APRIL 2023: Social & Environmental

Clinical Excellence Unlocked

For over 20 years, we have been the award-winning partner for aesthetic clinics, providing the expertise, technology, and support you need to unlock your full potential. With our award-winning products, from skincare to injectables and energy based devices, combined with our tailored training and education, marketing solutions, and practice management support, we are dedicated to helping you deliver exceptional patient care and achieve clinical excellence.

Muscle Anatomy for Toxin CPD

Practitioners explore facial anatomy to avoid toxin complications

Implementing

ESG In-Clinic How clinics can successfully execute ESG frameworks for business success

Transgender Feminisation

Miss Natasha Berridge presents a case addressing a patient’s gender dysphoria

A History of the Menopause

Dr Shirin Lakhani outlines how views on the menopause have developed over time

Distributor of the Year

Topical Skin Product/Range of the Year

The latest product and industry news

17 News Special: Standardising Formulations in Products

Aesthetics delves into the latest international guidelines on skincare product formulation requirements

18 Return of ACE Brings Top Class Education and Networking

Aesthetics reflects on the biggest and best ACE conference to date

22 Special Feature: Implementing ESG into Your Business

Executing ESG frameworks in aesthetic businesses to facilitate a sustainable society

CLINICAL PRACTICE

27 CPD: Muscle Anatomy for Toxin Injections

Practitioners explore facial anatomy for avoiding toxin complications

32 Case Study: Transgender Feminisation

Miss Natasha Berridge addresses a trans patient’s gender dysphoria with surgical and non-surgical interventions

35 Choosing Skincare for Skin of Colour

Cigdem Kemal Yilmaz shares considerations for SOC skin treatments

38 The Aesthetics Awards Winners

See the full list of Winners at The Aesthetics Awards 2023!

55 Assessing Skincare During Pregnancy

Dr Emma Goulding and Dr Amiee Vyas discuss safe use of skincare during pregnancy

58 Case Study: Treating Retrogenia with Fillers

Dr Mariam Al-Ani discusses treating a skeletal class two retrogenia with filler

60 A History of the Menopause

Dr Shirin Lakhani outlines how treatments surrounding the menopause have developed

62 Restylane: Your Expertise, Meets Ours

Discover Restylane Lyft from Galderma to enhance your aesthetic practice

63 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE

64 Greenwashing in Aesthetics

Ron Myers introduces the phenomenon of greenwashing in cosmeceutical skincare

67 Building Your Personal Brand

Lucy Hilson gives tips to make your brand stand out from the crowd

70 Utilising Mentorship Opportunities

Julie Scott discusses the importance of mentorship throughout your career

73 In Profile: Professor Sebastian Cotofana

Professor Sebastian Cotofana shares his passion for advanced anatomy in aesthetics

74 The Last Word: Butterfly Lip Technique

Dr Brendan Khong analyses the butterfly lip technique featuring in the consumer media

Special Feature: Implementing ESG into Your Business

Page 22

Clinical Contributors

Miss Priyanka Chadha is a plastic surgery registrar and co-founder of Acquisition Aesthetics. She is the principal investigator for a nationwide clinical trial evaluating the applications of neuromodulators, and is a global KOL for Galderma.

Miss Lara Watson is a registrar in maxillofacial surgery, co-founder of Acquisition Aesthetics and KOL for Galderma. She is a member of the Royal College of Surgeons and has a background in head and neck surgery.

Miss Shonnelly Novintan MBBS BSc MRCS(Eng) is a junior doctor and has graduated from Imperial College London. Having sat her membership exams in her first year, she is a surgeon aspiring to specialise in plastic surgery going forward.

Miss Natasha Berridge is a consultant oral, maxillofacial and aesthetic surgeon, dually qualified in medicine and dentistry. She is an honorary senior clinical lecturer on the University of Manchester’s Aesthetic Medicine Masters’ programme.

Cigdem Kemal Yilmaz is a chemical engineer, skincare formulator and founder of Skin Masterclass. She runs a CPD-certified skincare education and licensing platform for practitioners to upskill their skincare knowledge.

Dr Emma Goulding works in both the NHS and in private practice as an aesthetic practitioner in the North West. She practises a holistic approach to aesthetic medicine to achieve the most effective and natural results.

Dr Amiee Vyas is an aesthetic practitioner with a special interest in skin. Dr Vyas is a diverse skin specialist, a cosmetic dermatology KOL and founder of the Ultimate Aesthetics Mentorship Programme for medical practitioners.

Dr Mariam Al-Ani is the co-founder of Face Studio Clinic, a private dental and facial aesthetic clinic in Birmingham. She is a general dental surgeon and has completed a postgraduate certificate in Aesthetic and Restorative Dentistry.

Dr Shirin Lakhani is a cosmetic practitioner specialising in intimate health and HRT. Dr Lakhani regularly contributes to articles and speaks at aesthetics conferences, and is involved with the APPG for menopause.

Shannon Kilgariff Editor & Content Manager @shannonkilgariff

I’m not sure about you, but I have only just recovered from the epic two days that were ACE and The Aesthetics Awards 2023! Since my first ACE in 2016, I’ve loved how this event brings together the whole community for two days of learning, networking and collaboration – there is always such positive energy in the air and this year was no different! With 2,714 delegates, 97 exhibitors and 110 speakers, it truly was the biggest and best ACE yet. Thank you to everyone who supported us to make it such a success – from the visitors to the speakers and of course the sponsors and exhibitors, not to mention the amazing Aesthetics team who worked tirelessly to bring it all together (read our report on p.18). Of course, the weekend was concluded with The Aesthetics Awards! It was a privilege to welcome 980+ of the industry’s most respected and accomplished individuals and companies. The night was truly spectacular at our new Grosvenor House home – thanks to all who attended and to our sponsors, judges and everyone who supported.

Clinical Advisory Board

A huge congratulations to all Winners and those who received High Commendations and Commendations (read our special report on p.38). Of course, well done to all Finalists as with so many outstanding entries, even being shortlisted is a huge achievement that everyone should be proud of.

In the journal this month, we focus on the important subject of encouraging a positive future for not just our industry, but society as a whole. We have articles on how to promote Environmental Social Governance (ESG) into your business (p.22), understanding ‘greenwashing’ in aesthetics (p.64), and in our clinical section we have treating skin of colour (p.35) and a fantastic case study of a transgender feminisation treatment (p.32). Our History Of article is also worth a read, discussing the menopause and how the aesthetic medicine community can better support these individuals (p.60). I do hope you enjoy reading the journal this month. Remember to stay tuned for our next event CCR on October 19-20! Entry for the 2024 Aesthetics Awards will open in September – make sure you have opted in to receive emails from Aesthetics via your Membership portal to stay updated!

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

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN), previous UK lead of the BSI committee for aesthetic non-surgical standards, and member of the Clinical Advisory Group for the JCCP. She is a trainer and registered university mentor in cosmetic medical practice, and is finishing her MSc at Northumbria University. Bennett has won the Aesthetics Award for Nurse Practitioner of the Year and the Award for Outstanding Achievement.

Sharon Bennett, Clinical Lead

Mr Naveen Cavale has been a consultant plastic, reconstructive and aesthetic surgeon since 2009. He has his own private clinic and hospital, REAL, in London’s Battersea. Mr Cavale is the national secretary for the ISAPS, president of the Royal Society of Medicine, and vice-chair for the British Foundation for International Reconstructive Surgery.

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon. She is the lead oculoplastic surgeon at the Cadogan Clinic, specialising in blepharoplasty and advanced facial aesthetics. Miss Hawkes is a full member of the BOPSS and the ESOPRS and is an examiner and fellow of the Royal College of Ophthalmologists.

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 a member of the British Association of Plastic and Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons.

PUBLISHED BY

PORTFOLIO MANAGEMENT

Alison Willis • Director

T: 07747 761198 | alison.willis@easyfairs.com

EDITORIAL

Shannon Kilgariff • Editor & Content Manager

T: 0203 196 4351 | M: 07557 359 257 shannon@aestheticsjournal.com

Holly Carver • Senior Journalist | T: 0203 196 4427 holly.carver@easyfairs.com

Ellie Holden • Journalist | T: 0203 196 4265 ellie.holden@easyfairs.com

Kate Byng-Hall • Journalist | T: 0203 196 4265 kate.byng-hall@easyfairs.com

DESIGN

Peter Johnson

• Senior Designer

T: 0203 196 4359 | peter@aestheticsjournal.com

Dr Mayoni Gooneratne (MBBS, BSc, MRCS, MBCAM, AFMCP) was an NHS surgeon before establishing The Clinic by Dr Mayoni and founding Human Health – an initiative combining lifestyle with traditional and functional medicine to provide a ‘cell-up’ regenerative approach to aesthetics. She is also the co-founder of The British College of Functional Medicine.

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 Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the founder of the Great British Academy of Medicine and Revivify London Clinic. Dr Samizadeh is a Visiting Teaching Fellow at University College London and King’s College London.

ADVERTISING & SPONSORSHIP

Courtney LeBorgne • Event Director

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Judith Nowell • Business Development Manager

T: 0203 196 4352 | M: 07494 179535 judith@aestheticsjournal.com

Chloe Carville

• Sales Executive

T: 0203 196 4367 | chloe.carville@aestheticsjournal.com

Emma Coyne • Sales Executive

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MARKETING

Aimee Moore • Marketing Manager

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Emma Kurzyca • Marketing Assistant

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

Email: editorial@aestheticsjournal.com

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

Dr Stefanie Williams is a dermatologist with a special interest in adult acne, rosacea and aesthetic medicine. She is the founder and medical director of multi-award winning EUDELO Dermatology & Skin Wellbeing in London, and creator of Delo Rx skincare. She is the author of three books and has published more than 100 scientific articles, book chapters and abstracts.

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Aesthetics Media

Talk #Aesthetics

Regulation PMCPA releases new pharma social media guidelines

#AestheticsAwards

Dr Tapan Patel

@drtapanp

Joining the illustrious list of Outstanding Aesthetics

Awards Achievement winners is my biggest honour to date

#Toxin

Miss Priya Chadha

@drpriya.plastics

Some fantastic colleagues to speak alongside this evening at the official launch of Alluzience!

#ACE2023

Dr Lee Walker @leewalker_academy

Team Teoxane at ACE 2023 – with Dr Cetto, Dr Dhillon, Dr Lally and Dr Isaac

The Prescription Medicines Code of Practice Authority (PMCPA) has published new guidelines for pharmaceutical companies, offering directions on maintaining high standards for social media content. By law, prescription-only medications such as botulinum toxin cannot be directly promoted to the UK public, and the Association of the British Pharmaceutical Industry (ABPI) Code of Practice also has strict rules on how pharmaceutical companies and distributors can promote them to medical professionals while maintaining transparency about their use. The new guidance mentions areas such as public disease awareness, responding to misinformation, working with influencers, advertising jobs and posting about clinical trials, as well as how this differs when promotion is aimed at medical practitioners rather than the general public. It also touches on how social media should be used by employees of pharmaceutical companies.

Director of the PMCPA, Alex Fell, said, “We recognise that social media can pose particular challenges for companies under the ABPI Code. With its wide reach and international audience, information on medicines can be seen by people it wasn’t intended for. I hope this guidance will help companies navigate the potential pitfalls of social media with more confidence, a clearer knowledge of the principles to follow and the legal requirements.”

The full guidelines can be accessed on the PMCPA website. Advertising guidelines for aesthetic professionals and clinics can be accessed via the Advertising Standards Authority (ASA) online.

Alma makes debut in the UK market

#Women

Michelle McLean @aestheticallyyou

Happy International Women’s Day! Every day I feel lucky to be around a stream of women who break boundaries

#Podcast

Natali Kelly

@natalikellyldn

Thank you Abbey Clancy and Peter Crouch for having me on your podcast!

Medical device company Alma has opened its first subsidiary in the UK and Ireland, located near St Paul’s in London. According to the company, the subsidiary will allow medical practitioners in the UK and Ireland to access Alma’s devices, which include Soprano Titanium hair removal device, Alma PrimeX body contouring and skin tightening device and fractional ablative CO2 laser Pixel. The newly formed team is headed by general manager Kamran Shibli, who said, “We are delighted to be launching this division, to bring the UK and Ireland access to world-leading technology. At Alma, we offer the most comprehensive device portfolio for our customers and clients. Our experienced team is dedicated to delivering a premium customer experience and innovation. Our new Alma HQ will be home to our brand teams, including education, technical and clinic marketing specialists. At Alma, our ethos is to be there for you, for life.”

Alma will be taking over distribution and customer services in the UK and Ireland from ABC Lasers.

The Aesthetics Awards raises £12,000 for charity

On March 11, The Aesthetics Awards returned with a glamorous ceremony at Grosvenor House, London, alongside charity partner BFIRST.

The British Foundation for International Reconstructive Surgery & Training (BFIRST) aims to enhance best practice in plastic surgery around the world by providing training in countries like Tanzania, Kenya, Vietnam and Bangladesh. The charity was the official partner of the Awards for the second year running and raised more than £12,000 on the night from guests’ generous donations.

Plastic surgeon and chair of the charity Mr Naveen Cavale was delighted, commenting, “The money raised will make a massive difference to our future efforts to improve patient care across our projects around the globe, and we couldn’t be more grateful. This year, we would love to increase our capacity, train more doctors and improve care in more communities, and the funds raised at the Awards are a huge step in this direction.” The Awards celebrated Commended, Highly Commended and Winners across 26 categories, applauding the industry’s top practitioners and companies. Head to p.38 to see the full list of 2023 Winners!

Safety

Save Face reveals rising thread complaints

Research from national aesthetic practitioner register Save Face has revealed that complaints regarding thread lift procedures performed by non-qualified practitioners tripled in 2022 compared to the previous year. Ashton Collins, founder and director of Save Face, has stated that in 2022, the organisation received 118 complaints following thread lifting procedures – a 30% increase from 2021.

Practitioners require a Care Quality Commission (CQC) registration to perform a thread lift as it is classed as an invasive medical procedure, so registered medical practitioners can only administer them in certain settings to avoid serious complications including blood vessel injuries, nerve damage, infection, facial asymmetry, dimpling or protrusion/migration of the thread. Following this rise in complaints, Save Face has established the Thread Bare campaign in collaboration with aesthetic practitioner and thread specialist Dr Mahsa Saleki to raise public and industry awareness of what makes a thread lift procedure safe and how to find a reputable practitioner. The campaign also emphasises the importance of in-depth training before thread lift procedures are performed. Collins commented, “Every year we are receiving more complaints regarding thread lifts being administered by non-healthcare professionals. As the treatment increases in popularity, we feel compelled to work with the industry and key thread practitioners to help educate the public and encourage consumers to do their due diligence and research before choosing a clinic or practitioner for this treatment.”

Vital Statistics

(Hada Labo Tokyo, 2023)

global aesthetic medicine market is expected to grow at a rate of 8.5% CAGR from 32 million USD in 2022 to 52 million USD in 2028

(Market Watch, 2023)

In 2022, almost 75% of 2,200 US facial plastic surgeons saw an increase in patients under 30 requesting treatment (AAFPRS, 2022)

Of those in the US with hyperhidrosis, only 38% have consulted a healthcare practitioner about it

(Sweat Help, 2023)

(National Eczema Association, 2022)

Of 1,000 women in the UK, only a third (34%) use sunscreen every day

The

Black people are 1.7 times more likely to develop the skin condition eczema than white people

Of 10,500 reports of dermal filler adverse events, 25 were related to COVID-19 vaccinations

(Aesthetic Surgery Journal, 2023)

Events diary

21st April

BACN Spring Symposium www.bacn.org.uk/events

23rd May

BAS Conference 2023

www.bassclerotherapy.com/events

9th-11th June

SEASON Conference 2023

www.seasonaesthetics.org

30th September

BCAM Conference 2023 www.bcamconference.co.uk

6th-7th October

CMAC Global Conference 2023 www.cmac.ac.uk

19th-20th October

CCR 2023

www.ccrlondon.com

Hydrafacial launches new Syndeo device

Aesthetic treatment company Hydrafacial has unveiled its new technology, Syndeo.

According to the company, the system has been designed with automation features, and is optimised for customisation. The device includes 12 treatments in one system, including LightStim Elipsa LED therapy, lymphatic drainage, Keravive, Perk and Hydrabody. It also incorporates seamless gesture control for less hand-to-surface contact, automatic serum selection, compact gunkie with integrated light and magnifying glass, as well as wireless upgrades. UK and Ireland country manager, Lauren Gibson, said, “We’re thrilled to be launching the new Hydrafacial Syndeo in the UK. Our next generation device is smart, effortless and personalised, elevating every aspect of the Hydrafacial treatment with the most advanced delivery experience to date.”

SkinCeuticals releases new A.G.E Interrupter serum

THE MEDIA

VICE highlights botched cosmetic procedures

VICE has shone a light on the detrimental impact of unlicensed aesthetic treatments in Thailand. The documentary, entitled Unlicensed Doctors Botched My Face, shares the story of patients who have undergone injectable procedures from unlicensed practitioners, leading them to require extensive reconstructive surgery. They share that many people in Thailand are more likely to seek unlicensed aestheticians because their services are cheap and easily accessible, with procedures proving particularly popular among young patients who want to emulate K-Pop idols.

Christina Aguilera partners with Merz Aesthetics

American pop icon Christina Aguilera has partnered with Merz Aesthetics, publicly speaking on using Xeomin (incobotulinumtoxinA) to smooth her glabellar lines. Speaking on the treatment and her partnership with the brand, Aguilera said, “I think we all can rely on a little help. Why not?”

Skincare company SkinCeuticals has launched corrective cream A.G.E Interrupter Advanced. According to the company, the product builds on the original A.G.E Interrupter, which was launched 14 years ago, to target visible signs of ageing with more advanced skin technology. The product’s formulation uses wild fruit flavonoids, glycyrrhetinic acid and concentrated proxylane (20% more than the original A.G.E Interrupter) to optimise collagen matrix integrity, according to SkinCeuticals. Dr Ana Mansouri, key opinion leader for SkinCeuticals, commented, “Having reviewed the updated formulation of A.G.E Interrupter Advanced, I will be recommending my patients to implement this into their maintenance regimens post-procedure alongside in-clinic collagen induction procedures such as microneedling. It provides an innovative underlying science of targeting collagen degradation on a multi-dimensional level.”

NHS considering new vitiligo cream

Skin cream ruxolitinib, which can be used by vitiligo patients to restore pigment to the skin, might soon be offered in the UK on the NHS.

From April 2023, the National Institute for Health and Care Excellence (NICE) will commence the process of appraising the product (which carries the brand name Opzelura and has received US Food and Drug Administration approval), awaiting a decision on whether it will receive approval to be prescribed by UK medical practitioners.

The substance can be used to restore the natural pigment of a person’s skin, especially on the white skin patches experienced by vitiligo patients, but it also carries potentially serious side effects like increased susceptibility to infections. Nonetheless, an internal Opzelura study showed significant reduction in pigmentation after using the product for 24 weeks. The European Medicines Agency is also considering approving the medication for use on patients over 12. It is as yet unknown when Opzelura would become publicly available if it is approved.

Skincare

Skin

Warning against botulinum toxin slimming injections in Turkey

Patients have been warned not to fly to Turkey to receive botulinum neurotoxin (BoNT) injections in their stomach for weight loss following almost 70 reported botulism cases. According to the European Centre for Disease Prevention and Control (ECDC), 67 patients have been diagnosed with the life-threatening condition after receiving BoNT injections to relax the stomach wall and reduce appetite, with some requiring admittance into Intensive Care Units (ICU). Turkish investigations have found that a legitimate product was used during these procedures, but it was not licensed for this procedure. The involved facilities have since been shut down. The ECDC is now advising patients not to seek this treatment in Turkey, as it says the procedure carries a “significant risk of developing botulism.”

