group. This then associates your

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page with your group, helping patients and followers to find you. Once the group has been created, you can then include it in your onboarding process (inviting new patients to join the group), and promote it on your other social channels, and in email campaigns as a benefit of being a patient. Posting into groups is very similar to posting onto your pages, but you will find there are different options depending on the type of group you’ve chosen. This can include different formatting options for caption text, posting files into the group, and running polls.

Best practices for running a group Establishing and running a Facebook group is a commitment. Here are some tips based on my own personal experience of running the Aesthetic Entrepreneurs – Digital Facebook Group: 1. Establish the rules. Setting a few simple rules for your group and asking members to agree to them before joining creates a clear expectation and will ensure members feel confident that the group will be of a certain quality. Here are some good example rules for a Facebook group: • Be kind and courteous • No hate speech or bullying • No promotions or SPAM – this group is for sharing and learning • Respect everyone’s privacy 2. Be a great host. When new members join, announce them to the group, welcome them in, and let them know what they can expect and how to navigate the existing content. 3. Be consistent, but not overwhelming. Establish some regular posts or types of discussion and stick to them. Be consistent, i.e. this type of post happens every Wednesday night and this one happens every Friday morning. Don’t overwhelm the group with too much content – members don’t want to feel saturated or spammed. A good frequency would be every other day. 4. Use insights to post at peak times. Facebook group admins get access to a suite of analytics and insights reports which tell you in detail what kind of content is getting the most engagement, and when are the peak times for your group. Use these insights to determine what you should be posting. 5. Keep group content different to page content. It might be tempting at first to simply post the same content from your page into

your group. However, this defeats the object and benefits of having a group. Your group content should be unique, more intimate, more informal perhaps. 6. Protect the members by being a good moderator. When members break the rules, politely remind them, or remove them if they persist. This will show other members that this is a well-moderated group and a comfortable environment for them to hold discussions or ask questions. 7. Create exclusive group content. Create exclusive ‘first looks’, or special access for your group members so that they feel a real benefit to being part of it. For example, a clinic can reveal new treatment machines or treatment types to their group members first, to gauge feedback, and answer questions. 8. Make time. Facebook groups take time and effort to keep alive and engaged, so ensure you set aside the time each week to post content and respond to discussions. If you have a team member that you trust, then group moderation and management can be trained and delegated.

Getting started The best way to start is actually with a pen and paper! Map out your plan for the group, who will join, what the content will focus on, and some ideas for regular topics. Once you’ve got your plan, and some initial posts/topics, create your group and invite a handful of your regular patients into the group as founding members. Good luck, and I look forward to seeing your group established soon! Rick O’Neill is a digital consultant to the medical aesthetics, cosmetic surgery and pharma sectors. With more than 20 years’ experience in digital marketing, O’Neill is the founder and owner of digital agency Look Touch & Feel. He is also a founding partner of The Aesthetic Entrepreneurs, and currently the digital consultant UK and Europe to Allergan Aesthetics.

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Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Advertising Weight Loss Services Dr Kam Lally explains why setting up a non-compliant weight loss service could have serious repercussions Prescription weight loss treatments are becoming an increasingly common offering in aesthetic clinics. A prime driver over the past 12 months is that these services can be started and continued remotely with direct-to-your-door delivery. This ‘subscription’ service has been a way for clinics to have some income trickling in (in the same way as clinical skincare) with recurrent lockdowns hampering the traditional business model. However, advertising for such services needs to ensure it stays on the right side of the regulations and that prescription-only medicines (POMs) are not advertised directly to the public. A recent enforcement notice from the Advertising Standards Agency (ASA) highlights the importance of this and how often the rules are being ignored.1 This may feel like a case of déjà vu for practitioners and is certainly familiar ground for the ASA in their previous dealings with non-compliant neurotoxin advertisements.2 This article will give an overview of the expanding sector in the aesthetics market and how to keep your weight loss services compliant.