Digital Galderma to host webinar with Aesthetics

Pharmaceutical company Galderma will be hosting a webinar in partnership with the Aesthetics journal this month. The webinar will focus on clinical efficacy and safety of Abobotulinum toxin type A in powder and ready-to-use forms to help practitioners understand the use of both products in their practice. The ‘Innovation Through Science: The Clinical Evidence of Galderma’s Neuromodulator Portfolio’ webinar will be led by aesthetic practitioners Dr Munir Somji and Dr Lara Watson. Rene Wipperich, general manager at Galderma, commented, “We are very proud to have launched our new neuromodulator in March. Galderma will continue its commitment to bring new scientific solutions to our customers and drive innovation in the future.” The webinar will be taking place on April 25 at 7:30pm GMT. Innovation

New sustainable skincare technology revealed

Researchers from the University of East Anglia (UEA) have unveiled a potential technological breakthrough which could allow water- or oilbased skincare products to become rehydratable, increasing sustainability.

DRIES technology sees 98% of the water removed from skincare products so they become dehydrated into paper-like discs which are then rehydrated with water by the user, restoring them to their original consistency. UEA researcher Professor Sheng Qi says this has the potential to reduce both the carbon footprint and packaging wastage of the beauty and skincare industry, which could help accelerate net-zero goals. She says, “It’s definitely possible to mass produce items using this process as industrial-scale manufacturing machines already exist. It is yet to be seen how this could be made cost-effective for companies, but this could be balanced by the environmental benefits.” Professor Qi also explains that the lack of heating involved in the production process could make this method particularly useful for products high in active ingredients frequently seen in cosmeceuticals, because it does not break them down to the same degree.

BACN UPDATES

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

BACN SPRING SYMPOSIUM 2023

The BACN Spring Symposium is just a few weeks away and we couldn’t be more excited! Returning to London’s prestigious Royal Society of Medicine at 1 Wimpole Street, the day-long event is designed to focus on more advanced practice, and looking at a widening portfolio of services to consider regarding wellbeing and intrinsic health. We’ll be welcoming talks from the wonderful Dr MJ Rowland-Warmann, Dr Yusra Al-Mukhtar, Dr Lee Walker, Tracey Dennison and Dawn Attewell, among others. Your enthusiasm for this event has been fantastic, and incredibly we sold-out two months prior to the event. For those who have booked, we look forward to seeing you there!

WINTER NEWSLETTER

The BACN Winter 2022/23 newsletter was published on March 1, outlining the BACN’s 2023 events structure, upcoming events and regional activities. Reminder to all members that it is now available in the Member’s Area of the BACN website to read, alongside all previous BACN newsletters.

BACN EDUCATION & TRAINING COMMITTEE

The BACN Management Committee has reviewed the role, function, membership and operation of the BACN Education & Training Committee, and will be making announcements shortly about increasing its membership. We already have ‘Expressions of Interest’ from some members to join this Committee, which we are reviewing. If anybody else is interested in taking part, please contact BACN CEO Paul Burgess MBE.

BACN MANAGEMENT COMMITTEE MEETING

Taking place on April 20, the Management Committee will meet for its quarterly board meeting. All notes will be available to view and download in the Member’s Area of the BACN website after the meeting has taken place.

is written and supported by the BACN

Skin

L’Oreal

launches

Dermatological Beauty portfolio

Global skincare company L’Oreal has announced that its Active Cosmetics Division has become L’Oreal Dermatological Beauty.

L’Oreal Dermatological Beauty incorporates brands including CeraVe, La Roche Posay, SkinCeuticals and the recently acquired skinbetter science. The company states that the newly named division will highlight how L’Oreal products can be used by practitioners to improve skin health.

Karen Flavard-Jones, managing director of L’Oréal Dermatological Beauty UK & Ireland, says, “In the UK and Ireland, we strive to democratise dermatology to provide equal access to all 42.7 million sufferers of skin concerns across both countries by pioneering health and beauty. I’m proud of our new name which is a clear expression of who we are and what we stand for.”

Training

AlumierMD’s Growth Factor course returns

Medical-grade skincare brand

AlumierMD has announced the return of its Growth Factor course. According to the company, the Growth Factor course has additional support and new modules to help skincare practitioners connect with patients and maximise both business and patient results. AlumierMD has partnered with business growth company The Aesthetic Entrepreneurs to deliver the seven-part strategic business course, taking place in London, Manchester and Dublin throughout Spring. The new modules will address a focus on supporting practitioners to diversify their business model and capitalise on new product launches with patients, explains AlumierMD.

Daniel Hopkins, chief executive officer for AlumierMD, said, “Our continued commitment to protecting and growing the skincare revenues of aesthetic practices sits firmly at the centre of every action that we take as a business, and I am both very proud and excited to lead an incredible group of innovators to empower our sector.”

Education

Skincare

NEOSTRATA releases new HA skin product

Skincare distribution company

AestheticSource has unveiled that skincare brand NEOSTRATA is adding a new hyaluronic acid (HA) product to its portfolio.

The Hyaluronic Luminous Lift Gel includes three sizes of HA molecules, alongside 4% neoglucosamine, to exfoliate and boost daily skin hydration, explains the company. In an internal study of 31 females aged 36-63, 97% said their skin felt less dry, and 94% reported their skin looking luminous after four weeks.

CEO of AestheticSource, Lorna Bowes, commented, “NEOSTRATA Skin Active continues its 11-year journey of excellence with this light yet powerful plumping hydrator that will also exfoliate for a brighter and more even skin tone. We now have a selection of highly effective, evidence-based hydrating and moisturising products, so come and talk to us for training to see which regimen is best for your patients – and of course for you too!”

Research

Dr Jean Carruthers releases new books

Aesthetic practitioner and pioneer of the use of botulinum toxin in aesthetics Dr Jean Carruthers has released two new books for medical practitioners. Botulinum Toxin and Soft Tissue Augmentation offer insights into advancements in cosmetic injectables through a variety of compiled cases and studies. Dr Carruthers said, “I have been privileged to edit such fantastic work from all our colleagues – the very latest in the cosmetic use of neuromodulators and dermal fillers. Please enjoy the publications, and I hope they add great insight and happiness to your practices!”

SEASON Conference to tackle myths in aesthetics

The Science Enhanced Anatomy Safety Outcomes Network (SEASON) conference will be returning this June.

The three-day conference will provide individualised hands-on training with ultrasound and 3D imaging, with this year’s focal theme being Aesthetic Mythbusters. Topics covered on the agenda will include face and body anatomy, advanced injectable techniques, complication avoidance and management, plus an overview of regenerative medicine and new innovations on the horizon.

Mr Dalvi Humzah, conference director of SEASON, said, “The SEASON 2023 conference will build on the previous meeting, bringing together leading anatomy specialists and ultrasound experts for the cadaver hands-on sessions. The scientific days will look deeper into the science of exosomes, stem cells, PRP and other aspects of complications, toxins and fillers. This event will give practitioners a unique insight into developments in aesthetics to apply in their practice.” The SEASON conference will be taking place on June 9-11 at King’s College London Guy’s Campus.

ACE holds inaugural Awards for best exhibitor stands

At ACE 2023 on March 10-11, the 97 exhibitors were entered into the ACE Stand Awards for the first time, rewarding the stands with exemplary design, marketing and sustainable practices. The Awards aimed to congratulate those companies who made the experience of ACE visitors even better thanks to their dedication.

Congratulations to all our Stand Awards recipients: Award for Best Stand winner SkinCeuticals, Award for Best Stand Hospitality winner Neauvia, Award for Best Event Marketing Campaign winner Teoxane and Award for Most Sustainable Stand winner HA-Derma. Courtney LeBorgne, event director at Aesthetics, was delighted to welcome all the exhibitors to the Business Design Centre and celebrate their wins, saying, “A huge well done to all our ACE 2023 Stand Award Winners for leading the way in delivering exemplary customer service and hospitality, marketing campaigns and sustainable stand builds! The show floor was buzzing at this year’s ACE thanks to our exhibitors and their gorgeous stands. Thank you as always for ensuring our visitors stay abreast of all the latest research, products and innovations!”

Education

Allergan Aesthetics updates online training

Aesthetic pharmaceutical company Allergan Aesthetics has released AMI Digital World 3.0 – an updated version of its web educational platform for medical practitioners. According to the company, the new version of the platform hosts 24/7 educational resources including video-based training materials and live streamed Allergan events. The platform is now ‘mobile-first’, making learning accessible anywhere.

Clare Ledger, AMI manager at Allergan Aesthetics, explained, “The platform has been significantly updated and now includes educational material for injectors to continue their learning journey with courses on injection techniques, consultation skills, anatomy, Allergan products and access to a host of educational events.”

Device

Lumenis launches ULTRApulse Alpha device

Aesthetic device company Lumenis has unveiled its new device – the ULTRApulse Alpha. The company explains that its latest CO2 device incorporates pre-sets and automations for treatments including skin resurfacing, scar revision and minimally-invasive surgeries like blepharoplasty. Lumenis’ UK country manager Andrew Greenwell commented, “The ULTRApulse Alpha is the embodiment of excellence in CO2 laser technology that guarantees to make a difference to both patient and practitioner alike. With latest state of the art technology from the original innovators of laser, combined with simplicity of use in its design, ULTRAPulse Alpha promises to deliver excellence in safety, results and return on investment.”

Lauren Gibson, Hydrafacial country manager, UK&I

Tell us about the new Hydrafacial Syndeo device…

This year, it’s all about innovation for Hydrafacial. After years of research, we are proud to be launching the brand new Hydrafacial device. Syndeo symbolises Hydrafacial’s forward-thinking technology, designed to benefit both patient and clinic owner for a seamless experience.

What makes Syndeo different?

The device is compact and can neatly store its handpiece, lymphatic drainage and LED LightStim Elipsa tools out of sight, but still at arm’s reach for the practitioner. The device is operated by effortlessly automated hand gesture control, allowing practitioners to spend more time connecting with patients. Syndeo’s sound and light settings can be customised, meeting the needs of sensory sensitive patients. Meanwhile, Syndeo efficiently utilises automatic serum selection for more seamless usage, delivering only what the skin needs.

What treatments does Syndeo offer?

Syndeo is programmed to deliver 12 unique treatments, including six new Hydrabody treatments and an integrated Perk. With Syndeo, upsell opportunities are endless, and there are thousands of ways to personalise, with protocols woven into complementary treatments to maximise results and return on investment. Wi-Fi connected software updates take minutes, meaning you can stay up-to-date in just a few swipes.

What results can you experience from Syndeo?

Results from a Hydrafacial treatment are instant – a glowing complexion that looks and feels radiant, smooth and hydrated. Enhanced personalisation to target skin concerns can be found through tip or booster selection, all of which are verified by the Syndeo machine so you know you’re getting the real deal. Those looking to address fine lines and wrinkles may opt for Omorovicza’s new Advanced Skin Renewal booster, while acne can be targeted with Murad’s Clarifying booster. Skin personalisation is endless with Syndeo.

For more information on Syndeo and to arrange a consultation with a Hydrafacial representative, please visit: hydrafacial.co.uk.

This advertorial was written and supplied by Hydrafacial

Sharon Bennett’s Expert Insights

Aesthetic nurse prescriber Sharon Bennett is the Clinical Lead of the Aesthetics Clinical Advisory Board and the chair of the British Association of Cosmetic Nurses (BACN).

Here, Aesthetics imparts some of the wisdom gained from her 20+ years’ experience…

What innovative aesthetic concept have you got your eye on?

I’m actively looking into the research behind regenerative medicine and wellness at the moment. Aesthetics has always been centred on extrinsic appearance, but it’s time to look at intrinsic ageing as well, and I’m interested in incorporating this into my practice.

What are your go-to treatments for dull skin?

I always begin with skincare – ZO Skin is my goto – and I make sure my patients know how to use it effectively. Products like Restylane Skinboosters and Profhilo are other great options for prolonged hydration, and various devices can also help rejuvenate the skin. My patients love Hydrafacials and microneedling treatments – I have an Endymed Intensif RF and a SkinMed Derma FNS Pen.

What are your top tips for administering cheek filler?

Start off with an in-depth consultation to make sure cheek filler will actually address the patient’s concerns. Before administering the product, you need a good understanding of the anatomy and product rheology to optimise placement and results.

How do you choose what filler to use?

There are hundreds of fillers on the market, but I only go for those with US FDA approval. Listen to the evidence behind certain products rather than sales rhetoric. I’ve been using Restylane since it arrived in the UK in the late 1990s, and now also use Revanesse due to their safety profiles.

What are three reasons to join an industry association?

1. Practitioners often work in isolation, so it’s beneficial to build a support network

2. Associations present up-to-date and non-partisan information to boost your education

3. Having support from associations like ACE Group World or CMAC gives you confidence in the case of complications

Why do you recommend reading publications like Aesthetics?

There are golden nuggets in every publication you read. The Aesthetics journal, for example, provides news, case studies, advice and more, and publications like the Journal of Aesthetic Nursing or the British Dermatology Journal contain full papers on emerging research.

Education

Training held for NHS medics facing aesthetic complications

Aesthetic practitioner and Aesthetics Awards 2023 Winner Dr Sophie Shotter held a free, CPD-accredited training day for NHS professionals, providing instructions on treating and referring patients with aesthetic complications.

Aesthetic Complications for NHS Professionals was held on February 25 at the Royal Society of Medicine, welcoming NHS staff to expand their knowledge. According to Dr Shotter, she was inspired to establish the event after complications patients referred from NHS hospitals reported that staff lacked understanding and sometimes even empathy regarding adverse events.

The day included insights from a range of top aesthetic practitioners, all of whom were keen to share their knowledge for this cause. Speakers included Dr Shotter, as well as aesthetic practitioners Mr James Olding, Dr Manav Bawa, Dr Jennifer Owens, Dr Steven Land, Dr Catherine Fairris, Dr Nestor Demosthenous and cosmetic plastic surgeon Miss Nora Nugent, covering topics such as toxin complications, filler-related infections and surgical tourism. Dr Shotter commented, “We are all too aware of the lack of regulation in the aesthetic sector, something which is hopefully changing. But at present, if people have had treatments from unqualified or under-qualified practitioners and they then develop complications, they will naturally turn to the NHS for help. An understanding of who our patients are and their motivations, how to manage these problems acutely and who to refer onto will hopefully improve help available for victims of these procedures.”

Obagi Medical unveils GetHarley partnership

Skincare company Obagi Medical launched its partnership with skincare platform GetHarley at a Mayfair dinner event.

At the event, 30 practitioners come together to hear more from the two brands, who shared news of the popular Obagi products which practitioners will now be able to supply to their patients via the GetHarley platform.

After the event, Laura Higgins, head of sales and Obagi’s UK distributor Healthxchange, reflected, “Obagi Medical, Topical Skin Product/Range of the Year at The Aesthetics Awards 2023, is proud to collaborate with Best Clinic Support Partner 2022 GetHarley to provide a premium, tailored service supporting patient discovery, education, order fulfilment and customer retention.” Obagi Medical also announced its upcoming launch of NU-CIL Eyebrow Boosting Serum, which will join the NU-CIL Eyelash Serum as a solution to provide fuller and thicker brows, according to the company. The product will be available through prescription, with more details coming soon.

News in Brief

Galderma showcases Alluzience with UK launch event

On March 9, pharmaceutical company Galderma welcomed guests to the highly-anticipated launch of its new liquid neuromodulator Alluzience.

The evening showcased the company’s latest development, with top Galderma key opinion leaders presenting short talks about the new neuromodulator. Plastic surgery registrar Miss Priyanka Chadha expanded on the innovation of Alluzience, including its improvement on patient psychological wellbeing, its ease of use with ready-to-use liquid formulation and the fact that it has no animal or human derived excipients.

Nurse prescriber Alice Henshaw discussed the product’s precision, whilst aesthetic practitioner Dr Kuldeep Minocha looked into the performance and safety. A large quantity of evidence from clinical studies was used throughout the talks, demonstrating high patient satisfaction and the safety and tolerability of the product, as well as its adverse events and contraindications for use.

The final talk was presented by aesthetic practitioner Dr Yusra Al-Mukhtar who noted the importance of patients’ psychological wellbeing, complete with a video of patients sharing their personal experiences of how aesthetic treatments helped them regain confidence.

Rene Wipperich, general manager at Galderma, said, “We are very proud to have launched our new product in London – it was our pleasure to see the great interest in our innovation. Our launch meeting was attended by more than 250 healthcare practitioners in-person, as well as watched online. Galderma will continue its commitment to bring new scientific solutions to our customers and drive innovation in the future.”

On the Scene

Official launch of PLIM in London

Aesthetic service provider PLIM has officially launched in the UK with an event at the Mandarin Oriental Hotel, London. The event invited guests to hear from the company’s founder Nada Ali Redha about the new technology and why she decided to launch the company to the aesthetics community. Afterwards, PLIM’s chief financial officer Anuj Saxena showed a demonstration of the easy-to use platform.

Patients are able to create a profile and upload their ID onto the PLIM Marketplace. Partner clinics and their treatments will be listed so patients can browse, book and request their preferred buy now, pay later plan. Clinics’ patients will then pay PLIM via the chosen instalment plan after receiving treatments. After the demonstration, guests heard from two clinics that have been using the technology, noting a growth in patient demand and returning patients from the instalment scheme. Guests were then invited to ask questions and speak to the team directly about the new platform. For the future, PLIM hopes to introduce eight- and 12-month instalment plans for patients to choose from, as well as expanding its platform to Switzerland and the United Arab Emirates. Ali Redha commented, “It’s amazing to see the plans and vision coming to life. Everyone at PLIM is really excited for this project to take form, bringing these services to the UK. We want accessibility to be prevalent in every part of the journey for both partner clinics and their patients.”

Wigmore

Medical

Presents announces packed line-up

Wigmore Medical Presents educational meeting returns on April 29-30 at the Royal College of Physicians, London. The two days will provide content streams on injectables, devices and skincare, as well as a full-day agenda from the International College of Aesthetic Nurses and workshop sessions from top brands. Industry-leading speakers include Dr Zein Obagi, Dr David Eccleston, Professor Syed Haq, Dr Steven Land and Julie Scott.

Evolus continues expansion in Europe

Medical aesthetic company Evolus is furthering its reach into the European market as botulinum toxin Nuceiva is now commercially available in Germany and Austria. Nuceiva has been approved by the European Commission for temporary improvement of glabellar lines. David Moatazedi, president and CEO of Evolus, said, “We are excited to introduce Nuceiva to customers in the second largest aesthetic toxin market in Europe. Entering this dynamic European market is the latest in a series of geographical expansion milestones that will help fuel Evolus above market average growth.”

Circa Skin UK partners with Platform20

Aesthetic distribution company Circa Skin UK Ltd has unveiled its partnership with Platform20 Medical Services Ltd to share its medical aesthetic products with Irish and Northern Irish practitioners. Platform20 will be responsible for the KYSENSE dermal filler and WOW facial brands in Ireland and Northern Ireland. Claire Williams, CEO of Circa Skin Ltd, says, “We are thrilled to be launching this advancement in aesthetic technology in Ireland alongside a forward-thinking company such as Platform20.”

Celluma expands global headquarters

BioPhotas Inc., the manufacturer of the Celluma SERIES of light therapy devices, has announced its global headquarters are to move from Anaheim to a larger location in Tustin, California. According to the company, the location’s 25,000 square feet of office and warehouse space will allow BioPhotas to streamline shipping operations as the company grows. Patrick Johnson, chief executive officer of BioPhotas, said, “We are very excited to be moving into a new corporate headquarters that is two and a half times larger than our current facilities.”

Botulinum toxin

Standardising Formulations in

Cosmetic

Products

Aesthetics delves into the latest international guidelines on product formulation requirements

Being transparent and honest is a pivotal component of working in aesthetics. From advising your patients of the most suitable treatments in-clinic, to manufacturers promoting certain ingredients in their products, it is vital to be ethical throughout the specialty. However, with a lack of regulation in the industry, this can be a difficult task, with parallel importing and counterfeit products being circulated regularly.1

Last month, independent, not-for-profit public health and safety organisation National Sanitation Foundation (NSF) launched Guideline 527, Contents and Claims Certified for beauty, cosmetic and personal care products, like soap, skincare and over-the-counter drugs, for suppliers operating in or exporting to the US.2 The guideline is designed to improve integrity within the beauty and cosmetic industries by providing a complete programme which includes standardised definitions and criteria, formulation requirements, ingredient identity, testing criteria, as well as abiding with Good Manufacturing Practice (GMP).2

Guideline 527 aims to improve trust among customers, minimise liability, differentiate products from competitors and, most importantly, mitigate risk.2 Despite the guideline being applicable for the US, it is still important for any UK aesthetic clinic to be aware of these changes if they sell products, such as skincare, from the US or if their UK distributor works directly with US companies. The new guideline will ensure that these products meet the highest regulatory requirements, ensuring clarity and transparency for consumers. To find out how this new guideline may affect the UK aesthetics specialty, we spoke to CEO of AestheticSource, a skincare distributor which works with numerous US skincare companies, Lorna Bowes, and Katherine Fillinger, senior manager of global certification at NSF.

Transparency is key

In December 2022, President Joe Biden signed into law The US Modernisation of

Cosmetic Regulations Act (MoCRA), requiring companies to register facilities and list products and ingredients with the US Food and Drug Administration (FDA) by the end of 2023.3 Currently, in the UK, product regulation is strict, with manufacturers having to meet specific requirements before being placed on the market.4

Bowes notes that it could be useful to be aware of NSF if brands are planning to export skincare to the US and therefore in time may be adopted elsewhere, Bowes adds, explaining, “Manufacturers choosing to work with NSF are doing so to underline the safety of a product, the compliance and accuracy of claims made, GMP-compliance and other regulatory definitions. The US FDA is currently working to finalise work on the MoCRA at the end of 2023, in response to an increased consumer appetite for transparency in terms of claims made on products being objectively reviewed and verified, which I believe is a crucial step forward in terms of regulation.”3 Fillinger explains that this new guideline is especially noteworthy for distributors looking to trade in the US market or for anyone buying cosmetic/medicinal products from the US. She comments, “While more details are pending from the FDA about how this new registration will work, Guideline 527 is a smart step in the right direction for cosmetic and personal care manufacturers, suppliers, retailers and distributors looking to build or protect a competitive edge in the US market.”

Cosmetic scrutiny

Within the new guideline, standardised definitions and criteria have been implemented, particularly around terms such as ‘pure’ and ‘natural’. This is to ensure that companies are using the same terminology when developing, testing and marketing products.2

A few of the criteria mentioned include:2

• A label review which reiterates that all claims on product labels are accurate and truthful

• Formulation requirements

• Ingredient identity and testing criteria to ensure product safety and effectiveness

• Product purity and physical

characterisation for products to be free from contaminants and meet required characteristics such as colour, consistency and fragrance

Fillinger reiterates that the new guideline won’t affect the formulation of skincare products, but will require companies and manufacturers to provide more detailed information surrounding their contents, including ingredients. “This increased transparency and regulation may indirectly impact the formulation of skincare products in the future as companies strive to comply with the new regulations,” she explains. For Bowes, the new guideline aims to promote transparency and accuracy of claims which in term drives product safety, she notes, “US manufacturers will likely be working to the guidelines even if they are not displaying the logo. Brands exporting to the US will also be under pressure to do the same. Speaking for the brands we are proud to represent at AestheticSource, our due diligence processes already ensure our clients can be confident in our claims of clinical efficacy and safety, as well as our suppliers’ GMP credentials.” Bowes further supports the focus on honesty and accuracy of claims as this is pivotal for patient safety.

Evaluating cosmetic products

With Guideline 527 coming into fruition in the US, Bowes reflects that UK products should be upholding the relevant regulatory frameworks, however, if adopted, the guideline could mean US products coming to the UK are meeting the highest standards. She adds, “All cosmetic products on the UK market should be registered and have the UK Government ‘Office for Product Safety and Standards: Submit Cosmetic Products Notification’ (SCPN) portal numbers. This ensures safety, labelling compliance, GMP status and PIF accuracy.”

Bowes concludes, “It would be reassuring for clinics and their patients to know that products and brands on the market in the UK have been checked for accuracy in their SCPN notification.”

Return of ACE Brings Top Class Education and Networking

Kicking off another fantastic year in aesthetic medicine, Aesthetics reflects on the biggest and best ACE conference to date

Last month brought with it one of the busiest weekends in the UK aesthetics community – ACE and The Aesthetics Awards! Over two days at the Business Design Centre, London, aesthetic practitioners, clinic owners and aesthetic companies united to champion learning and development at ACE.

Both established, industry-leading figures and those looking to break into the world of medical aesthetics congregated to discuss and share the latest learnings and innovations, all with the goal of enhancing patient safety and satisfaction whilst strengthening the UK aesthetics community even further.

During the two days, registration sponsor Church Pharmacy helped welcome 2,714 delegates, alongside 97 exhibitors and 110 speakers across the two days, with dozens of hours of content across five stages. Members of the press were also invited to hear about the latest developments in the world of aesthetics. This year brought the largest meeting of practitioners ACE has ever seen, and demand to

hear more about the latest innovations, advanced techniques and tips for best practice was enormous.

Courtney LeBorgne, event director of Aesthetics, commented, “It was wonderful to return to the Business Design Centre for ACE 2023! This year was really special – the quality of the content and live demonstrations was exceptional, with all five theatres packed on both days. A big thank you to our wonderful speakers for providing 16 CPD points for our delegates across a range of top-quality educational content. We are delighted with this year’s event, and extend a massive thank you to the exhibitors, sponsors, visitors, speakers, associations and partners who make ACE a success year on year. Roll on CCR in October!”

Pioneering learning with Teoxane

Teoxane was the Headline Sponsor at ACE 2023, and as well as supporting the entire event, they hosted a jam-packed two-day schedule of top-quality clinical content. Some of the biggest names in the UK medical aesthetic specialty gathered to represent the company and demonstrate how its products can help achieve excellent results. Day one began with an all-female line up for the first ‘Beauty is Personal’ session, with Dr Saleena Zimri performing a live injectable demonstration alongside speakers Dr Sabrina Shah-Desai, Dr Tahera Bhojani-Lynch and aesthetic nurse prescriber Rachel Goddard. ‘Every Lip is Unique’ followed in the afternoon, with top practitioners Dr Lee Walker and Dr Jeremy Isaac joining Dr Shah-Desai and Dr Zimri to focus on exemplary lip treatment techniques. Following her session, Dr Zimri said, “ACE 2023 has been absolutely fantastic. We kicked off the Teoxane symposium with an all-female panel on day one. It was a pleasure to treat a full-face perimenopausal woman live to a packed-out audience in the morning, and a millennial

lip in the afternoon. The results and feedback were incredible. Thank you to ACE for being incredible hosts!”

Day two offered just as many learning opportunities, with the second ‘Beauty is Personal’ session hosted by Dr Walker, Dr Kam Lally and Dr Wassim Taktouk, complete with a live injection from Dr Benji Dhillon. Another ‘Every Lip is Unique’ session rounded off Teoxane’s content with Dr Dhillon, Dr Isaac, Dr Lally, Dr Walker and Dr Raul Cetto sharing even more of their clinical expertise.

Jordan Sheals, deputy country manager at Teoxane UK, shared, “It was wonderful to be back at ACE for 2023, an event that is a staple in the Aesthetics calendar. Every year this event seems to get bigger and better, and this year was no different! Teoxane welcomed over 1,000 practitioners to their symposiums across the two days, as well as our business booth talks. As always, the focus for Teoxane at ACE is education and being able to offer practitioners new and exciting way of learning, bringing educational content led by our world-renowned faculty to a community of like-minded injectors who are all as passionate about creating the safest and most impactful experience for patients as we are.”

Business insights explored in the new In Practice Zone

For the first time, ACE was home to the brand new In Practice Zone – a hub for visitors’ business queries. Delegates could visit AesthetiDocs, Aesthetic Nurse Software, e-clinic, Enhance Insurance, Hamilton Fraser, InDesk, Inspire to Outstand, MeTime, PLIM and Web Marketing Clinic to learn more about all the fabulous support on offer for clinic owners to boost their business. The Zone was hugely popular, with hundreds of practitioners relishing the opportunity to discuss solutions from business providers all in one place. The In Practice networking drinks on the first day offered a further opportunity to share tips and connect with clinic support partners.

The In Practice Theatre, sponsored by PLIM, was the ideal place to collect expertise, with talks discussing social media, navigating VAT in aesthetics, opening a new clinic, building a brand, dealing with negative reviews, balancing work and family life and thriving in a recession. The two days of content were rounded off with an all-star panel of international KOLs discussing their role as global speakers and educators, featuring Dr Cetto, Dr Walker, Dr Tapan Patel and Miss Sherina Balaratnam.

CEO of PLIM Nada Ali Redha reflected, “We proudly sponsored the In Practice Theatre at ACE this year, and the line-up of speakers and industry experts was incredible. We had an inspiring and interactive few days. Thank you to all of you who visited our PLIM stand – it was lovely to meet you all and we are delighted to already have a number of visitors partnered with PLIM.”

The In Practice Theatre’s eclectic content line-up was coordinated by editor and content manager of Aesthetics Shannon Kilgariff, who said, “Clinical education and demonstrations of best practice are essential for any medical aesthetic conference, but I believe that top-class business advice is too. We know that many of our valued visitors are busy people with lots going on both in and out of clinic, and the business side of things can often be a huge challenge. I am delighted that we provided a whole agenda full of business expertise at ACE this year to help practitioners focus on how to boost their efficiency and profits. Our incredible range of speakers were so generous to share their knowledge, and our wonderful In Practice exhibitors were on hand to provide more invaluable support.”

Ground-breaking content at the Innovation Stage

The Innovation Stage was packed with content from a variety of aesthetic companies exploring their latest product launches and technologies, solidifying ACE as the place to be to learn about everything new in the aesthetics field.

Aesthetic companies AesthetiCare, AestheticSource, BTL Aesthetics,

The Visitor Experience

“I’ve come to ACE every year for the last three years and I look forward to it every time! This is an amazing experience and there are always lots of things to know and discover. I think it’s highly recommended – everyone who’s interested in aesthetics has to come here, and they will leave amazed. Brilliant day!”

Marie Bartholomew, aesthetic nurse at Aesthetics by Anna Marie

“Everything has been really good! I’ve tried to get in as much as possible in my time here and I’ve done a lot. I enjoyed the conference sessions and was really inspired, and I managed to get around most of the stands. Definitely got what I came for!”

Dr Radhika

Varsani, dentist at Dr RV Aesthetics

Cutera, Eden Aesthetics, EvoCyte, HA-Derma, Lynton Lasers, Solta Medical, TargetCool and VIVACY Laboratories all showcased innovations, from injectables to devices. Delegates enjoyed hearing about advancements in some of the specialty’s most in-demand treatments, with enlightening talks on facial muscle stimulation, treating acne with devices, addressing cellular ageing, the use of exosomes in aesthetics and much more.

In-depth learning in the Masterclass Agenda

“It’s my first time here so it was really exciting. I’ve found a lot of new companies, and it’s been a really valuable day. The live demonstrations were amazing too! I’ve been speaking to all of the exhibitors and it’s good to find new ones and learn more about the industry.”

Dr Nutchanun Poolworaluk, aesthetic practitioner

“The day has been really good and the quality of the talks have been really interesting. We work with a lot of the exhibitors here already, so it was nice to chat with them face to face and touch base with them.”

Shadae Brown, aesthetic nurse at AestheticsByShadae

The Masterclass Agenda was the prime location for deep dives into the latest clinical education and treatment skills, providing insight into advanced techniques for patient safety. Hosted by top KOLs, aesthetic companies Church Pharmacy, Dermaroller, Lumenis, SkinCeuticals and Sofwave shared insights into optimising dermal fillers, medical-grade skincare and aesthetic devices for your patients on the first day. On day two, an Allergan Aesthetics takeover provided delegates with invaluable facial assessment and treatment planning tips using different products for patients in their 30s, 40s and 50s. Speakers Dr Patel, Dr Nestor Demosthenous and Dr Eithne Brenner each highlighted the versatility of dermal filler Juvéderm and hybrid injectable HArmonyCa in live injectable demonstrations. Dr Demosthenous commented, “Allergan’s Medical Institute masterclass was very well received, with delegates lining up to attend and the conference room full to capacity. There was an influx of enquiries for further training and more information on the Juvéderm range of fillers, as well as Allergan’s latest innovative product HArmonyCa, at the stand. This has been one of the best years for Allergan at ACE.”

Live demonstrations at the Symposium Stage

On the Symposium Stage, the industry’s top pharmaceutical brands showcased even more innovative techniques, featuring leading aesthetic practitioners. The sessions on this stage helped delegates enhance their skillset by watching live treatment demonstrations, discovering the latest advancements for injecting.

Companies featured included Croma, Neauvia and Prollenium, all showcasing incredible injectable results with optimal, evidence-based techniques. Galderma also hosted sessions on both days, focusing on combining Restylane HA and Sculptra biostimulator to maximise patient outcomes from Dr Munir Somji, Dr Priya Chadha, Dr Rikin Parekh and aesthetic nurse prescriber Jackie Partridge, and exploring brand-new, ready-to-use liquid neuromodulator Alluzience from Dr Somji, Dr Lara Watson and Dr Kuldeep Minocha.

A plethora of industry-leading exhibitors

Alongside the five content streams, all 97 exhibitors made ACE the perfect hub for visitors to learn about the latest in aesthetic business, injectables, skincare, devices and more.

For the first time ever, the achievements of exhibitors were marked with the inaugural ACE Stand Awards, congratulating the industry’s top companies for their efforts in making ACE great. A huge well done to the winners:

• Award for Best Stand – SkinCeuticals

• Award for Best Stand Hospitality – Neauvia

• Award for Best Event Marketing Campaign – Teoxane

• Award for Most Sustainable Stand – HA-Derma

Director of SkinCeuticals UK, Anton Petrov was delighted, saying, “Our mission is to drive industry education about advanced professional skincare and its integration into clinical treatment programmes for the best patient outcomes. On the stand at ACE this year, we celebrated our iconic antioxidant range with the bottle-shaped entrance, and our representatives were happy to hear about the needs of new and current clients, as well as provide popular facial consultations with our SkinScope. We would like to thank everyone who came along and supported us!”

Building connections at ACE

Aesthetic conferences like ACE are an excellent opportunity to not just learn, but also catch up and network with peers and colleagues, as well as establish new partnerships or mentorship relationships. The clinical talks were a perfect chance to meet practitioners with similar interests, as well as pose questions to industry-leading KOLs.

As well as the In Practice Networking drinks, Hydrafacial hosted a fabulous networking drinks reception on its stand to round off the first day of ACE. Both drinks receptions were the place to be to mingle with like-minded professionals and find out even more about some of the specialty’s biggest companies and organisations.

Lauren Gibson, Hydrafacial country manager for the UK and Ireland, commented, “Our networking drinks at ACE were so powerful to reconnect with our clients and meet new industry professionals. It is so refreshing to hear how the industry is evolving and growing, and we get to be part of that journey as a brand!”

VIP Experience sponsor HA-Derma kindly hosted esteemed guests in a comfortable and intimate VIP Lounge, where VIPs could mix their networking with refreshments. On day two, HA-Derma hosted The Aesthetics Awards 2023 Finalists for an exclusive pre-drinks reception, complete with hair and makeup appointments for the Finalists to get glam.

Hana Te Reo, HA-Derma operations director, reflected, “We were delighted to sponsor the ACE 2023 VIP Experience for VIP delegates attending the conference. The space enabled visitors to catch up over refreshments during the two days, as well as book in for their hair and makeup appointments to get ready for the glamorous Aesthetics Awards. There was a lovely atmosphere during the Finalists’ drinks reception, and we were delighted to see so many of our IBSA portfolio and Profhilo partner practitioners there.”

The Aesthetics Awards took place on March 11 at Grosvenor House, London, where the Winners were revealed – turn to p.38 to see the full list!

See you next time!

ACE is over for another year! Save the date for March 15-16, 2024, as ACE and The Aesthetics Awards return once again. CCR – the next event hosted by Aesthetics – will be at ExCel, London on October 19-20. Keep an eye out for more details soon, and we’ll see you there!

Implementing ESG Into Your Business

ESG. In the last year or so, this might be a term that you’ve heard mentioned more and more. But what exactly is it?

ESG stands for environmental, social and governance, and refers to a framework that relates to a wide range of issues that might directly impact a business (Figure 1).1 This framework helps businesses understand how a company is managing risks and opportunities related to the above categories. These might include climate change,

inequality, health and safety and cybersecurity.

It has been noted by the ESG Organisation, the top organisation that promotes this globally, that two thirds of investors take ESG into account when investing in a business, so improving your ESG really does have the opportunity to grow your company.1

To help you implement ESG as part of your business strategy, we got the lowdown on the ways you can set up your own framework for success.

Environmental

Environmental factors are increasingly becoming more important in today’s society, with climate change a focal point of conversation. In fact, reports on the topic have doubled since 2018 across newspapers, radio and television.2 In addition, a study of 2,000 adults from 2022 found that 40% of consumers were choosing brands with more environmentally sustainable practices and values as part of their own commitment to protecting the planet.3 Product manager for waste disposal company Initial Medical, Rebecca Waters, notes, “This shows that many individuals will not only appreciate increased sustainability by the aesthetic clinic they approach, but that this could be a deciding factor in whether they proceed with a particular provider.”

She adds that for any business, minimising environmental impact is about reducing the negative effect on the natural world through more sustainable and ethical practices. She explains, “These include reducing energy use and utilising renewable energy sources to achieve net zero, minimising carbon emissions, introducing greener products within daily life, and increasing the reuse of items where it is safe to do so. On a practical level, there are various things that aesthetic clinics can do.”4

For instance, Waters explains that energy consumption can be limited through simple actions like turning off lights, air conditioning/heating, and electrical equipment when it is not in use. “LED light bulbs use up less electricity than traditional alternatives,” she says, “While these are highly affordable and easy-toimplement changes, the resulting reduction in energy consumption will be minimal in

Figure 1: ESG frameworks

How aesthetic clinics and companies can start executing ESG frameworks into their business to help facilitate a better more sustainable society

the grand scheme of things. For greater impact, larger-scale adjustments need to be made, like properly insulating premises and employing technologies that use less energy.” Of course, Waters notes, these can be cost-prohibitive and therefore not viable for all aesthetic clinics, but they are still worth considering over time or if you are moving or taking on new premises. “Water consumption should also be reviewed and may be reduced by implementing automatic taps, for example, that minimise water wastage in the patient and staff washrooms, as well as choosing sterilisation equipment that uses less water,” she adds.

To utilise renewable energy, there is the possibility of switching your energy provider to one that uses green energy sources. Waters explains, “This could help to achieve a net zero status – whereby the amount of greenhouse gas emissions produced is balanced by the amount removed from the atmosphere. Installing solar panels at your premises may also be an option and could further promote renewable energy consumption.”

Improving the sustainability of products and consumables is a difficult area for businesses in the healthcare sector, and needs to be balanced with patient safety and infection control priorities, Waters emphasises. “Single-use items are common in surgery and many of these are difficult and expensive to replace – not to mention the added costs of sterilisation and storage if reusable alternatives are employed,” she says, “However, there are still ways of boosting sustainability in this area. Paper or recycled plastic cups for visitors, digital documentation and recycling bins are all beneficial. When it comes to bigger items, consider sustainably sourced materials for furniture, flooring and décor, as well as energy-efficient appliances and general equipment in the staff and reception areas.” She adds that right down to your waste containers and bins, there are sustainable options available on the market that utilise as little plastic as possible. “Even the smallest changes help make a difference and will likely be noted by your patients and staff!”5

Measuring the impact

Waters explains that the best way to measure your impact on the environment is to calculate your carbon footprint. This can either focus on greenhouse emissions generated directly by your business;

indirect emissions from the things you use like electricity, heating and water; or total emissions that are produced by the entire supply chain you depend on to operate your business. She says, “The maths can be complicated, but your total emissions are essentially your total energy consumption x emission factors. You will need to collect data for your total energy usage, water usage, fuel for vehicles and waste. Conversion factors can be found on the Government website and there are resources that can help with the calculation through data input online.”6 Once determined, Waters notes that recording and checking your carbon footprint annually can help you to monitor your progress over time, which is especially useful if you are striving to reduce your environmental impact.