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therapies rise in tandem as a number of patients seek help to battle the bulge. As you may be aware, non-invasive, energybased treatments for body contouring and peripheral fat loss have been around for a number of years. Recent advances in the science behind energy-based devices are allowing for more focused fat targeting, often combined with skin tightening and increasingly with muscle-toning abilities too. However, over the past couple of years there has been a rise in the number of pharmacological fat-loss methods being promoted by medical and non-medical clinics alike. Specifically, POMs traditionally used in the diabetic arena have been advertised up and down the country – sometimes overtly, sometimes under the guise of a ‘not-sosubtle’ moniker. The main focus of this article is the family of medicines known as glucagon-like peptide 1 (GLP-1) receptor agonists (RAs). They work by mimicking endogenous GLP-1 that is normally released following the consumption of food and drink. GLP-1 belongs to the incretin family of hormones and regulates glucose levels by stimulating insulin secretion, inhibiting glucagon secretion and slowing gastric emptying. This leads to a feeling of satiety sooner after eating, thus resulting in an overall calorie reduction (whilst on treatment) and associated weight loss.7 This simple overview does not take into account the numerous other extrinsic and intrinsic factors that contribute to the prevalence of obesity. One thing that is for certain is that this family of medications are here to stay, as ongoing research shows the benefits of GLP-1 RAs are widespread: from offering cardiac benefits to neuroprotection, and not just restricted to controlling blood glucose levels and losing weight.7

Advertising rules Weight loss and aesthetics PANDEMIC. Even a year ago, this would have been a word that you could use more comfortably – without an acute sense of dread and an associated daily death rate. However, we were in the midst of a different pandemic at the time – a more covert one – an obesity pandemic. In the year between 2018 and 2019, 876,000 NHS England admissions had obesity as a contributing factor – an increase of 23% on the previous year. 67% of men and 60% of women were in the overweight or obesity categories.3 Unfortunately, the recurrent lockdowns and subsequent impact on the job market across a number of sectors has led to a significant proportion of the population turning to food and alcohol for comfort.4 Combining this with a disruption in routine and a more sedentary lifestyle gives you the perfect recipe for weight gain. This has been referred to as the ‘quarantine 15’ (pounds) in a New York Times article last year,5 but going into 2021, it is surely becoming the ‘COVID-19’ (pounds). According to the World Health Organization, obesity appears to be a global issue and is only getting worse.6 But hang on a minute, you’re reading the Aesthetics journal not The Lancet – what is the relevance? When you have the perfect storm brewing for weight gain, enquiries for fat-loss

As alluded to in the introduction, the trigger for this article was a recent enforcement notice issued by the Committee of Advertising Practice (CAP).1 This body writes the advertising rules that are then enforced by the Advertising Standards Agency (ASA) – an independent regulator. The Medicines and Healthcare Products Regulatory Agency (MHRA) can also become involved (as the statutory regulator for medicines and medical devices in the UK) ‘where a significant risk to public health has been identified from advertising to the public for unlicensed or prescription-only medicines’.8 This particular enforcement notice coincided with a relevant article by

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Prescriptiononly medicines or prescriptiononly medical treatments may not be advertised to the public Wilding et al. in the New England Journal of Medicine.9 It summarises results from an ongoing randomised controlled trial involving newer members within this family of medicines that exhibit evidence of even better weight loss results. This led to the inevitable flurry of advertising activity via marketing email and social media posts – the vast majority (if not all) of which completely breached advertising guidelines.1 Rules and enforcement notice The primary reason for the enforcement notice was breach of Rule 12.12 of the CAP Code that states: ‘Prescription-only medicines or prescription-only medical treatments may not be advertised to the public’.1,10 However, the enforcement notice was not just limited to this. Another reason for the notice was due to advertisements claiming that people can lose specific amounts of weight within a certain time, which breaches Rule 13.9 of the CAP code.1,11 In addition, some of the ads included testimonial claims about weight-loss which are not compatible with good medical and nutritional practice – such as losing more than 2lbs per week in an ‘overweight’ (as opposed to ‘obese’) person (CAP Code: Rule 13.10).1,11 There were also incidences where businesses were promoting weight-loss to people who do not qualify for treatment because they are not even in the overweight/ obese categories!6 This clearly exploits any underlying insecurities about body image purely for financial gain and goes against social responsibility rules and ethics (see CAP Code: Rule 1.3).1,12 Finally, another problem area is promoting ‘off label’ use for a POM that has a license for a different indication. The Enforcement Notice grace period ran out on February 12, 2021; therefore, any non-compliant advertisements on websites or social media are exposing the practitioner

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and their business to targeted enforcement. This can include fines, referral to the MHRA, referral to the practitioner’s relevant regulatory body and legal action.1 So, what does this mean practically and what can you do to promote your weight loss services without breaching any of the aforementioned rules?