Social

According to Sue Thomson, managing director of business services provider SJ Partnerships, the social aspect of ESG

encompasses many elements such as equality and diversity, fairness, safety, working conditions and how a company can impact the environment and community around it.7 She adds, “A great quote that I believe is important for any organisation comes from professor of finance Alex Edman’s book Grow the Pie: ‘The most successful companies don’t target profit directly but are driven by purpose – the desire to serve a societal need and contribute to human betterment’.”4

Recruitment and retention

According to Thomson, one of the most important things that we see for clinics when they adopt a clear and positive ESG policy, is that they are far more likely to attract and retain great talent. She explains, “We see through the recruiting arm of our business that Millennials and Gen Z (those born between 1980-1994, and between 1995-2012), gravitate far more towards companies who demonstrate good ESG values. They are motivated in a different way

Figure 2: Process for analysing the social impact of your business

“Big salaries only work for a short time, it’s how you make people feel and what your organisation does to make staff feel valued”

Sue Thomson

What the team behind Aesthetics are doing…

Easyfairs,the company behind the Aesthetics brand, encompassing CCR, ACE, The Aesthetics Awards and the Aesthetics journal, has been making its own efforts to improve its ESG. This includes a strong focus on education and support for both its staff and exhibitors. Among other initiatives, some are explored below.

Environmental:

ACE and CCR recently removed printed show guides and replaced with an interactive digital app to avoid unnecessary paper use. ACE also launched a new sustainable stand award to incentivise exhibitors to focus on ESG. HA-Derma was the first company to receive this award. The events also now encourage green mobility options and promote sustainable travel for staff, exhibitors and event visitors. Easyfairs has also recently launched a Net Zero Roadmap to reduce emissions by 50% by 2030.

Social:

Across the globe, Easyfairs has partaken in many charity initiatives over the last year. In the Netherlands, £25,000 was raised for cancer research after employees cycled up Alpe d’HuZes, and in the Nordic region colleagues collected donations for Music Aid which supports children fleeing war and conflict. In the UK, volunteers helped offer a festive Christmas celebration day for the lonely and vulnerable; and our editor Shannon Kilgariff took part in an 11 hour virtual fundraising event for mental health. Easyfairs is also supporting Ukraine, with each five regional hubs undertaking various solidarity actions, such as providing supplies to a Ukranian coffee shop, collecting funds for UNICEF, and exploring the possibility of hosting refugees.

Governance:

Last year, a cybersecurity audit was done and Easyfairs has now developed an action plan based on this.

from the Baby Boomers and Gen X (those born between 1946-1964 and between 1965-1979) generations.”

Whilst the older generations were climbing the property ladder and were often tied down with earlier financial commitments, Thomson explains that the younger generations face a new set of challenges and financial complexities and are now more often driven by fairness and global responsibilities. “They’re therefore more likely to vote with their feet if their needs are not being met,” she says, “We hear regularly within the recruitment division of our own company that Gen Z and Millennial candidates are less likely to stay with a company for the same length of time than their predecessors. We also frequently ask employers we work with: ‘What are you doing to motivate and retain your team?’ Big salaries only work for a short time, it’s how you make people feel and what your organisation does to make staff feel valued. The job market is a very different place, even from five years ago!”

To help retain your staff through the implementation of social policies, Thomson suggests focusing on three areas: promoting

inclusivity, improving health and safety and providing your staff with opportunities. She explains that encouraging diversity, equality and any sort of inclusion in a company attracts great talent as well as promoting a happier and healthier working environment. “Making a conscious effort to build a clinic team based on values around diversity and equality is only going to provide a richness of knowledge, experience and positive difference within your workforce. Staff feel more motivated and valued, and are likely to stay in a role for a longer period,” she says.

Critical to this is the creation of a clear, transparent diversity and equality policy, explains Thomson. She notes, “You need to have a staff handbook if you don’t already, outlining your policies. Not only can a great diversity and equality policy provide a team with the company’s process, it can also prevent serious or legal issues that could arise as a result of any accusations of discrimination.”

In terms of health and safety, Thomson explains that all companies should also have a health and safety policy within

their business, regardless of the type of business.8 She adds that the positive impacts of creating and implementing one are significant, noting that there are several reasons to create a policy, including:9

• It’s the right thing to do and staff feel protected and safe

• It protects your staff and may reduce absences as a result of avoidable events

• As a result of reduced absences, revenue can remain higher

• Your company has less likelihood of litigation

• Your business can be attractive to future employees and potential business opportunities/partners

When it comes to staff opportunities, Thomson adds that you should be ensuring that all opportunities are open equally to all staff members. “I am also a huge advocate of creating champions within a team,” she continues, “By creating an ESG champion/s, this allows a team member to own a project and work not only with the leadership team to identify early challenges, but it also enables early intervention whereby potential situations do not arise.” She explains that providing that team member with responsibilities and ownership supports their personal development, as well as

“When it comes to bigger items, consider sustainably sourced materials for furniture, flooring and décor, as well as energy-efficient appliances”

Rebecca Waters

affording them the opportunity of actively participating in ensuring that their ESG policies are working or require adapting to meet the needs of the team.

Thomson suggests that if you are going to consciously consider adopting an ESG policy into your clinic, it must start with an honest assessment of your business as it currently stands (Figure 2). She says, “When you have collated this information across all of the ESG elements, you will be able to identify where there are gaps and what needs to be done.”

Pro bono work

As part of the ‘S’ in ESG, company relationships have been identified as important. This refers to external relationships with local businesses, charities, communities and causes. Some aesthetic practitioners choose to partake in pro bono work as part of this.

Aesthetic practitioner Dr Joshua Van der Aa started doing pro bono work, having been approached by a cleft lip patient. He notes, “I was so impressed with the difference I made through aesthetic treatment, it made me realise my work could definitely benefit more people. These people have, typically, gone through so many painful surgeries, but can often still benefit from some fine aesthetic adjustments, just to finesse their results and to improve symmetry and light reflection here and there.”

He believes that the aesthetics industry can really benefit from lending their help to causes such as these, noting, “There’s much more the profession can do to help in this way, certainly. I definitely feel it should. It’s incredibly rewarding, not simply because of the change you can make to someone’s life, but because the work is challenging too. That appeals to me because of my penchant for challenging cases and stretching myself.” On how practitioners can get started in pro bono work, Dr Van der Aa notes, “I started by making my followers aware via

my social channels and this generated enquiries. From there, word has spread via recommendations and local cleft support groups in different parts of the country.”

While Dr Van der Aa works independently, there are many organisations that practitioners can join to partake in volunteer and pro bono work, by reaching out to different local charities or wider charities in the aesthetic sphere such as Aesthetics charity partner BFIRST for surgeons.

Dr Van der Aa emphasises that if you are engaging in pro bono work with patients, managing expectations is absolutely key.

He explains, “I usually ask to see photos first to be sure I can help before someone makes the journey to see me. And it’s vital to communicate well in advance; usually what we’re aiming for is subtle but appreciable differences – near-perfect symmetry is never usually going to be possible.” He adds that you may also have to accept that you don’t have the right expertise to treat everyone who approaches you. “So far, I’ve not had to turn down anyone who’s asked for my help,” he says, “I make it known that while I’ll consider everyone who gets in touch, I can’t absolutely promise that means I’ll see everyone who does.” Of course, helping external causes goes beyond giving free aesthetic treatments, and there are many other ways that you can volunteer in your local community to help make a difference.

Governance

While environmental and social factors are most applicable to aesthetic practitioners and businesses, it’s still important to have an understanding of governance to help you navigate the framework. ESG governance refers to the implementation of decision-making, board oversight, rules, policies and procedures throughout an organisation.1

Some key topics and themes within ESG

governance include:1

• Shareholder structure

• Board diversity

• Executive compensation

• Company policies

• Business ethics and conduct

• Tax transparency and strategy

• ESG regulatory compliance

• Risk management

• Anti-competitive practices

• Data protection, privacy and cybersecurity10

Starting your ESG journey

Although the above might seem like a lot to take on, Waters notes that taking it step by step and doing what you can is the most important thing. She concludes, “At the end of the day, no matter how small a change you are able to implement, it will only be a positive thing for your aesthetic clinic, staff and clients. ESG criteria are becoming essential for all business models, not least because consumers are demanding that companies take greater responsibility for reducing their environmental and social impact, in addition to maintaining closely regulated working conditions for their people.”

So, what change can you make today?

REFERENCES

1. ESG Organisation, What is ESG, 2023, <https://www.esg.org/ what-is-esg>

2. Thackeray et al. 2020. Civil disobedience movements such as School Strike for the Climate are raising public awareness of the climate change emergency. Global Change Biology. DOI: 10.1111/gcb.14978

3. Deloitte. How consumers are embracing sustainability. Annual report. 2022. <https://www2.deloitte.com/uk/en/pages/ consumer-business/articles/sustainable-consumer.html>

4. BBC, What is Net Zero, 2021, <https://www.bbc.co.uk/news/ science-environment-58874518>

5. Rebecca Waters, Implementing Sustainability in Your Clinic, 2022,

6. Carbon Footprint, Carbon Calculator, <https://www. carbonfootprint.com/calculator.aspx>

7. Alex Edman, Grow the Pie, 2020

8. Health and Safety handbook, 7 advantages of having effective workplaces health and safety policies, 2017, <https:// healthandsafetyhandbook.com.au/bulletin/7-advantages-ofhaving-effective-workplace-health-and-safety-policies-andprocedures/#:~:text=Health%20and%20safety%20policies%20 and%20procedures%20are%20essential,a%20consistent%20 way%20throughout%20your%20business.%20More%20items>

9. Occupational Safety and Health Consultants Register, What are the Benefits of Health and Safety Practices, <https://www. oshcr.org/what-are-the-benefits-of-following-health-and-safetypractices/#:~:text=Following%20health%20and%20safety%20 guidelines%20and%20maintaining%20a,direct%20costs%20 of%20absences%2C%20such%20as%20paying%20salaries.>

10. Anthony Green, Understanding Cybersecurity, 2022, <https://aestheticsjournal.com/feature/understanding-cybersecurity>

“Creating an ESG champion allows a team member to own a project and work with the leadership team to identify early challenges”

Sue Thomson

Allergan Aesthetics are delighted to announce that HArmonyCa™ was awarded Product Innovation of the Year at the prestigious Aesthetics Awards 2023

The future of Hybrid Injectables

HarmonyCaTM combines hyaluronic acid (HA) with calcium hydroxyapatite (CaHA), which may give your patients the benefits of an immediate lift effect from HA and sustained collagen stimulation associated with CaHA, for a new way to facial harmony.

Produced and funded by Allergan Aesthetics, an AbbVie company.

Please see HArmonyCa™ IFU for the full list of contraindications, warnings and precautions.1

* Results from a pre-clinical animal study of HArmonyCa™ with results demonstrated over 12 weeks.2 † Results from a pre-clinical animal study of HArmonyCa™ with results demonstrated over 8 weeks.3

HArmonyCa™ Lidocaine is referred to as HArmonyCa™.

HArmonyCa™ is a dermal filler intended for facial soft tissue augmentation and should be injected into the deep dermal and sub-dermal layers. The lidocaine in the product is for reducing pain during treatment. 1

For use in patients ≥ 18 years old only. ©AbbVie 2023. All rights reserved.

References

1. Allergan Aesthetics. HArmonyCa™ Lidocaine IFU. M032 V01. 2021.

2. Allergan Aesthetics. Data on File. INT-HAR-2150036. HArmonyCa™ Lidocaine. Lift capacity. Jul 2021.

Book

Adverse events should be reported.

Reporting forms and information can be found at:

UK adverse events reporting https://yellowcard.mhra.gov.uk/

Adverse events should also be reported to Allergan Ltd.

UK_medinfo@allergan.com or 01628 494026

Irish adverse events reporting https://www.hpra.ie

Adverse events should also be reported to Allergan Ltd.

UK_medinfo@allergan.com or 01628 494026

3. Allergan Aesthetics. Data on File. INT-HAR-2150040. HArmonyCa™ Lidocaine. Collagen stimulation. Jul 2021.

Model has not been treated with HArmonyCa

Understanding Muscle Anatomy for Toxin Injections

Miss Priyanka Chadha, Miss Lara Watson and junior doctor

Miss Shonnelly Novintan explore the muscle anatomy of the face and its importance in avoiding complications when administering toxin injections

Botulinum toxin is a potent neurotoxin produced by Clostridium Botulinum. There are eight distinct serotypes of exotoxin (A, B, C1, C2, D, E, F and G). Serotype A (BoNT-A) is the most potent and the only exotoxin that is licensed for cosmetic use. The toxin is injected using a needle into the target muscle, with variable dosing depending on the target muscle and patient factors.1 The molecule works by inhibiting the release of the neurotransmitter acetylcholine at the presynaptic membrane of neuromuscular junctions of peripheral cholinergic nerve terminals. This results in the flaccid paralysis of ‘botulism’, which occurs as varying degrees of neuroparalysis. Seven of the eight serotypes have been linked to paralysis, and human botulism is mainly caused by A, B and E, and uncommonly F and G.1

Medical use of botulinum toxin

Botulinum toxin is used as an invaluable tool in the treatment of a variety of medical conditions. Originally, it was licensed to treat strabismus pioneered by ophthalmologist Alan Scott in 1981, with US Food and Drug Administration (FDA) approval eight years later.2 Since then, a host of therapeutic uses have been discovered, including treatment of focal dystonia, spasticity, tremors and migraines.3 In 2002, the US FDA licensed cosmetic use of certain neuromodulators for treating glabellar frown lines, and in 2013, approved usage in treating lateral canthal lines (crow’s feet). FDA approval continues to develop for other areas, such as overactive bladder and axillary hyperhidrosis. Its off-label usage in practice is frequent, such as in treating other muscle groups for cosmetic indications.4,5 The applications of botulinum toxin in facial aesthetics are widely documented and understood.1,3,6 The agent relaxes facial muscles (typically muscles of facial

Glabella complex Corrugator supercilii

expression) which are responsible for the development of rhytids to create a smoother skin surface appearance and reduce the development of signs of ageing. The treatment is generally quick to perform (less than 30 minutes), administered outside of a hospital setting with minimal discomfort and downtime and can often produce satisfactory results within a few days.1,3,6

Medial portion of the arcus superciliaris of the frontal bone

Orbicularis oculi Nasal part of frontal bone, frontal process of maxilla, medial palpebral ligament, lacrimal bone

Masseter Superficial part: maxillary process of zygomatic bone, inferior border of zygomatic arch (anterior 2/3)

Deep part: deep/inferior surface of zygomatic arch (posterior 1/3)

Underside of the frontalis and into the dermis at the junction between the middle and lateral thirds of the eyebrow

Skin of orbital region, lateral palpebral raphe, superior and inferior tarsal plates

Lateral surface of ramus and angle of the mandible

Glabellar frown lines Eyelid ptosis

Brow lift/lateral canthal lines

• Eyelid ptosis

• Diplopia

• Infection can cause lagophthalmos in the upper eyelid and ectropion in the lower eyelid

Excessive gingival display (gummy smile)

• Asymmetrical facial expressions

• Difficulty opening mouth

Mentalis Incisive fossa of mandible Mentolabial sulcus Chin dimpling/ preventing downturned mouth corners

Levator labii superioris Zygomatic process of maxilla, maxillary process of zygomatic bone

Levator labii superioris alaeque Nasi

Frontal process of maxilla

Blends with muscles of upper lip Excessive gingival display (gummy smile)

Skin of ala of nose and upper lip Excessive gingival display (gummy smile)

Frontalis Galea aponeurotica Orbicularis oculi and corrugators (laterally) and procerus muscle (medially)

Platysma Skin/fascia of infra- and supraclavicular regions

Temporalis Temporal fossa (up to inferior temporal line), temporal fascia

Lower border of mandible, skin of buccal/cheek region, lower lip, modiolus, orbicularis oris muscle

Apex and medial surface of coronoid process of mandible

Horizontal forehead wrinkles

Prominent vertical bands/ horizontal neck lines

• Speaking difficulties (depressor labii inferioris)

• Lip asymmetry (orbicularis oris)

Infraorbital nerve damage and facial vessels

Infraorbital nerve damage and facial vessels

• Brow ptosis

• Undesirable eyebrow shape, ‘Mephisto sign’

Temporary dysphagia

Migraines Hourglass deformity (hollowness of the temples)

Table 1: Different muscles and the insertion point for botulinum toxin7

Appreciation of anatomy

To treat facial muscles using botulinum toxin, one must have a firm understanding of the anatomy. This will in turn produce satisfactory and predictable results, and more importantly, prevent inflicting unnecessary complications, which will be explored in this article.

Complications

With use of the correct technique and dosing, botulinum toxin is well tolerated.6,8 Most side effects are transient and consistent with injection: they are often mild in nature and self-limiting. The most common side effect is headaches, occurring in 5.38% of patients, which is due to the toxin initially causing muscle spasm before reaching paralysis.6,8 Most headaches are mild and resolve within days.9 The issue of headaches in the cosmetic use of botulinum toxin is not considered a significant one, as was demonstrated in a particular study that reported the incidence of headaches after Botox treatment for upper face wrinkles was not significantly higher than the placebo group.9 Other adverse effects are akin to injection side effects, such as mild bruising (0.54%), localised pain (0.13%), erythema (0.06%), oedema (0.036%), mild nausea and transient numbness of the treatment area.6,10,11 Other complications can occur, but for the basis of this article, we have focused on anatomy and how understanding this will enable the prevention of complications. Site-specific complications can arise due to inadvertent targeting (or occasionally product diffusion) into nearby structures. This further emphasises the importance of having an awareness of the anatomy of the face to avoid such issues. These complications are explored in further detail below and summarised in Table 1

Glabellar

The glabellar complex is made up of the procerus, corrugator supercilii, depressor supercilii and orbicularis oculi muscles, as well as frontalis fibres.6 The main complications of injecting into the glabellar complex at an incorrect depth, dose or volume are brow and eyelid ptosis. Brow ptosis usually occurs if the glabellar complex injections are targeted inappropriately superior to the corrugator muscles, weakening the frontalis.6 This issue may also occur if injections targeting the frontalis are placed excessively low. For some patients, the resting position of the brows is supported by a contracting frontalis muscle.6 These patients may be at particular risk of developing brow ptosis following treatment with botulinum toxin.6

Upper eyelid ptosis (blepharoptosis2) has an incidence of 1-5%.12,13 This may occur due to migration of the botulinum toxin from the injection point at the corrugator supercilii to the levator palpebrae muscles. One anatomical study shows that a supraorbital foramen may be present in some patients and constitutes a shortcut from the brow area directly into the orbital roof, following the supraorbital neurovascular pedicle.13 This anatomic variation can also alter the propensity for developing blepharoptosis.13

This complication can be reduced by ensuring injections to the tail of corrugator supercilii are administered superficially, at least 1cm above the supraorbital ridge and medial to the mid-pupillary line.13,14 Compliance with post-treatment instructions such as avoidance of manipulation of the area, active contraction of the treated muscles and remaining in an upright position four hours post-treatment may also mitigate the risk of blepharoptosis.13,14 Caution should be exercised with those who already have levator palpebrae weakness, and this should be carefully documented in the consent form.13,14 Botulinum toxin induced blepharoptosis is usually temporary and resolves without treatment within several weeks.13,14 Excessive ptosis, however, can be treated using alpha-adrenergic eye drops.13,14

Orbicularis oculi

Diplopia (double vision) is a rare complication that may occur when injection into the orbicularis oculi leads to migration of the toxin into the inferior oblique or lateral rectus.15 Recovery without treatment occurs within three to four months, but it can be managed with eye patches or application of Fresnel membrane prisms to eyeglasses.16 Maintaining the distance between the needle and the trochlea and avoiding deep penetration into the orbital septum reduces the extent of diffusion.16

Masseter

The masseter is frequently injected to treat masseteric hypertrophy due to teeth grinding and/or to create a slimmer lower face shape.16 Knowledge in the anatomy of the masseter and its borders is vital in minimising diffusion into the zygomaticus complex or risorius. Injections should be aimed at the masseter bulk, posterior to the anterior border and inferior to the cheilion-tragus line.16 Asymmetrical facial expressions can also occur if dosing isn’t adjusted to account for any discrepancies in muscle bulks bilaterally or any unilateral preference to chewing.16 Injecting too anteriorly can result in the risorius muscle being temporarily paralysed, causing an asymmetrical smile.16 Muscular bulging can also occur when superficial masseter muscle fibres compensate for the weakened deeper fibres.16 Less common complications include iatrogenic paralysis of lateral pterygoid muscles, resulting in decreased ability to open the mouth, or parotid gland, which is associated with xerostomia.17,18

Mentalis

The mentalis can be injected to treat dimpling of the skin over the chin, and often, the depressor anguli oris accompanying the mentalis can be injected to prevent downturned mouth corners. Incorrect injection into the mentalis can result in the toxin diffusing into depressor labii inferioris and orbicularis oris, causing speaking difficulties and incompetent lip or facial asymmetry, respectively.19,20

Frontalis

The frontalis is a large fan-shaped muscle that has right and left halves which can contract independently to move the brow in a vertical, lateral and angular direction; it is the vertical movements of the brow

Most side effects are transient and consistent with injection: they are often mild in nature and self-limiting

that result in targeted forehead wrinkles.14 It is important to understand the topographical extent of the frontalis to ensure both lateral and medial muscle fibres are sufficiently paralysed; failure to do so can result in ‘Mephisto’ eyebrow. ‘Mephisto’, ‘Spock’ or ‘Joker’ brow is characterised by a lateral upwards curvature, resulting in the distal part of the eyebrow being in a superior position compared to the medial counterpart.5 This occurs because of an imbalance between the paralysed central fibres and lateral fibres of the frontalis, and can be corrected by injecting the lateral region further.6,8 Common complications include eyebrow ptosis (0.98%) and eyelid ptosis (0.71%), which can be avoided by injecting 2-3cm above the supraorbital ridge.6

Platysma

The platysma is a flat muscle located in the anterior neck between the deep and superficial cervical neck fascia, and is a popular target for facial rejuvenation and the eponymous ‘Nefertiti neck lift’. A cited complication of botulinum toxin injection into the platysma is dysphagia (5.2%).21 The dysphagia is mild in nature and self-limiting, usually resolving within three and a half weeks.21 Good injection technique (at the correct dose, depth anatomically and the correct volumes) can prevent inadvertent diffusion to impact the muscles of deglutition responsible for swallowing.21

Levator labii superioris

Excessive gingival display, known as ‘gummy smile’, can be due to hyperactivity of the upper lip elevators; primarily levator labii superioris alaeque nasi (LLSAN), but also levator labii superioris (LLS) and the zygomaticus muscles. Effective doses of neuromodulator to these muscles can result in reduced gingival show and aesthetic dropping of the lip line.22 The infraorbital nerve plexus and facial vessels run deep and lateral to the injection sites, respectively, and can be damaged during treatment.22

Temporalis

The temporalis is commonly injected to treat migraines rather than for cosmetic reasons. Complications are rare and the only cited complication in the literature is hollowing at the temples creating an ‘hourglass deformity’.23 This disuse atrophy was a consistent side effect in one study that was observed in all 92 patients, to varying degrees, and complete recovery of muscle mass was demonstrated by all subjects.23

Understand your anatomy

The most common complications of toxin injection include headache, bruising and site discomfort. The most common anatomical complications are eyelid ptosis and brow ptosis, and the risk of both can be minimised if attention is paid to anatomical boundaries. Site-specific complications are less common but hold equal importance, as they are often preventable if adequate precautions are taken. As with any procedure, toxin injections can have complications, but these are mostly transient, well tolerated and manageable. Knowledge of anatomy is essential in preventing complications. Research is constantly undertaken to identify new neuromodulators. Undertaking anatomy lectures is essential prior to injecting botulinum toxin.

Miss Priyanka Chadha is a plastic surgery registrar and co-founder of Acquisition Aesthetics. She is an advanced trainer in aesthetic injections both nationally and internationally. She is currently the principal investigator for a nationwide clinical trial evaluating the applications of neuromodulators in the UK and is a global key opinion leader for Galderma.

Qual: MBBS(Lond), BSc(Hons), DPMSA(Lond), MRCS(Eng), MSc(Lond)

Miss Lara Watson is a registrar in maxillofacial surgery in Oxford, co-founder of Acquisition Aesthetics and key opinion leader for Galderma. As a member of the Royal College of Surgeons and with a background in head and neck surgery, Miss Watson’s extensive understanding of facial anatomy enables her to deliver the highest standards of teaching in the principles of safe practice in facial aesthetics.

Qual: BM, BMedSci, BSc, MRCS(Eng), BDS(Hons)

Miss Shonnelly Novintan is a junior doctor and has graduated from Imperial College London. Having sat her membership exams in her first year, she is a surgeon aspiring to specialise in plastic surgery.

Qual: MBBS, BSc, MRCS(Eng)

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

Possible answers

Questions

1. Which form of botulinum toxin is licensed for cosmetic use?

2. What is the most common complication of botulinum toxin injections?

3. Mephisto sign is most commonly caused by injection to which muscle?

4. How can brow ptosis be prevented?

a. A

b. B

c. C1

d. D

a. Bruising

b. Ecchymosis

c. Headache

d. Oedema

a. Platysma

b. Frontalis

c. Masseter

d. Glabella complex

a. Injection 1cm medial to the supraorbital ridge

b. Injection 1cm lateral to the midpupillary line

c. Injection 1cm above the supraorbital ridge

d. Injection 1cm above the brow line

5. Injection of botulinum toxin into which muscle causes temporary dysphagia?

a. Platysma

b. Frontalis

c. Temporalis

d. Masseter

Answers: A,C,B,C,A

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

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Alluzience, 200 Speywood units/ml, solution for injection - Prescribing Information (United Kingdom)

Presentation: Each vial contains 125 Speywood units of Clostridium botulinum toxin type A haemagglutinin complex in 0.625 ml of solution.

Indications: Alluzience is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines (vertical lines between the eyebrows) seen at maximum frown in adult patients under 65 years, when the severity of these lines has an important psychological impact on the patient.

Dosage: Botulinum toxin product units differ depending on the medicinal products. Botulinum toxin units are not interchangeable from one product to another. Doses recommended in Speywood units are different from other botulinum toxin preparations.

Paediatric Population: The safety and efficacy of Alluzience in children aged up to 18 years have not been established. The use of Alluzience is not recommended in patients under 18 years. Method of administration: Alluzience should only be administered by a healthcare practitioner with appropriate qualifications and expertise in this treatment and having the required equipment, in accordance with national guidelines. A vial of Alluzience should only be used to treat a single patient, during a single session. Remove any make-up and disinfect the skin with a local antiseptic before administration. The intramuscular injections should be performed using a sterile needle with a suitable gauge. Dosing and treatment intervals depend on assessment of the individual patient’s response. The median time to onset as reported subjectively by patients was 3 days (the majority of patients reported an effect within 2 to 3 days with some patients reporting an effect within 24 hours). An effect has been demonstrated for up to 6 months after injection. The treatment interval should be no more frequent than every 3 months.

Administration instructions: The recommended dose is 0.25 ml of solution (50 Speywood units) divided into 5 injection sites, 0.05 ml of solution (10 Speywood units) administered intramuscularly into each of the 5 sites: 2 injections into each corrugator muscle and one into the procerus muscle, near the nasofrontal angle. The anatomical landmarks can be more readily identified if palpated and observed at patient maximum frown. Before injection, place the thumb or index finger firmly below the orbital rim in order to prevent extravasation below the orbital rim. The needle bevel should be pointed upward and medially during the injection. In order to reduce the risk of ptosis, avoid injections near the levator palpebrae superioris muscle, particularly in patients with larger brow-depressor complexes (depressor supercilii). Injections should be made into the central part of the corrugator muscle, at least 1 cm above the orbital rim. General information: In the event of treatment failure or diminished effect following repeat injections, alternative treatment methods should be employed. In case of treatment failure after the first treatment session, the following approaches may be considered:

• Analysis of the causes of failure, e.g. incorrect muscles injected, inappropriate injection technique, and formation of toxin-neutralising antibodies

• Re-evaluation of the relevance of treatment with botulinum toxin A.

Contraindications: Hypersensitivity to the active substance or to any of the excipients. Presence of infection at the proposed injection sites. Presence of myasthenia gravis, Eaton Lambert Syndrome or amyotrophic lateral sclerosis.

Precautions and Warnings: Care should be taken to ensure that Alluzience is not injected into a blood vessel. Injection of Alluzience is not recommended in patients with a history of dysphagia and aspiration. Adverse reactions possibly related to the spread of toxin effect distant from the site of administration have been reported very rarely with botulinum toxin. Swallowing and breathing difficulties are serious and can result in death. Very rare cases of death, occasionally in the context of dysphagia, pneumopathy (including but not limited to dyspnoea, respiratory failure, respiratory arrest) and/or in patients with significant asthenia have been reported following treatment with botulinum toxin A or B. Patients should be advised to seek immediate medical care if swallowing, speech or respiratory difficulties arise. Alluzience should be used with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission. These patients may have an increased sensitivity to agents such as botulinum toxin, and excessive muscle weakness may follow treatment. It is essential to study the patient’s facial anatomy prior to administering Alluzience. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to this anatomy, as a result of previous surgical interventions, should be taken into consideration. Dry eyes have been reported with use of Alluzience in periocular regions. Attention to this side effect is important since dry eyes may predispose to corneal disorders. Protective drops, ointment, closure of the eye by patching or other means may be required to prevent corneal disorders. The recommended dose and frequency of administration for Alluzience must not be exceeded. Patients treated with the recommended dose may experience exaggerated muscle weakness. Caution should be taken when Alluzience is used in the presence of inflammation at the proposed injection sites or when the targeted muscle(s) show excessive weakness or atrophy. As with all intramuscular injections, use of Alluzience is not recommended in patients who have a prolonged bleeding time. Each vial of Alluzience must be used for a single patient treatment during a single session. Any excess of unused product must be disposed of and specific precautions must be taken for the inactivation and disposal of any unused solution.

Antibody formation: Injections at more frequent intervals or at higher doses may increase the risk of neutralising antibody formation to botulinum toxin. Clinically, the formation of neutralising antibodies may reduce the effectiveness of subsequent treatment.

Traceability: In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.

Sodium content: This medicine contains less than 1 mmol sodium (23 mg) per 125U vial, that is to say essentially ‘sodium-free’.

Interactions: Concomitant treatment with Alluzience and aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) should only be used with caution since the effect of botulinum toxin may be potentiated. No interaction studies have been performed.

Pregnancy, Breastfeeding and Fertility: Pregnancy: There are only limited data from the use of botulinum toxin type A in pregnant women. Animals studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity. As a precautionary measure Alluzience should not be used during pregnancy. Breastfeeding: It is unknown if Alluzience is excreted in human milk. Alluzience should not be used during breast-feeding. Fertility: There are no clinical data examining the effect of Alluzience on fertility. There is no evidence of direct effect of Alluzience on fertility in animal studies.

Effects on ability to drive and use machines: Alluzience has a minor or moderate influence on the ability to drive and use machines. There is a potential risk of localised muscle weakness or visual disturbances linked with the use of this medicinal product which may temporarily impair the ability to drive or operate machinery.

Undesirable Effects: A majority of adverse reactions reported with Alluzience in clinical trials were of mild to moderate intensity and reversible. The most frequently reported adverse reactions were headache and injection site reactions. The incidence of adverse reactions tended to decrease with repeated treatments. Adverse effects related to the spread of toxin effect distant from the site of administration have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcomes in some cases). Adverse Drug Reactions Observed in Clinical Studies were as follows:

Very common (≥ 1/10): Headache, injection site reactions (periorbital haematoma, haematoma, bruising, pain, paraesthesia erythema, swelling, pruritus, oedema*, rash*, irritation*, discomfort*, stinging*), asthenia*, fatigue*, influenza-like illness*; common (≥ 1/100 to < 1/10): Facial paresis*, eyelid ptosis, eyelid oedema, brow ptosis, dry eye, lacrimation increased, asthenopia*, muscle twitching (twitching of muscles around the eye)*; uncommon (≥ 1/1,000 to <1/100): Dizziness*, eyelid twitching, visual impairment*, vision blurred*, diplopia*, hypersensitivity (eye allergy, hypersensitivity, rash), rash*, pruritus*; rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder*, urticaria*

*additional adverse drug reactions only observed with powder formulation of the same active substance in clinical trials

Prescribers should consult the summary of product characteristics for further details.

Packaging Quantities and Cost: Pack containing x2 vials: £ 160.00 excluding VAT.

MA Number: PL 03070/0009

Legal Category: POM

Further information is available from:

Galderma (UK) Ltd, Evergreen House North, Grafton Place, London, NW1 2DX. Telephone: +44 (0)300 3035674

Date of Revision: September 2022

Adverse events should be reported. United Kingdom

Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Galderma (UK) Ltd:

E-mail: medinfo.uk@galderma.com Tel: +44 (0)300 3035674

*Alluzience is a liquid formulation with no need to reconstitute. 1 † Results from two randomised, controlled trials (n=250, placebo n=122). 23% of patients noticed an onset of effect within 24 hours. At 6 months, 24% of patients had a ≥ 1 grade improvement from baseline by Investigator Live Assessment vs. 4% for placebo (p<0.0001). At one month, patients treated with Alluzience showed improvement in score for each FACE-Q scale vs. placebo (nominal p<0.0001). 2

Reference: 1. Alluzience SmPC 2022. 2. Hilton S, et al. Dermatol Surg. 2022;48(11):1198-202.

THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONALS ONLY • THIS ADVERTISEMENT HAS BEEN CREATED AND FUNDED BY GALDERMA.

The beginning of this Prescribing Information is on the previous page

Case Study: Transgender Feminisation Treatment

The term ‘transgender and gender diverse’ (TGD) refers to individuals with gender identities or expressions that differ from the gender socially attributed to the sex assigned to them at birth.1 According to a recent health-system based study, the reported proportion of TGD individuals ranges from 0.02% to 0.1% of the global population.1 Within the literature, there is overwhelming evidence that gender-affirming facial interventions such as surgery and minimally invasive procedures (like injectables and facial hair removal) significantly improve the quality of life and psychosocial wellbeing of TGD individuals.2

Affirming identities

Facial feminisation is a medically necessary clinical intervention for many transgender women, as it not only supports their transition socially, but can also alleviate the psychological distress and dysphoria associated with gender incongruence.3 As a medical professional providing care to TGD individuals, it is imperative to have a sound anatomical understanding of the facial features associated with gender incongruence. Inherently, the female face is distinctly different to the male face, primarily related to the effects of the sex hormones on the underlying facial skeleton and overlying soft tissues. The masculine face is more angular, with a prominent forehead/browbone and chin/ jawline, M-shaped hairline with potential temporal recession, flatter low-set eyebrows, longer and broader noses, flatter malar eminences, thinner lips with longer nose-upper lip distance, prominent laryngeal cartilage, coarser more sebaceous skin and differences in the distribution of facial hair and fat.4,5 Transgender women may be taking feminising hormones (oestrogen and/or a testosterone blocker) to support their medical transition. Oestrogen hormone treatment in transwomen induces a softening of the skin, reduction in skin oiliness and facial hair distribution, as well as an increase in cheek fat within three to six months.1,6 Fortunately, given the

considerable developments in non-surgical aesthetic techniques, facial feminisation is no longer only achievable surgically. There is not a ‘one size fits all’ approach for patients wishing to feminise the appearance of their face, and gender-affirming facial interventions are tailored to the individual’s unique transition journey. In my surgical practice, injectable treatments such as botulinum toxin and dermal fillers play an important role in the surgical transition journey of our TGD patients. Additionally, some patients opt solely for non-surgical facial feminisation with injectables for a variety of reasons, including reduced associated risks, non-permanency and lower financial burden. It is acknowledged that there has been increased visibility for trans people, coupled with marked advances in the care of TGD individuals in recent years. Medical professionals are now able to offer TGD individuals a comprehensive variety of gender affirming procedures. This case study highlights the complementary nature of surgery (performed by another practitioner) and injectable treatments in providing transgender feminisation.

Patient presentation

A 59-year-old Caucasian transgender female presented to clinic seeking gender affirming facial feminisation to alleviate the dysphoria associated with her large ‘masculine’ nose, high frontal hairline and prominent Adam’s apple, in addition to her jowls which she felt were prematurely ageing her. She was fit and well and had no reported mental health issues. She had been receiving gender affirming feminising hormone treatment (oestrogen gel) for four years prior to consultation. Additionally, she was also taking finasteride to prevent scalp hair loss. She had no known drug allergies, was a non-smoker and infrequently drank alcohol. Clinical examination findings revealed a markedly high frontal hairline with low set brows and marked lateral hooding, a masculine nose with moderate dorsal hump,

ptotic tip and markedly deviated septum (from previous nasal trauma in adolescence). An elongated upper lip with minimal vermillion show, moderate jowls with skin laxity and notable wrinkles in the upper face, particularly in the periorbital region, and a moderately prominent Adam’s apple can also be seen (Figure 1).

The patient expressed her desire for a ‘natural’ feminisation, not only to ease the burden of the highlighted masculinising features, but also to address ageing soft tissues. As part of the pre-operative work-up, relevant imaging and bloods were requested, in addition to a formal referral letter from a Health and Care Professions Council (HCPC) registered mental health professional. The definitive treatment was planned as staged procedures, with secondary facial rejuvenation being performed eight weeks after surgical intervention (Figure 2) as detailed below.

Stage one – facial feminisation surgery (FFS)

1. Hairline/scalp advancement

2. Brow lift

3. Feminising septorhinoplasty

4. Upper lip lift

5. Lower face lift

6. Thyroid cartilage reduction, otherwise known as chondrolaryngoplasty

Stage two – non-surgical facial rejuvenation

1. Botulinum toxin type A (using Bocouture from Merz Aesthetics) to address the dynamic wrinkles in the upper part of the face (targeted orbicularis oculi muscle), maintain brow position (targeted corrugator and procerus muscles) and improve chin aesthetics (targeted mentalis muscle hyperactivity to accentuate projection and contour)

2. Hyaluronic acid (HA) dermal fillers (using Ultra Deep, RHA 4 and RHA Kiss from Teoxane) in the malar region to improve cheek contour and projection, in the lips/ perioral region to add volume/structural support and in the chin to create a more heart-shaped lower face

3. Regular at home daily skincare routine (using SkinCeuticals) to address the effects of long-term sun exposure and improve textural skin changes

Post-treatment care

Routine aftercare was performed and regular follow-ups were scheduled for the patient at 10 days, three weeks, six months and

Miss Natasha Berridge presents a case combining both surgical and non-surgical techniques to address a transgender female patient’s gender dysphoria

one year post-operatively. The patient had an acceptable degree of post-operative surgical oedema that responded well to a cooling therapy device (Hilotherm). Aside from the expected temporary neurosensory impairment of the small areas of the scalp and forehead (typically lasts up to 12-18 months), there were no other reported associated risks. Only one session was needed for the injectable treatments, and the patient did not report any complications associated with these minimally-invasive procedures. The patient had an uneventful post-operative course and was delighted with the aesthetic outcome of her combined chosen surgical and non-surgical treatments (Figure 3). Furthermore, the process of facial feminisation has undoubtedly significantly improved the patients’ self-confidence, thereby positively impacting upon her psychosocial functioning.

A unique approach

Not every transgender female wants or needs facial feminisation as part of their transition. For those who wish to feminise their face, it is imperative that practitioners manage their expectations for what is achievable. Practitioners and patients need to work closely during consultations to facilitate an individualised approach to facial feminisation. During the informed consent process, I ensure my patients are aware of the comprehensive range of surgical and non-surgical options available. It is important to highlight that a TGD individual’s decision to accept a treatment option will not only be determined by need/ preference, but also by the phase of their transition. For example, the growth of primary sexual characteristics such as the forehead/ brow bone, nose, chin/jawline and thyroid

cartilage will not be medically reversed by taking feminising hormones. These masculine features are typically modified with facial feminisation surgery, or if deemed to be mild, can be camouflaged with dermal fillers. Exogenous hormonal influence can lead to changes in male secondary sexual characteristics such as frontal/temporal hairline, distribution of facial hair and fat and skin quality. I typically recommend patients undergo a minimum of six months of feminising hormones before surgical options are discussed to modify these hormonally influenced features.