Responsible advertising The main thing you need to remember is that you are offering a service, therefore it is the service/consultation that can be advertised.13 The POM is one part of the service that the patient may, or may not, opt for after having a thorough consultation. The ensuing steps after that initial consultation with you may involve input from practitioners such as a dietician, psychologist, personal trainer, counsellor or physiotherapist. The journey the patient will be embarking upon may not need a POM, therefore this should not be at the forefront of any advertising or promotions. Any direct mention of drug names or brand names breaches the rules and there should not be any reference to the pharmaceutical manufacturer either.14 Even when promoting the service, realistic weight-loss parameters need to be used that comply with good medical and nutritional practice. You also should not promote targeted/regional fat loss if your service relies solely on pharmacological weight loss methods as opposed to energy-based devices.11 Appropriate imagery should go with the promotion of the service – for example, there should not be an image of a slim person next to the service advert as this would be seen as promoting the service to a cohort of people that do not need it.1,10 This also goes against the licensing guidelines for the medication – as a slim person would not fall within treatment parameters (BMI greater than or equal to 30kg/m2, or BMI greater than or equal to 27kg/m2 with at least one weightrelated co-morbidity). When promoting the service, you must avoid hinting at POMs indirectly by using suggestive emojis/GIFs/memes or images of patients carrying out treatments. This includes influencer marketing stories and posts. You can showcase the consultation and elements of the weight loss journey, but not show any POMs being administered or consumed. Also, hashtags that indirectly refer to the POM must not be used.1 A way of indirectly promoting weight loss services is by running a Disease Awareness Campaign (DAC). A DAC around the topic

of obesity is ideal in the current climate and would be seen as an ethical yet effective way of promoting your services. Some key points for a compliant DAC are that it must be accurate, up-to-date, evidence-based, comprehensive, balanced, easily readable and with an identifiable source.9 Finally, we should take a step back here and think about the ethical implications of advertising POMs in this specific sector. As a doctor, I don’t want to encourage unnecessary POM use in my patients – this goes against the ‘Primum, non nocere’ or ‘First, do no harm’ part of the physician’s oath we adhere to in medicine. Also, inappropriate use could have significant implications – especially in those that are not overweight or obese. Body dysmorphic disorder is a real problem and unfortunately on the rise – particularly amongst the vulnerable adolescent group.15 Doctored images bombarding us over social media and selfproclaimed ‘experts’ offering fast-track ways to achieve ‘body perfection’ in impossible or unsafe time frames are rife. Therefore, illegal (and unethical) POM advertisements will only compound the issue further.

Remember the rule for prescription medications Setting up a weight management service needs to be done in an ethical way. Focusing on the patient journey through various aspects of the services one may offer should be the mainstay of any promotional material, rather than any particular POMs that are used along the way. Using the approach outlined in this article across all marketing platforms should keep you out of hot water and on the right side of the guidelines. Piece of cake, right?! Dr Kam Lally graduated from the University of Oxford, went on to qualify as a GP and is the RCGP national aesthetic medicine lead. He runs a weight management service in his Aestheticology clinics based the Midlands and is an obesity consultant for Novo Nordisk. He is also a KOL for Hansbiomed International, Teoxane and Sinclair Pharma. Qual: BMBCh (Oxon), BA (Hons), MRCGP (UK), PG Dip Aes Med

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Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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“The more I learnt about the specialty the more passionate I became” Dr Nestor Demosthenous discusses why aesthetics is more than just dermal fillers Born in South Africa, Dr Nestor Demosthenous lived in the US and Cyprus before finally settling in Edinburgh to undertake his medical degree. “I started out in aesthetics the way most people do,” he recollects, “It was something on the side of my surgical career. After completing my junior doctor years, I pursued a surgical career, moving to Glasgow to train in trauma and orthopaedic surgery, and gaining experience in plastic surgery. It was during this time I developed an interest in the specialty.” Dr Demosthenous decided to undertake training in dermal fillers and botulinum toxin at the Aesthetics Training Academy in Glasgow. He reflects “I did my initial training with Dr Simon and Dr Emma Ravichandran, and they steered me into my aesthetics career. Even after my training was finished, they would let me bring my patients to their clinic, as I was still working in the NHS and didn’t have a base, and would supervise me.” Although a basic foundation training is all that’s needed to start administering injections, Dr Demosthenous wanted to make sure he gained as much knowledge as he could before going out on his own. “I think that in aesthetics it’s up to the individual to learn – some people take a short-day course and think they know everything,” he says, noting, “But I threw myself into trying to learn as much as I could so that I could be successful and treat my patients in the safest and best way possible. I attended lots of training courses and conferences. It fascinated me, and the more I learnt about the specialty the more passionate I became. I was inspired by some global practitioners (Dr Mauricio de Maio), and local (Dr Tapan Patel). Every piece of information I have picked up in my 10 years in aesthetics has helped me to become a better practitioner.” Dr Demosthenous notes that moving into aesthetics full time in 2013 was a natural progression in his career. He comments, “Once I started to get more of a reputation in Scotland and had patients who wanted to see me on specific days and times, it got to the

point where I had to choose between working for the NHS or working in aesthetics. After owning a small Glasgow clinic for a few years, I moved across to Edinburgh in 2016 and that’s when I opened The Medical Cosmetic Centre.” As well as offering fillers, botulinum toxin and skincare treatments, Dr Nestor’s Medical Cosmetic Centre, which won The ACE Award for Best Clinic Scotland in 2019, opened a women’s health department which focuses on treating both hormonal health and intimate health; as well as offering lifestyle medicine and body contouring treatments. On his decision to expand his treatment offering, Dr Demosthenous comments, “To me, aesthetics isn’t just about quick-fix filler results. I always knew that I wanted my clinic to represent wellness, whether that’s in my patients becoming healthier, stronger, or more educated. I want to address what’s bothering my patient and help them become better than they were the day before.” A year ago, The Medical Cosmetic Centre became the first clinic in Scotland to offer the truSculpt Flex device, and Dr Demosthenous is now a key opinion leader for its manufacturer, Cutera. He explains, “Muscle stimulation feeds into the ethos of my clinic because it isn’t just about appearance and helping the patient shed some extra pounds – it’s about concentrating on the physique and bodily structure.” Dr Demosthenous highlights that muscle stimulation devices can also help nonaesthetic concerns. “They can really benefit people who have suffered injuries and muscle trauma, patients with lower back problems that need to strengthen their core muscles, as well as older patients who can’t push themselves as much as they did before,” he explains, adding, “Given my background in orthopedics, this is not only something that I’m passionate about, but is really rewarding when you make a difference to the everyday life of patients.” The popularity of muscle stimulation devices reflects the growing nature of the industry,

believes Dr Demosthenous. He comments, “From a business point of view, I always think that practitioners should offer as much as they can to suit their patients’ needs. I don’t think the term ‘aesthetic medicine’ really covers our specialty anymore – it’s a beautiful melting pot of specialties that don’t fall within the NHS but have found a home under the aesthetics umbrella.” With a lot of aesthetics involving lone working, Dr Demosthenous highlights the importance of having a good support network of peers and colleagues, particularly when it comes to new treatments and devices. He says, “There are so many new products and devices coming out in the industry all the time. It’s useful having friends who I can discuss things with before I jump into something. I also did a Master’s in aesthetic medicine a few years ago and that really helped to look into the evidence behind treatments and products, and learn from others. We’re lucky to be in an industry that is constantly expanding its knowledge and we need to make the most of that!”

My advice to new practitioners… Be hungry and stay humble! Always have the urge to learn and grow, but stay grounded through your success.

What’s the most challenging thing about the industry… It has to be the lack of regulation. It’s disheartening to keep trying to make a difference and nothing happening. I’ve personally written to the Scottish Health Secretary – we need to make a change.

My plans for the future… I’m launching my own wellness retreat in Scotland, hopefully in August! I’m also joining the new clinic Ouronyx in Mayfair – watch this space!

Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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Aesthetics

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connotations. If they still wish to go ahead, consider referring them to a colleague who is offering this treatment. If you are fully equipped with the knowledge of the ‘Fox Eye’ trend and decide you are happy to offer this treatment at the clinic, it may be an idea to consider whether you would be open to re-phrasing the colloquial ‘Fox Eye’ term in your aesthetic practice and in your marketing messages.

The Last Word Dr Sieuming Ng explores the controversy surrounding the ‘Fox Eye’ trend in aesthetics The trend The ‘Fox Eye’ look is one of the latest beauty trends, made popular by A-list celebrities such as models Bella Hadid, Kendall Jenner and Megan Fox. To date, the popular social media platform TikTok has amassed more than 129 million views with the trending hashtag #foxeye.1,2 The growing popularity of this trend has led to an increase in demand for the use of non-surgical aesthetic techniques to achieve it.3 The technique involved is typically a combination of the use of threads, dermal fillers and botulinum toxin. The aim is to use dermal filler to fill the hollowness of the temples, botulinum toxin to achieve a level of brow lift and to reduce periorbital movements, then finally use dissolvable threads to lift the distal portion of the eyebrow to achieve that straighter brow tail finish. The overall procedure takes between 45 to 60 minutes depending on the combination of techniques used, and the results typically last between 12 to 18 months.

Why is there controversy? Unfortunately, this much-coveted current look has come with its fair share of backlash. The East Asian community are not all happy with the ‘Fox Eye’ trend now being a celebrated look and are calling it out for cultural appropriation. This is largely due to the fact that the trend is a replication of a particular East Asian facial feature which we have grown up being teased and bullied for. Moreover, celebrities, social media influencers or anyone imitating the hand gesture of pulling their eyes up next to

their eyebrows by the temple region, to exaggerate this facial effect in photos and videos, are mirroring the action historically used to ridicule the East Asian community. As such, this stereotype is a universally recognised symbol of xenophobia and can be extremely triggering to some. To add insult to injury, those who have spoken out about taking offence to this trend have been accused of overreaction, which has understandably not helped the situation.4-7

Managing patients As an aesthetic practitioner and member of the Asian community I do, to a certain extent, believe in respecting the wishes of my patients. I certainly do not believe in stopping anyone from wanting to achieve a certain look, and neither is it my place to change their desired aesthetic. However, with regards to this particular trend, I believe there are steps that many practitioners can take to approach the situation more appropriately. Understand the cultural connotations In my opinion, many aesthetic practitioners need to be better informed when it comes to fashions such as the ‘Fox Eye’ trend before treating patients. Research and understand the connotation associated with the term ‘Fox Eye’ and consider if this is an aesthetic trend that you would like to promote in your aesthetic practice. If it makes you uncomfortable providing this treatment for personal, social and/or any other reasons, the best approach is probably to be upfront in explaining this to your patients and also educating them about the

Manage expectations It is also important to bear in mind that often patients may come in asking for a particular look but what they ask for might not necessarily reflect what they mean. For example, they might actually want a simple brow lift to brighten their face but may use the term ‘Fox Eye’ to describe it. Do they specifically want the almond-shaped eyes or are they actually more concerned about their eye bags? Or is it ptosis of the eyelids? Once you have established that it is indeed the almond-shaped eyes they are after, assess their suitability to decide if the nonsurgical approach is suitable in achieving those results.

Respecting cultural opinions I personally feel pride and joy in the celebration of my East Asian features. However, I do not condone the use of hand gestures to exaggerate the ‘Fox Eye’ effect and can fully appreciate why the East Asian community may take offence with this trend. While it may not have stemmed from malicious racial intent, the bottom line remains that any discomfort expressed by the East Asian community around this trend should be heard and respected. Dr Sieuming Ng is a GMCregistered member of the Royal College of Surgeons. After completing her medical studies at the University of Nottingham, she trained as a general surgeon in Cardiff and London. Dr Sieuming has completed advanced training in injectables such as botulinum toxin and dermal fillers, and runs her own aesthetic practice in London. Qual: BScD, BSc(Med)

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Reproduced from Aesthetics | Volume 8/Issue 5 - April 2021

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