Minimally-invasive treatments play an important role in my clinical practice for facial feminisation. Botulinum toxin can be used to feminise the brow complex, periorbital, perioral and lower facial regions. The feminising effects of neurotoxin in these areas will lift the brow complex, widen the eyes, soften rhytids (thereby impacting the textural appearance of the skin), improve vermillion lip eversion and create a softer, heart-shaped lower face. Specifically, the latter effect is achieved via a combination of neurotoxin injected into the masseter muscles to induce atrophy and/or mentalis muscle if hyperactivity is evident. Additionally, HA dermal fillers can be used to feminise the forehead, nose, malar and chin regions. The feminising effects of filler will soften a prominent supraorbital ridge, acute frontonasal transition and nasolabial angle, enhance prominence of the cheekbones and create a more pointed chin. In general, larger amounts of these injectables are needed to feminise a transgender female compared to a cis-gender female of the same age, due to greater underlying muscle mass and bone structure in those individuals assigned male at birth.7 Moreover, common feminising effects of

oestrogen on the skin include a reduction in oiliness and facial hair growth, increased epidermal thickness and melanocyte activity.8 Such effects may make transgender women’s skin more prone to dryness and itchiness.8 It is therefore important to encourage transgender patients to follow a daily skincare regime to maintain good skin health. We should not underestimate the powerful impact of skin quality in optimising the outcomes of surgical and/or non-surgical treatments, as well as gender perception.

Holistic care

Although there are no specific guidelines for the exact timing of facial feminisation, practitioners must remain mindful that the provision of such treatment will support maleto-female TGD patients in their social, medical and psychological care.

Miss Natasha Berridge is a London-based consultant oral, maxillofacial and aesthetic surgeon who is dually qualified in medicine and dentistry. She is an honorary senior clinical lecturer on the University of Manchester’s Aesthetic Medicine Masters’ programme, specialist advisor for the PMFA Journal and co-leads the non-promotional Aesthetic Medicine Fundamentals Workshop by Galderma. Qual: BSc (Hons), BDS (Hons.), BM (Hons.), MFDS (Eng.), MRCS (Eng.), MSc (Aesthetic Medicine & Skin Ageing), FRCS (OMFS)

Figure 3: Two weeks after non-surgical facial rejuvenation with botulinum toxin to the corrugator, procerus, frontalis, orbicularis oculi and mentalis muscles, and HA-based dermal filler injected to augment the malar regions, lips and chin

Figure 1: 59-year-old Caucasian transgender female presenting with gender dysphoria associated with masculine hairline, nose, long thin upper lip and dislike of jowls. Image courtesy of Mr Christopher Inglefield, London Transgender Clinic.

Figure 2: Post-operative image, taken six months after FFS which involved hairline advancement, brow lift, feminising septorhinoplasty, upper lip lift, lower face lift and thyroid cartilage shave. Image courtesy of Mr Christopher Inglefield, London Transgender Clinic.

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Choosing Skincare for Skin of Colour

According to a 2022 survey report with 3,500 participants, ‘multi-ethnic consumers’ spend £230 million on health and beauty products – 25% more than any other consumer.¹ The same report reveals that despite these figures, nearly four in 10 black female shoppers state it’s not easy to find cosmetics and skincare suitable for their skin type.1 These statistics are compounded by another survey conducted in 2020 that revealed 92% of black women said it was a challenge to find a skincare professional who could meet their needs and that 90% of respondents said the experience and knowledge of treating skin of colour (SOC) was the primary reason they chose a particular clinician.2 This data goes some way in highlighting the necessity and importance of robust and effective skincare science education when conducting skin consultations for patients with SOC, defined specifically as skin types IV to VI on the Fitzpatrick scale. The current Fitzpatrick scale denotes six different skin types ranging from very fair (skin type I) to very dark skin (skin type VI) and is predominantly influenced by genetic disposition and reaction to sun exposure.3

Aesthetic practitioners should have a proficient understanding of the differences in anatomy between skin types, and the most common skin conditions to be aware of when treating SOC. It’s also important to consider what ingredients work best to ensure the most effective results for the patient, whilst reducing product and financial wastage that fits within the patient’s personal budget.

Understanding skin anatomy and physiology

Acknowledging and understanding the anatomical and physiological differences between skin types when consulting SOC patients is essential, as these differences can lead to indications presenting differently between skin types.

The pigment of the skin is widely recognised as the most visibly notable difference between skin types.4,5 Skin colour is partially determined melanin, which is made by cells called melanocytes which make up approximately 8% of the epidermal cells and can be found in the stratum basal layer of the skin.6 The number of melanocytes are the same regardless of race.6 Differences in skin colour are determined by the quantity of melanin produced, the size of the melanin and the degree to which they aggregate.6 Pigmentation also relates to the most abundant cells of the epidermis, keratinocytes – the largest recipients of melanin.7 Different types of melanin contribute to the determination of the skin’s colour. Eumelanin (dark brown to black) is produced in individuals with skin types IV-VI and pheomelanin (red to yellow) in individuals with skin types I-III.8

In addition, other differences between skin types to be observed include, but are not limited to:

• The stratum corneum: black skin has more corneocyte layers and a more compact stratum corneum with greater intercellular cohesiveness compared to white skin, for example.9

• Lipid content: plays a significant role in barrier function and differs in lipid content as a type VI epidermis is somewhat higher than type I, for example.10

• Skin pH: darker skin types are slightly more acidic (4.5-5.0) than lighter (5.0-5.5).11

• Ceramide levels: black skin has 50% lower ceramides than white or Hispanic skin, whilst Asian skin has the highest ceramide levels.12

• Transepidermal water loss (TEWL): evidence suggests that TEWL is higher in individuals of SOC, particularly in skin types V and VI.13

Skin conditions in SOC

Dermatologic disorders that present most commonly in skin types V and VI include acne, post-inflammatory hyperpigmentation (PIH) and scarring.

Acne vulgaris

Affecting an estimated 650 million people worldwide,14 acne is a multifactorial disorder of the dermis. Hyperkeratinisation and sebum accumulation causes the microcomedo wall to rupture, resulting in an inflammatory effect.15

Although acne can present on all skin types, it can be particularly challenging to manage in SOC due to sequela conditions such as PIH and keloidal and hypertrophic scarring. There are differing opinions as to whether sebum production in SOC affects an individual’s propensity to developing acne,15 however, all factors should be considered as part of the skin consultation process.

Post-inflammatory hyperpigmentation

PIH results from an overproduction of melanin or abnormal melanin deposition in the epidermis or dermis following inflammation.16 A sequela of acne can affect any skin type but tends to affect individuals with skin types IV, V and VI with greater frequency and severity, where it can present as dark brown patches or a grey-blue discolouration.16

When PIH occurs in the epidermis, the production and transfer of melanin to surrounding keratinocytes increases.17 PIH in the dermis results from inflammation-induced damage to basal keratinocyte which releases large amounts of melanin.17 Treatment should be started early to help hasten its resolution and begin with management of the initial inflammatory condition. A combination of corrective topical depigmenting agents and preventative broad-spectrum sun protection should be used.17 Topical tyrosinase inhibitors such as azelaic acid, kojic acid, arbutin, hydroquinone and liquorice extract can all effectively lighten areas of PIH.17 Retinoids, mequinol, ascorbic acid, niacinamide, N-acetyl glucosamine, soy, glutathione and tranexamic acid can also be effective.17 The individual benefits of some of these ingredients are discussed later in this article.

Scarring

A normal part of dermal healing and another sequela of acne is scarring, and occurs as the result of trauma and

Skincare formulator Cigdem Kemal Yilmaz discusses the considerations for carrying out skincare consultations for individuals with skin of colour

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associated inflammation to the dermis. Vulnerability to some types of scarring such as keloid scarring is increased for individuals with Fitzpatrick skin types IV, V and VI.18 It is thought that this relates to melanin production and melanocyte activity, but only a few studies have addressed this association according to some reports.19,20 Hypertrophic and keloid scars are common, and it is not completely understood why an individual develops one over the other. Topical modalities are used often as an adjunctive to treatments and although they cannot always completely remove the scar (particularly in the case of keloid scars), they can help to manage the appearance.20

Skincare ingredients

There are several ingredients that can be beneficial to SOC, and some of the most used are listed below. However, prior to prescribing any topical treatment, it’s essential to conduct a thorough consultation that establishes the bespoke needs and skin type of the patient.

Retinaldehyde

Retinaldehyde (retinal) is synthetically produced from β-carotene. However, it can also be directly oxidised from retinol. Retinal can be reversibly reduced to produce retinol or it can be irreversibly oxidised to produce retinoic acid.21

Retinoids such as retinal reduce pigmentation on the skin and contribute to a proper distribution of melanin in the skin.21 Topically applied retinoids also influence the function of melanocytes, providing regular arrangement of melanin in the epidermis. They also block the transport of melanin to epidermal cells and reduce the activity of stimulated melanocytes.21

Azelaic acid

Azelaic acid is a dicarboxylic acid with anti-inflammatory and antioxidant properties that is found to be effective in reducing acne, melasma and hyperpigmentation.22,23 Specifically, it reduces the thickness of the stratum corneum, shrinks keratohyalin granules by reducing the amount and distribution of filaggrin (a component of keratohyalin) in the epidermal layers, and lowers the number of keratohyalin granules. Keratohyalin is a protein structure found in cytoplasmic granules of the keratinocytes in the stratum granulosum (granular later) of the epidermis.22,23

Mandelic acid

Mandelic acid is an alpha hydroxy acid (AHA) that is a larger molecule than glycolic acid and lactic acid, making it better tolerated on the skin with a slow epidermal penetration.24 It is a gentle exfoliant that decreases corneocyte adhesion, which aids in desquamation of the upper layers of the stratum corneum. Mandelic acid is advantageous in that it possesses antibacterial properties, whereas glycolic and lactic acids do not.25

Aside from acne treatment, mandelic acid is often used for skin rejuvenation and lightening of areas of pigmentation. Based on this, dermatologists now suggest mandelic acid as an appropriate treatment for a wide variety of skin pathologies, from acne to wrinkles; it is especially good in the treatment of adult acne because it addresses both of these concerns.24,25 Mandelic acid is suited for those with sensitive skin and who may be sensitive to beta hydroxy acid. Mandelic acid is also recommended as a pre-laser and post-laser resurfacing treatment, reducing the amount and length of irritation.24,25

Niacinamide

An active form of vitamin B3, niacinamide is advantageous when treating SOC because it ends in the improved synthesis of proteins and keratin, stimulation of ceramide construction, and expedition of the differentiation of keratinocytes. These constituents provide a stabilising impact on epidermal barrier function and an enhancement in the moisture content of the horny layer.26 Topical niacinamide has noted anti-inflammatory attributes.28 Niacinamide has been proved to hinder histamine release and contain the lymphocyte transformation test. Additionally, niacinamide has been shown to repress cytokine-mediated induction of nitric oxide synthase in various cells, resulting in lowered inflammation.27 This makes it a particularly effective ingredient when treating acne.17,28,29 Additionally, both in-vivo and in-vitro, niacinamide consistently diminished melanin content or pigmentation. Moreover, niacinamide reduced the melanosome transfer from melanocytes to keratinocytes.17,28,29

Vitamin C

Vitamin C’s use as a treatment modality for hyperpigmentation is well documented.30 Tetrahexyldecyl ascorbate (THD ascorbate) is a fat-soluble vitamin C that works well for SOC, as it has a very low irritability potential.30

It is highly stable, compatible with most skin types, and is non-irritating. THD ascorbate also aids in enhanced skin penetration.30 Magnesium ascorbyl phosphate (MAP) is a mineral form of vitamin C that helps with acne scarring and skin tone. It is the most stable derivative of vitamin C with hydrating and soothing properties.30 It pairs well with niacinamide in comparison to azelaic acid which has a nullifying effect. It is suitable for high-risk skin types III to VI that are prone to PIH.31

Sodium ascorbyl phosphate is a mineral form of vitamin C that is growing in popularity. It is particularly well-suited for acne-prone skin as it converts to azelaic acid when in the skin (in-vivo) and has lower irritancy, making it more suitable for sensitive skin types and SOC.32

Choosing the right ingredients

The consultation process is essential in treating SOC effectively, and practitioners should ensure they are fully aware of how topical ingredients can be used to treat different indications. Robust skincare education and advanced ingredient knowledge encourages integrity and ensures that any information given to patients is factually sound, clinically proven and scientifically based. It also offers practitioners a greater depth of understanding of the product formula, and the ability to match the product ingredient list to the function, quality and effectiveness of the product.

Qual: MEng Hons, AMIChemE VIEW

WWW.AESTHETICSJOURNAL.COM

Cigdem Kemal Yilmaz is a chemical engineer, skincare formulator and founder of Skin Masterclass. She runs a CPD-certified skincare education and licensing platform for career-driven skin professionals looking to upskill their skincare knowledge and scale their business.

The Winners

On March 11, the ‘Oscars of Aesthetics’ returned with a bang! With more than 980 guests, The Aesthetics Awards 2023 was the biggest event in its 10-year history. Our brand-new venue, Grosvenor House, showcased the glitz and the glam with endless photo opportunities, aerial silk performers and a mouth-watering three-course dinner. Shortly after, the highly-anticipated Awards ceremony kicked off, celebrating the amazing achievements of our 270 Finalists and unveiling who was awarded, Commended, Highly Commended and Winner.

Thank you to all our 80+ judges, who are listed on the Aesthetics Awards website, for carefully assessing each entry in their assigned categories, ensuring their scores and feedback were both fair and balanced, as well as to our voters for their fantastic feedback. Special thanks must also go to our sponsors as their support enabled us to deliver such a spectacular event! A huge congratulations to all Winners, as well as those who received Commendations and High Commendations. We had a vast number of entries this year, so to be a Finalist is an achievement in itself. You should all be proud of everything you’ve achieved and contributed to the specialty this year!

THE AWARD FOR OUTSTANDING ACHIEVEMENT IN MEDICAL AESTHETICS

WINNER: DR TAPAN PATEL

“I can honestly say that I am lost for words! The Aesthetics Awards have given me an honour which I can’t even describe, I am on cloud nine. This Award is one of the proud accolades I can really reflect on, if not the proudest, and it’s something that money can’t buy! I dedicate this Award to the ‘unsung hero’; we get the easy job of being in the limelight and getting to shine, but we couldn’t do what we do without the support we have, from company reps to staff. They may not get the glory, but they make us who we are and I want to dedicate this Award to them.”

Dr Tapan Patel

Entrance sponsor Stationary sponsor Afterparty sponsor

SUPPLIER TRAINING PROVIDER OF THE YEAR

WINNER: LYNTON

“It is an honour to win this Award. We are so passionate about training at Lynton so to have this Award is great! It’s really amazing to have the recognition that you are doing things right and that we are supporting our clients and customers so it’s been lovely!”

Dr Samantha Hills, clinical director

Highly Commended: HA-Derma Ltd

Commended: Teoxane UK Ltd

Finalists:

• SkinPen® Precision Microneedling Masterclass

• VIVACY Laboratories

• Wigmore Medical

THE HYDRAFACIAL AWARD FOR BEST NEW CLINIC, UK & IRELAND

WINNER: BEECHWOOD HOUSE HEALTHCARE

“It is amazing to win, I can’t believe it! It is such an honour. Out of all the amazing clinics which were Finalists, to be the Winner just feels fab. Even for us, you can feel like the underdog in a big industry, but actually everyone can do it – this is only the beginning!”

Telisha Jenkinson, clinic owner

Highly Commended: The Clinic by Dr Maryam Zamani

Commended: Taktouk Clinic

Finalists:

• Dr A Aesthetics Clinic

• Dr Kane Aesthetics Co.

• House of Saab

• Natali Kelly Clinic

• The Courtyard Aesthetic Clinic

• The Clinic Holland Park

THE JOHN BANNON PHARMACY AWARD FOR BEST CLINIC IRELAND AND NORTHERN IRELAND

WINNER: ARRAY AESTHETICS

“It feels really good to win. To echo Dr Tapan Patel’s words, it is so little about us and more about the other people – our team around us – who do so much for us and we are so thankful. There are a lot of Awards ceremonies out there, but when you look at the entry process for The Aesthetics Awards, there is a genuine objective as to who wins and who doesn’t and that is what has attracted us to enter.”

Dr Chris Hutton, clinic owner

Highly Commended: Elite Aesthetic Clinic Ltd

Commended: Dr Bonny Clinic

Finalists:

• Belfast Skin Clinic

• Eden Medical Clinic

• FaceTherapyNI

THE SKINCEUTICALS AWARD FOR ENERGY DEVICE OF THE YEAR

WINNER: STELLAR M22™ (LUMENIS BE UK LTD)

“We feel so privileged to have won this Award! This Awards ceremony means everything to this industry so to be recognised among peers means a lot. The show has been incredible, the production has been amazing and we are super proud to be represented in this way by the Awards.”

Andrew Greenwell, UK country manager

Highly Commended: Secret PRO (Cutera)

Commended: GentleMax Pro Plus (Candela)

Finalists:

• Alma Hybrid (Alma Lasers)

• BYONIK® Pulse Triggered Laser (Pure Swiss Aesthetics Ltd)

• CRISTAL Pro® (Deleo)

• Emerald™ Laser (Erchonia Lasers Ltd)

• LaseMD ULTRA™ (Lutronic UK)

• Potenza (Cynosure UK)

• SkinPen® Precision (Crown Aesthetics)

• Sofwave™ (Sofwave Medical Ltd)

• Thermage FLX (Solta Medical)

• XCellarisPRO Twist (mi.to.pharm UK Ltd)

• ORA Skin Clinic

• The Laser and Skin Clinic

THE GETHARLEY AWARD FOR BEST CLINIC NORTH ENGLAND

WINNER: DR YUSRA CLINIC

“It feels unbelievable to have won. I’m over the moon and so grateful to the Aesthetics team for putting the ceremony together and to my team. The Aesthetics Awards are like the ‘Oscars’ of the aesthetics specialty, so it is an honour to be in a room where everyone celebrates excellence and is striving to be the best they can be for their patients, so it means a lot and I’m so grateful. Thank you!”

Dr Yusra Al-Mukhtar, clinic owner

Highly Commended: Dr Sobia Medispa

Commended: MySkyn Clinic Ltd

Finalists:

• Aesthetically You

• Bank MediSpa

• Freyja Medical

• KP Aesthetics

• Laser Clinics UK, Manchester

• Paragon Aesthetics

• Skyn Doctor

• The Wynyard Clinic

• VL Aesthetics

• Yorkshire Skin Centre

DISTRIBUTOR OF THE YEAR

WINNER: HEALTHXCHANGE GROUP

“It feels fantastic to have won the Award for Distributor of the Year. It is our sixth time winning, but we didn’t expect at all to win. We love the team at Aesthetics for putting together the Awards; they have done so much for the industry, from being cosmetic to solely cosmetic/medical which is so important to the doctors, dentists and nurses as well as the companies involved.”

Dr John Curran, founder and chairman

Highly Commended: HA-Derma Ltd

Commended: AestheticSource

Finalists:

• Church Pharmacy

• Cosmeditech Innovations Ltd

• Harpar Grace International

• Sculpt Pro Aesthetics

• Wigmore Medical

THE HAMILTON FRASER AWARD FOR BEST CLINIC SOUTH ENGLAND

WINNER: FACIAL AESTHETICS LTD

“I’m blown away to be a Winner of this Award. This Award is for my team, I feel so happy because they are happy and it’s a collective – I’m taking this home for the patients! It’s about what you put out in this industry and what you get back. It’s the people in this specialty and what we give to one another. Just to have this recognition is so special – I can’t even describe it!”

Julie Scott, clinic owner

Highly Commended: Health & Aesthetics

Commended: Atelier Clinic

Finalists:

• Azthetics

• Cosmex Clinic

• Elite Aesthetics Ltd

• Escape Aesthetics

• Koha Skin Clinic

• L1P Aesthetics

• Perfect Skin Solutions

• Radiance Aesthetic Clinic

• Revitalise Skincare Clinic

• Romsey Medical Practice

• Vie Aesthetics

THE ACE AWARD FOR BEST MANUFACTURER OF THE YEAR

WINNER: VIVACY LABORATORIES

“It is so amazing to have won this Award. We have done so much and worked so hard over the last four years since we launched into the UK market, which is very competitive, so we are delighted! We are proud of the whole team and our clients too!”

Terina Denny, national sales manager

Highly Commended: Teoxane UK Ltd

Commended: Lumenis Be UK Ltd

Finalists:

• Boley Nutraceuticals Ltd

• Bottled Science Ltd

• Candela

• Crown Aesthetics

• Lynton

• Prollenium Medical Technologies®

THE MACOM MEDICAL AWARD FOR BEST SURGICAL RESULT

WINNER: MR SOTIRIOS FOUTSIZOGLOU

“I feel extremely honoured to have won the Aesthetics Award for Best Surgical Result. I am very thankful to the panel for choosing me as the Winner among equally experienced and respected surgeons. I would like to dedicate my win to my mum who has terminal cancer. She has always been there for me, and to my specialty, plastic surgery, the love and passion for which have taken me to faraway places around the world to watch and learn from the best.”

Mr Sotirios Foutsizoglou, plastic surgeon

Highly Commended: Miss Elizabeth Hawkes

Commended: Mr Daniel Ezra and Mr Jonathan Roos

Finalists:

• Mr Duncan Atherton

• Dr Furqan Raja

• Miss Sujatha Tadiparthi

• Mr Tunc Tiryaki

• Dr Maryam Zamani

THE HEALTHXCHANGE AWARD FOR BEST NON-SURGICAL RESULT

WINNER: DR MANAV BAWA

“I am shocked to have won this Award at the Aesthetics Awards 2023 – I did not expect it. Thank you so much to the Aesthetics team and the judges, as well as my wonderful patient who featured in the entry. It feels great that some of my expert colleagues have judged me and have awarded me this Award. It feels so humbling.”

Dr Manav Bawa, aesthetic practitioner

Highly Commended: Dr Zainab Al-Mukhtar

Commended: Dr Tanja Phillips and Dr Rekha Tailor

Finalists:

• Dr Yusra Al-Mukhtar

• Dr Nina Bal

• Dr Rehanna Beckhurst

• Dr Harriett Cant

• Sarah Donaldson

• Dr Anna Hemming

• Dr Andrew Kane

• Dr Varna Kugan

• Lynn Lowery

• Dr Ana Mansouri

• Dr Megan McCann

• Dr Emily Stanworth

• Dr Jasmin Taher

• Dr Joshua Van der Aa

THE MAP-IQ AWARD FOR BEST CLINIC MIDLANDS AND WALES

WINNER: MEDIZEN CLINIC

“Receiving this Award is a huge honour for both me and my team. We are incredibly proud to have been recognised for our contribution to the industry as well as our recent growth and achievements. We look forward to continuing to be at the forefront of the aesthetics specialty over the years to come.”

Dr David Eccleston, clinic owner

Highly Commended: Air Aesthetics & Wellness Clinic

Finalists:

• Dr CP Aesthetics

• Dr Sharon’s Facial Aesthetics

• Freyja Medical

Commended: Secret Aesthetics

• Kat & Co

• Laser Clinics UK, Birmingham Grand Central

• Pure Perfection

TOPICAL SKIN PRODUCT/RANGE OF THE YEAR

WINNER: OBAGI MEDICAL (HEALTHXCHANGE GROUP)

“We are thrilled to have won this very prestigious Award. We are honoured, humbled and so excited for Obagi’s future. I can’t believe we have won two Awards – a double whammy! Winning the Awards is a mark of success in many ways and vindicates

Highly Commended: skinbetter science® (AestheticSource)

Finalists:

• Heliocare 360 (AesthetiCare)

• iS Clinical Cosmeceuticals (Harpar Grace International)

• Prep & Enhance Collections (AlumierMD)

• Profhilo® Haenkenium® (HA-Derma Ltd)

• Pro Restore (Dermalogica PRO)

all the work you have done over the years and you feel very privileged to be at The Aesthetics Awards.”

Laura Higgins, head of sales

Commended: PCA Skin (Church Pharmacy)

• Revision Skincare® (AestheticSource)

• SkinCeuticals AOX Authority (L’Oreal)

• VIVACY Beauty (VIVACY Laboratories)

• ZO Skin Health (Wigmore Medical)

THE LUMENIS AWARD FOR BEST CLINIC LONDON

WINNER: LONDON AESTHETIC MEDICINE

“We are absolutely thrilled! This is our second year winning this Award in a row; we are so grateful and congratulations to everyone in the community too. It feels phenomenal to win Awards but it’s also about bringing everybody together and being part of a community. It’s been wonderful – 980 people together – so congratulations to the Aesthetics team.”

Dr Uliana Gout, clinic owner

Highly Commended: Cadogan Clinic Commended: PICO London

Finalists:

• 111 Harley St.

• Adonia Medical Clinic

• Cosmetic Surgery Partners

• Harley Street Injectables

• Laser Clinics UK, Brent Cross

• London Professional Aesthetics

• Skinfluencer

• Simply Clinics

• Thames Skin Clinic

• The MediShed by Dr Dil

THE FILLMED AWARD FOR BEST CLINIC SCOTLAND

WINNER: FTT SKIN CLINICS

“I’m really, really pleased and so happy to have won The FILLMED Award for Best Clinic Scotland. I haven’t entered for an Award in a while – and I won it! The Aesthetics Awards are the ‘Oscars’ of the industry; there is nothing above this so I’m so thrilled!”

Frances Turner Traill, clinic owner

Highly Commended: Clinetix

Commended: Dermal Clinic Ltd

Finalists:

• Alpha Clinic

• Est-Ethics Clinic

• Laser Clinics UK, Glasgow

• Platinum Medi Cosmetic Clinic

THE SILKANN CANNULA AWARD FOR INJECTABLE PRODUCT OF THE YEAR

WINNER: TEOSYAL RHA (TEOXANE UK LTD)

“The whole team stand behind this product 100%. We are super proud of what it can do; we know it’s different and everybody loves it, so it’s great to receive the recognition! I think The Aesthetics Awards have been

the most credible Awards provider for the last decade in this industry. We come along every year and will keep on attending.”

Jordan Sheals, deputy country manager

Highly Commended: Restylane Lyft (Galderma) Commended: Revanesse Contour™ (Prollenium Medical Technologies®)

Finalists:

• Profhilo® Body (HA-Derma Ltd)

• Sunekos® (Medfx)

THE CROMA PHARMA AWARD FOR BEST CLINIC TEAM OF THE YEAR

WINNER: ELITE AESTHETIC CLINIC

“It’s amazing to win this Award and receive recognition from such a prestigious Awards ceremony. My team are my brand ambassadors; we are a family rather than just work colleagues and we support each other. Behind every successful woman, there is a tribe of people supporting me and who have my back all the time.”

Emma Heaney, clinic owner

Highly Commended: Dr Sobia Medispa Commended: Trikwan Aesthetics

Finalists:

• Atelier Clinic

• Cosmetic Surgery Partners

• Freyja Medical

• Health & Aesthetics

• Laser Clinics UK, Richmond

• Look Lovely London

• Natali Kelly Clinic

• Radiance Aesthetic Clinic

• Skinfluencer

• Taktouk Clinic

• The Clinic Holland Park

• VL Aesthetics

• Younique Aesthetics Clinic

BEST CLINIC SUPPORT PARTNER/PRODUCT OF THE YEAR

WINNER: SOPHIE ATTWOOD COMMUNICATIONS LTD

“It feels incredible to have won this Award! It is a big responsibility telling all of the stories from such an incredible industry, so it’s not something we take lightly, and it’s just lovely to be recognised! This industry is very much about safety, innovation and excellence, and The Aesthetics Awards represents all of this.”

Sophie Attwood, manager and director

Highly Commended: Aesthetic Nurse Software

Commended: DermaFocus

Finalists:

• InDesk

• T Chauhan Consultancy Ltd

• The Clinic Builders

COMPANY REPRESENTATIVE OF THE YEAR

WINNER: JULIE HOPE (ALUMIERMD)

“I’m in shock at winning this Award as there were such strong people in this category, so I completely didn’t expect this! Being rewarded, not only the Winners, but all the Finalists of our hard work, which can often go unnoticed, so it’s really nice to have this recognition, even if you don’t win. It’s lovely to be surrounded by your colleagues in the industry, so I think it’s fabulous!”

Julie Hope, account manager

Highly Commended: Daniel Cohen (Bottled Science Ltd)

Commended: Chloee Alesbury (VIVACY Laboratories)

Finalists:

• Katie Bennett (Prollenium Medical Technologies®)

• Amy Cameron (L’Oreal)

• Elaine Krebs (Galderma)

• Grainne Miskelly (BF Mulholland and Med-fx)

• Kerry Stewart (AestheticSource)

• Sue Thomson (SJ Partnership)

• Kelly Tobin (Artemis)

PROFESSIONAL INITIATIVE OF THE YEAR

WINNER: BLACK SKIN DIRECTORY

“Winning feels amazing! It’s been a very hard year trying to get this particular initiative off the ground, so it’s very special to be recognised for the amount of work that’s gone into it. The Aesthetics Awards, for me, have always been the pinnacle. I always describe them as the ‘Rolls-Royce’ of the industry, so why wouldn’t you want to be associated with The Aesthetics Awards.”

Dija Ayodele, founder

Highly Commended: Aesthetics United Charity Conference

Commended: Human Health by The Clinic™

Finalists:

• IBSA Derma Me as a Masterpiece Campaign

• Integrated Practitioners of Aesthetic Wellness

• In the Consulting Room by S-Thetics Clinic

THE CCR AWARD FOR BEST INDEPENDENT TRAINING PROVIDER OF THE YEAR

WINNER: COSMETIC COURSES

“It feels absolutely amazing to have won Best Independent Training Provider of the Year. It is always lovely to be recognised for your hard work and it’s an excellent event which brings the community together celebrates everyone’s achievement.”

Dr Olya Vorodyukhina, clinical lead

Highly Commended: Interface Aesthetics

Commended: Clinical Point of Care Ultrasound in Aesthetics (Dalvi Humzah Aesthetic Training) and MAP-IQ

Finalists:

• Acquisition Aesthetics

• Athena Medical Aesthetic Training Ltd

• Inspired Cosmetic Training

• JCCP Fast Track Assessment and PgCert (Learna Limited)

• Skin Masterclass PRO (CHIDEM Ltd)

• Younique Aesthetics Academy

THE DIGITRX BY CHURCH PHARMACY AWARD FOR PRODUCT INNOVATION OF THE YEAR

WINNER: HARMONYCA™ LIDOCAINE (ALLERGAN AESTHETICS)

“It feels fantastic and we are very proud to have won this Award. A lot of work has gone into this from the team and the launch. This is just the beginning, people haven’t really seen the full launch we are preparing for in 2023. This is amazing, so thank you very much!”

Djamshid Ghavami, general manager

Highly Commended: Topilase® (Prollenium Medical Technologies®)

Commended: Letybo® (Croma Pharma UK)

Finalists:

• Alluzience (Galderma)

• Biretix Tri-Active Gel (AesthetiCare)

• Cyspera Intensive System™ (AestheticSource)

• GlycoAla (Medical Aesthetic Group)

• GF5 Bio-Regenerative Growth Factor Serum (CellDerma)

• Revision Skincare Revox™ Line Relaxer (AestheticSource)

THE ALUMIERMD AWARD FOR RISING STAR OF THE YEAR

WINNER: MR JAMES OLDING

“It feels great and super unexpected to have won the Rising Star Award. The fact that mentorship and training, something that I live and breathe, were recognised is amazing! This is a great pat on the back, it doesn’t change who you are or what you’ve done, but it’s really nice to have that recognition so I’m feeling great right now!”

Mr James Olding, maxillofacial surgery registrar

Highly Commended: Dr Raquel Amado and Dr Jemma Gewargis

Commended: Dr Amrita Bhogal

Finalists:

• Dr Chloe Aucott

• Dr Dorota Chudek

• Dr Ahmed El Muntasar

• Dr Hannah Higgins

• Rebecca Hopkinson

• Dr Andrew Kane

• Dr Goziem Onuchukwu

• Jill Smith

• Dr Arreni Somasegaran

• Dr Rachel Tunney

• Dr Natasha Verma

• Sean White

THE AESTHETICSOURCE AWARD FOR NURSE PRACTITIONER OF THE YEAR

WINNER: MELANIE RECCHIA

“I’m shocked and flabbergasted about winning but it is fantastic! I feel like I’ve won this for lots of other nurses who do a fantastic job as well. Having been in the industry for quite some time, I’m really chuffed. The Aesthetics Awards are a great opportunity to celebrate everything, bring everyone together and highlight what a brilliant business we are in.”

Melanie Recchia, nurse prescriber

Highly Commended: Anna Kremerov and Michelle McLean

Commended: Susan Young

Finalists:

• Amy Bird

• Sara Cheeney

• Alice Henshaw

• Natali Kelly

• Tanya Khan

• Áine Larkin

THE SKINADEMD SURGICAL PROGRAMME AWARD FOR BEST CONSULTANT SURGEON OF THE YEAR

WINNER: MR JEFF DOWNIE

“It feels awesome to have won this Award; it was unexpected but I’m very pleased, thank you! I’ve been doing some interesting cases this year and thought I would give it a go at entering. The Aesthetics Awards brings together all sorts of specialities and backgrounds together in one room and we are here for education, the development of our practices and the patients.”

Mr Jeff Downie, consultant oral and maxillofacial surgeon

Highly Commended: Miss Rachna Murthy

Commended: Miss Sujatha Tadiparthi

Finalists:

• Mr Sotirios Foutsizoglou

• Mr Lorenzo Garagnani

• Miss Elizabeth Hawkes

• Dr Maryam Zamani

• Lynn Lowery

• Christina Param-Phillips

• Khatra Paterson

• Lisa Waring

• Jan Whiteford

THE DERMALOGICA PRO AWARD FOR MEDICAL AESTHETIC PRACTITIONER OF THE YEAR

WINNER: DR SOPHIE SHOTTER

“I literally don’t know whether to laugh or cry – I am completely overwhelmed by all of the support as I couldn’t have done this alone. I never rest on my laurels and whilst this Award is amazing, I think there is so much we can do in the UK to raise standards and work collaboratively. I want to work with others who are trying to do things right and raise standards and hopefully see many more people coming up through the ranks and winning this Award in years to come.”

Dr Sophie Shotter, aesthetic practitioner

Highly Commended: Dr Uliana Gout Commended: Dr Yusra Al-Mukhtar and Dr Shirin Lakhani

Finalists:

• Dr Rehanna Beckhurst

• Dr Ahmed El Houssieny

• Dr Ifeoma Ejikeme

• Dr Mayoni Gooneratne

• Dr Anna Hemming

• Dr Steven Land

• Dr Brian McCleary

• Dr Aileen McPhillips

• Dr Dev Patel

• Dr Emma Ravichandran

• Dr Eleanor Reid

• Dr Souphi Samizadeh

• Dr Sobia Syed

• Dr Preema Vig

See you next year!

We thoroughly enjoyed celebrating with you all this year, and congratulations to all our Winners, High Commendations, Commendations and Finalists! Don’t forget to tag us on Instagram @aestheticsjournaluk in the photos of you and your team, and remember that entry opens for The Aesthetics Awards 2024 in September, so keep your eyes peeled for more details soon!

The Aesthetics Awards will return on March 16, 2024.

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Assessing Skincare During Pregnancy

More than 90% of women develop skin abnormalities and changes during pregnancy which can potentially have a huge impact on their life.1 These skin changes can be very distressing for women, so it is important that as practitioners we are able to offer safe and effective treatment plans. This article explores how we can achieve this with appropriate skincare. Women experience many physiological changes during pregnancy, including hormonal increases (such as oestrogen, progesterone, prolactin, b-HCG), a shift in blood flow to account for the developing foetus, a change in immune response and also changes to the metabolism of proteins, lipids and carbohydrates.2 As these physiological alterations occur, skin abnormalities may develop as a consequence, including pigmentation issues and acne. These disorders are attributed mainly to the rise in oestrogen and progesterone, making them most prevalent in the second and third trimester as the placenta develops.2

Hyperpigmentation

Pigmentation issues, particularly melasma, are the most common skin complaints during pregnancy, affecting approximately 50-70% of patients.3 It can often be referred to as the ‘mask of pregnancy’. Melasma is derived as oestrogen and progesterone stimulate the melanocytes to produce more melanin pigments when exposed to UV light.4 It starts from the first trimester of pregnancy and may continue throughout.

Melasma is generally a clinical diagnosis consisting of symmetric reticulated hypermelanosis in three predominant facial patterns: centrofacial, malar and mandibular. The major clinical pattern in 50-80% of cases is the centrofacial pattern, which affects the forehead, nose and upper lip. The malar pattern is restricted to the malar region of the cheeks on the face, whilst mandibular melasma is present on the jawline and chin.4

The first line of management for melasma is to avoid direct sunlight where possible and wearing daily SPF 30+. This is demonstrated by a study performed by Lakhdar et al. who found that from 200 pregnant patients who wore SPF 50+ and UVA protection factor, only 2.7% of these developed melasma during pregnancy.5

The most suitable sunscreen is a physical sunscreen as this is not absorbed through the skin and is less irritating (especially as the skin can become more sensitive during pregnancy). These work by forming a protective layer, often made up of titanium dioxide and zinc oxide molecules, on the skin which reflects and scatters UV radiation. There has been some controversy around the use of chemical sunscreens in pregnancy due to their use of the organic compound benzophenone-3 (BP-3). It was suggested that BP-3 could penetrate the blood-placenta barrier and induce toxicity and abnormal development of the foetus.6 Yet, even at higher doses they do not penetrate the skin barrier and can therefore be considered safe.7

Hydroquinone

The gold standard treatment for hyperpigmentation is hydroquinone with tretinoin and steroids (triple therapy). It exerts its effect by inhibiting tyrosinase, the rate-limiting enzyme in melanin synthesis. Hydroquinone also affects the membranous structures of melanocytes and causes their apoptosis. Yet, research has shown that 35-45% is systemically absorbed following topical use in humans, and within a few minutes, levels are measurable in urine.8,9

When applied topically throughout pregnancy to 68 women in a study by Mahe et al. there were no adverse outcomes from its use during pregnancy when compared to the control sample.10 Yet, given that this was such a small sample size, and the fact its systemic absorption is so high, its use is absolutely contraindicated in pregnancy. Studies are limited in this area due to the risks associated with testing treatments during pregnancy, and the ethical implications limits further work which would need to be done in this area to come to an absolute conclusion.

Alternatives

During pregnancy it is advised that alternatives such as vitamin C be used.11,12,13 Vitamin C inhibits melanogenesis by acting as a reducing agent at various oxidative steps in melanin synthesis. Additionally, niacinamide can be used in conjunction with vitamin C. This is the active amide of vitamin B3 that reduces pigmentation by inhibiting the transfer of melanosomes to keratinocytes.11

There are also alpha-hydroxy acids (AHAs) such as glycolic, lactic and mandelic to improve the treatment of skin pigmentation. At low concentrations they

Dr Emma Goulding and Dr Amiee Vyas discuss the safe and effective use of skincare during pregnancy

reduce the cohesion of the corneal extract corneocytes and stimulate the proliferation of cells in the epidermis.14,15

Acne

Acne is most common during the first and second trimesters of pregnancy, affecting up to 42% of patients.16 An increase in progesterone levels causes glands to grow and produce more sebum, which results in an accumulation of cellular debris and hyperkeratosis. This promotes microbial proliferation and inflammatory processes which cause acne breakouts.15

Standard topical treatment for acne usually includes retinoids, antibacterial agents, benzoyl peroxide and salicylic acid, but this needs to be adjusted during pregnancy.18

Topical retinoids/vitamin A

Systemic retinoid medications are an absolute contraindication during pregnancy due to their known teratogenic qualities. There have been four published reports of birth defects associated with topical tretinoin use, consistent with retinoid embryopathy.19-22 These studies reported ear, eye and central nervous system malformations of the individual patients.23 Additional risks were thought to include miscarriage and premature delivery, yet research has proven this to be insignificant.24 Further meta-analysis to rule out any risk of the use of both oral and topical retinoids across 654 pregnant women has been suggested to be statistically safe, yet this is still not enough to justify use throughout pregnancy.24

Alternatives

Benzoyl peroxide has strong keratolytic, comedolytic and antibacterial properties.23 Approximately 5% is absorbed systemically, and it is completely metabolised into benzoic acid. Because of rapid renal clearance, no systemic toxicity is expected, and the risk of con-genital malformations is theoretically small.23

Azelaic acid exerts broad antimicrobial effects via an unknown mechanism and has a well-documented safety profile during pregnancy due to only 4% of the drug being absorbed after topical application.25 Research has also shown nil adverse effect on foetuses and newborn animals, even when administered in high doses during pregnancy.26 Azelaic acid is a naturally occurring dicarboxylic acid with antimicrobial, comedolytic and mild anti-inflammatory properties, with an added benefit of decreasing post-inflammatory hyperpigmentation.27 Therefore this is an ideal multi-tasking ingredient that can be used for a number of skin conditions during pregnancy. Both beta hydroxy acids (BHAs) and AHAs are frequently used for acne treatment.18 These acids promote cell shedding on the surface of the skin and help to restore hydration. Salicylic acid is a popular BHA for acne treatment and the situation for topical use and potential toxicity in pregnancy is minimal.8 This contrasts with therapeutic doses of oral salicylates, which due to their antiprostaglandin properties cause reduced birth weight, increased blood loss at delivery and increased perinatal mortality.28 Mandelic acid is a safe and effective AHA which is used for both acne and melasma and is also highly suited to skin of colour patients.29 Another point to consider is the rising use of prebiotics to treat acne.30 These pregnancy-safe ingredients are an alternative to those who wish to treat acne without the use of acids or retinol. Noni stem cells are able to prevent the growth of acne-causing bacteria, whilst allowing the beneficial flora to thrive.31 Bioflavonoids imitate the effect of retinoic acid on the skin, without the common side effects of retinol such as drying and irritation.31

Striae gravidarum

Striae gravidarum (stretch marks) develop in approximately 90% of pregnant women and can cause significant emotional and

phycological distress.32 They form as the dermis becomes stretched and broken in places. Reliable methods to prevent their formation are scarce, and current techniques such as applying cocoa oil or olive oil has been proven to be ineffective.32

Instead, it is recommended to maintain a healthy diet and lifestyle throughout pregnancy as per NHS guidance to help to minimise excessive weight gain, and therefore theoretically reduce the risk of striae gravidarum formation.33

Keeping patients safe

Although there are some clear contraindications for active ingredients during pregnancy, we can still formulate beneficial plans focusing on barrier building and reducing inflammation to help our pregnant patients manage their skin conditions effectively during pregnancy and aid their overall wellbeing during this special time. In addition, it is important to give specific advice to patients regarding the amount and application of products to be sure they remain well within safe limits.

Dr Emma Goulding works in both the NHS and in private practice as an aesthetic practitioner in the North West. She practises a holistic approach to aesthetic medicine, to achieve the most effective and natural results.

Qual: MbCHb, BSc, Hons

Dr Amiee Vyas is an experienced aesthetic practitioner with a special interest in skin. An advocate for patient education, Dr Vyas features as an expert regularly on TV, is a diverse skin specialist, a key opinion leader in cosmetic dermatology and the founder of the Ultimate Aesthetics Mentorship Programme for medical aesthetic practitioners.

Qual: MBBS, BSc

niacinamide, azelaic acid

Table 1: Ingredients to avoid in skincare during pregnancy8-31

Case Study: Treating Retrogenia with Fillers

Dr Mariam Al-Ani shares how she treated a skeletal class two retrogenia with dermal filler

The chin is one of the defining focal features of the face. Retrogenia, also known as a weak or recessed chin, poses an aesthetic problem as it disturbs the balance and harmony of the face. It is the mandible which provides structure to the chin and determines its position. Retrogenia presents when the mandible is smaller in size (micrognathia) or set too far back (retrognathia).1 This underdevelopment is the most common growth disorder of the facial skeleton in Western Europe and is associated with an angle class two dental malocclusion, a convex profile and mandibular deficiency.2 Mandibular deficiency has many causes, from genetics to embryogenesis. The condition can occur in isolation or in association with congenital malformation syndromes. Depending on its severity, it can require orthodontic or a combination of orthodontic and surgical treatment.3 A recessed chin may be linked to issues such as an open bite or overbite, which can be treated with orthodontics alone.3 However, if the origin is skeletal, a combination approach with surgical and non-surgical interventions may be required.

Ageing of the lower face

In many cases, a receding chin is a natural part of ageing as loss of bone in the lower jaw can reduce the size of the mandible. In the lower face, the mandible undergoes anterior and inferior resorption, which is aggravated by loss of teeth.4 The angle of the mandible increases with age because of resorption in its inferior border, resulting in the chin becoming more anterior and shorter with ageing.3 In addition, there is atrophy of superior and inferior mandibular fat compartments and dehiscence of the mandibular septum, causing the fat pads to move downward to the neck. These changes, together with skin atrophy, result in loss of jawline definition and jowl formation.5

A weak chin is considered unattractive in both men and women. In a female, a strong chin is associated with attractiveness, and for males, contributes to a masculine

appearance.6,7 Several studies reported that certain malocclusions, including skeletal class two, are associated with decreased masticatory efficiency, abnormal speech, pain and decreased social interaction.8-10 Interestingly, people with retrogenia often present with the appearance of a ‘larger’ nose, even though it is within normal dimensions in relation to the entire face.11

A weak chin can present with a retrusive unsupported lower lip and deepened labiomental fold. Therefore, assessing the lip, chin and nose together is essential in balancing the facial profile.10

Case study

A 28-year-old female presented to my clinic wanting to improve her facial appearance as it was affecting her confidence. Her concern was that her chin was ‘too small’ for her face. She also wanted a more defined jawline and to add volume to her lips. The patient had a history of orthodontic treatment with dental extractions as a teenager to correct her class two dental malocclusion. However, this did not address her facial profile as she had an underlying skeletal discrepancy (mandibular retrognathia). She had also undergone a surgical rhinoplasty a few years before to address her nose which she felt was too large.

Assessment

A facial assessment is crucial in the diagnosis of skeletal and soft tissue discrepancies so the appropriate treatment can be advised and performed. The clinician must examine the soft tissue and skeletal profile thoroughly from both the side profile and anterior plane. Assessing the vertical dimensions from an anterior perspective will highlight if we need to add length to the chin. This can be assessed by dividing the patient’s face into thirds, where each third should be similar in length. The upper third extends from the hairline to the glabella, the middle third from the glabella to the base of the nose and the lower third from the base of the nose to the apex of the chin.11

The anteroposterior plane must be assessed

to determine the relationship between the maxilla and mandible. A class one skeletal malocclusion yields a harmonious connection between the maxilla and mandible. A class two suggests overgrowth of the maxilla or insufficient growth of the mandible or a combination of both, and a class three suggests an overgrowth of the mandible or insufficient growth of the maxilla or a combination of both.11 This assessment determines if the patient would benefit from chin projection.11

A soft tissue profile assessment of the lip position in relation to the nose and chin can be achieved using the Ricketts’ E line.12 This is a line between the most anterior point of the soft tissue nose and chin. A straight instrument, like a ruler, can be used to measure. It is suggested that the lower and upper lip should be behind this line by 2mm and 4mm respectively. The ideal position of the chin in the side profile is thought to be one that extends to, or just behind, a vertical plane that drops down from the nasal base, with the lower lip behind the upper lip.12 An assessment of my patient’s side profile revealed an underdeveloped mandible, resulting in a deepened labiomental sulcus, retruded lower lip, recessed chin and a poorly defined jawline and angle of mandible. Mild asymmetry was noted, and her upper lip lacked support in relation to the lower lip. An anterior assessment revealed a mild vertical deficiency in the lower third. The position of the dentition affects the lip profile, and further examination revealed my patient had a class two division two incisor relationship where the upper teeth were retroclined, contributing to the lack of upper lip support.

Following the assessment, I concluded that my patient would benefit from adding projection and length to the chin, softening the labiomental groove and augmenting the lip, focussing on the upper lip in order to enhance its projection and shape.

Treatment options

After a diagnosis is made, all treatment options available, both surgical and non-surgical, should be discussed with the patient during the consultation so an informed decision can be made regarding treatment. Dermal fillers can be used to create the appearance of a normal jaw without the need for surgery. They can reshape the jawline, lift soft tissues and improve facial proportions. The advantages are that it is relatively inexpensive, minimally invasive and carries little recovery time and

risk. It is a suitable option for someone who is considering surgery but would like to see how their face looks before committing.13 Adverse effects of injectables must be communicated to the patient, and include risk of infection or foreign body granulomas, and necrosis through vascular compromise.13

Surgical options include chin implants or orthognathic surgery. Chin implant procedures, known as mentoplasty, use synthetic materials such as silicone to augment the chin. This procedure is suitable for those looking for a permanent result but who do not want to commit to the lengthy treatment times of combined orthodontic treatment and orthognathic surgery.14 This procedure is not suitable for chins that are severely vertically shortened as there are limitations to how much a chin can be lengthened using a gel compared with an implant. Risks include infection, nerve damage, particularly lower lip/chin paraesthesia and the implant moving.14 Orthognathic surgery involves horizontal sliding genioplasty or mandibular and maxillary surgery. Horizontal sliding genioplasty is a preferable alternative, and suitable for severely receded and vertically shortened chins. It involves realignment of the chin bone by cutting and repositioning it using plates and screws.

Surgery may be considered if there is a discrepancy in the maxilla or if a combined orthodontic and orthognathic surgical correction is required. Therefore, maxillary surgery, mandibular surgery or both are viable options. Potential risks include bleeding, bruising, infection, scarring and temporary or permanent paraesthesia of the chin or lower lip. Complications related to surgery include bleeding from injury to the inferior alveolar artery or masseteric artery, unanticipated fractures and unfavourable splits, avascular necrosis, condylar resorption, malposition of the proximal segment and worsening of temporomandibular joint symptoms.15

Treatment and results

Prior to treatment, it is paramount to assess the patient’s clinical and medical history, allergies and use of medication. In this case, my patient was medically fit and had no known allergies, so there were no contraindications for treatment.

The aim of treatment was to achieve ideal facial proportions and soft tissue support of the chin and surrounding structures. My patient did not want to commit to surgery and wanted a quick and minimally invasive option to address her chin, making treatment with fillers the ideal option.

To improve chin projection, I injected Belotero Intense dermal filler onto the periosteum using a 27 gauge 13mm needle and placed in the anterior portion – the pogonion. To augment its length, the same filler was injected inferiorly in the menton area. Approximately 2.4ml was used. A further 0.25ml on each side of the angle of the mandible was injected onto the periosteum using a 27 gauge 13mm needle to help define the jawline. I used this filler because it is firm with a high lifting ability and can maintain its shape without being easily deformed under pressure.

To blend the filler and restore the jawline, I injected Belotero Volume medial to the jowl using a cannula (25 gauge 32mm) where the entry point was lateral to the pre-jowl. The filler was placed in a retrograde fashion in both the submuscular and superficial subcutaneous planes. Approximately 0.3ml was placed on each side. A sandwich technique was adopted to fill the labiomental groove using a 25 gauge 32mm cannula in both the deep and superficial planes. I placed 0.5ml of Belotero Volume directly into the crease. This helped to soften the area and provide support to the retruded lower lip. This product was used because of its high level of plasticity, elasticity and cohesivity, which delivers excellent modelling capability, lifting power

and integration within the tissues. A softer, more dynamic viscoelastic filler was used (Teosyal RHA 2) to sculpt the lips, using 1ml to add volume and projection. A 30 gauge 4mm needle was used to augment the tubercles of the lips (three upper and two lower). This was blended using a 30 gauge 13mm needle in a retrograde manner. The final result (Figure 1) was achieved with Belotero Intense and Volume in the chin and jawline using a needle and blended with a cannula in the anterior jaw, using a total of 4ml. This was carried out over three visits, approximately six months apart. The treatment could have been completed sooner, but the patient wanted to get used to the change gradually.

Consider all facial structures

The facial profile comprises of primarily the nose, lips and chin. It is crucial to address these features together rather than in isolation. When considering lip filler with a recessed chin, we should also consider enhancing the chin as this can emphasise the discrepancy, thereby changing the structure of the lower face. Similarly, if the nose is addressed without considering the chin position, it can appear more dominant than if the chin was placed in the correct position. Whilst surgical options are available, patients have a less invasive and more inexpensive option with non-surgical profile balancing using dermal fillers. This should be considered as part of a holistic treatment plan for patients with retrogenia. As was the case here, treatment can be carried out gradually in order to ensure that the patient is satisfied with the results.

Dr Mariam Al-Ani is the co-founder of Face Studio Clinic, a private dental and facial aesthetic clinic in Birmingham. She is a general dental surgeon and gained her qualification to the Membership of the Faculty of Dental Surgery (MFDS). She went on to complete a post graduate certificate in Aesthetic and Restorative Dentistry. Qual: BDS, MFDS RCSED, PGCert Aesthetic and Restorative Dentistry

Figure 1: 28-year-old patient before and 18 months after dermal filler treatment in the chin, jawline and lips.

A History of the Menopause

The menopause has historically been seen by society as a negative event, thus encouraging the stigma that is associated with it today. Awareness of the menopause can be traced back to ancient Greece, with Aristotle describing the age between which women stopped having menstrual discharge and losing the ability to bear children.1 Other than these early references, it was ignored by science and society until the 18th century, with references being scarce. The reason for this is attributed to the fact that women did not survive long enough for menopause to be a matter for consideration, tending to survive until only 35 due to childbirth.2,3

Only three species of mammals live into their post-reproductive years: humans, and two types of whales.3 An evolutionary reason for menopause has been postulated – the ‘Grandmother Theory’ – where there is an evolutionary advantage to females surviving beyond their ability to bear offspring to aid the survival of future generations. Although popular, it is not accepted by all, with some hypothesising that our increased survival is due to improved lifestyle factors.3

Signs of the menopause

Defined as the permanent cessation of menstruation and reproductive capability, menopause is an inevitable consequence of growing older, and affects nearly every woman. The ovaries stop producing eggs and the levels of sex hormones, oestrogen, progesterone and testosterone fall. These hormones have multi-system effects, and their deficiency leads to a vast range of symptoms.4

Strictly speaking, the menopause is an event that lasts a day. Natural menopause is when there have been no menstrual periods for 12 consecutive months in the absence of any other obvious physiological or pathological causes or clinical interventions.5

The age at which natural menopause occurs is between 45-55 years.5 Premature menopause is defined as occurring before the age of 40. Menopause can also be induced because of surgical procedures that involve the removal of both ovaries or medical interventions that cause cessation of ovarian function (for example, radiation

therapy or chemotherapy).5 Many women may have stopped menstruating before menopause, either due to hysterectomy or endometrial ablation, or medications such as hormonal contraception. These women may experience changes related to the menopausal transition or perimenopause.5

Symptoms of the perimenopause, which can precede the menopause by several years, are vast, and may include hot flushes, night sweats, difficulty sleeping, reduced sex drive, problems with memory and concentration, vaginal dryness and pain, itching or discomfort during sex, headaches, mood changes such as low mood or anxiety, palpitations, joint stiffness, aches and pains, reduced muscle mass, recurrent urinary tract infections, hair loss and weight gain.6 The diagnosis of menopause is usually clinical, however, in women under the age of 45, it is necessary to exclude other diagnoses that cause secondary amenorrhea. Management of the menopause focuses on treating the myriad symptoms of perimenopause and includes lifestyle interventions, supplements and hormone replacement therapy (HRT). However, understanding of the impact of menopause on cardiovascular disease, cognitive dysfunction and depression continues to evolve, and more healthcare practitioners are advocating the use of prevention strategies to maintain the long-term health of women.

Movements of the menopause

During the 16th century, many of the accounts of witch trials described women over 50 showing physical changes that can be attributed to menopause: facial hair, fragile bones, wrinkled skin and thinning hair.1,2 The Age of Enlightenment in the 18th century saw the start of the medicalisation of menopause, and a shift in the attitudes towards menopause and women’s sexual health.1,2 Women were regarded as inherently sinful beings, their minds controlled by their reproductive organs, leading to the evolution of dangerous therapeutic practices including chloroform, belladonna and injecting the vagina with lead.1,2

By the Victorian era, it was a common belief that the link between the womb and the brain

made all women susceptible to insanity.3

Menopausal women were especially demonised. They were believed to suffer from a condition called ‘climacteric insanity’ – the symptoms of which included depression, sleeplessness, restlessness and anxiety.3

Edward Tilt, author of the first full-length book on menopause in English, The Change of Life in Health and Disease, thought that menopause could cause alcoholism or mania, and could even make women murderously violent.7 Women were routinely locked up in asylums, and ideas of the link between their sexual organs and insanity continued, resulting in menopausal women undergoing oophorectomies (ovary removal surgeries) to make them ‘virtuous’ again.3,8,9

The word ‘menopause’ was coined in 1821 by French physician Dr Charles-PierreLouis de Gardanne, and with the discovery of oestrogen in 1929, the landscape for menopause management changed.1 Within a decade, the first commercially available oestrogen replacement drugs were launched.1 Pharmaceutical company Merck introduced a treatment called Ovariin, comprised of cow ovaries blended with a flavoured powder. This was followed by a product called Emminen, which was manufactured with the urine of pregnant women.8 When this proved too costly and time-consuming to manufacture, the cheaper alternative made from pregnant mares’ urine, Premarin, was developed.8

In the early 20th century, the science of endocrinology evolved with the identification of hormones: chemical signals produced in the ovaries and other glands, carried to remote regions of the body through the blood. In 1929, scientists isolated oestrogen, and within a decade, the first oestrogen replacement drugs were available, created with the view that replacing oestrogen could preserve femininity as menopause was seen as a deficiency disease.10

Development of HRT

Menopause has long been associated with becoming old and a feeling of loss of femininity, leaving behind childbearing years, and it has continued to be portrayed as something women should fear. In his 1966 book Feminine Forever, US gynaecologist Dr Robert Wilson described it as a “serious, painful and often crippling disease.”11

Comparing the effects of oestrogen on post-menopausal women to those of insulin for people with diabetes, he promised that HRT would enable women to preserve their youth, vigour, mental acuity and sexual

Dr Shirin Lakhani provides an overview of how knowledge surrounding the menopause and treatments has developed in aesthetic medicine

attractiveness. Wilson’s research, book and speaking tours were funded by Wyeth, the company that made Premarin.11 HRT surged in popularity, and Premarin became the number one prescribed drug in the US.3,8-10 In 1975, there was a hurdle in the popularity of HRT when it became apparent that unopposed oestrogen increased the risk of endometrial cancer, but with the addition of progestin to reduce this risk, HRT surged in popularity.3,8-10

In the early 2000s, the results of two large studies were published by the Women’s Health Initiative (WHI) in the US and the Million Women Study (MWS) in the UK. These raised concerns about the safety of HRT, particularly with regards to breast cancer and heart disease, and caused widespread panic among patients and doctors.3,6,8,9,12

Doctors stopped prescribing HRT and many women abandoned it immediately, causing a return of their menopausal symptoms. The number of women taking HRT fell by 66%, and consequently, there has been almost a whole generation of women who have been denied the opportunity of improved quality of life during their menopausal years.13 Despite the initial findings, the subsequent publication of the full results retracted the previous findings as incorrect, and the studies were shown to be flawed.12,13

The balance of benefit to harm always needs to be assessed but appears to have shifted favourably for HRT. If women start HRT around the time of menopause, the risk is small, but there is only limited data for continued usage beyond the age of 60.15 It is not usually appropriate for women over 60 to start HRT as the risks of stroke, cardiovascular disease and venous thromboembolism begin to overshadow the other benefits, but this does not mean that women who started HRT earlier must stop it on reaching 60.12,14,15 Many women seek advice on the effects of HRT on sexual activity and desire. Oestrogen in HRT can help maintain or return sex drive and could also help other symptoms such as vaginal dryness and pain with intercourse.16-19 If vaginal symptoms are the only problem, then the use of local vaginal oestrogen may be preferable. Testosterone use is often overlooked by the NHS when treating menopause as it is traditionally considered to be a male hormone, however, it is vital to maintain libido, urinary tract health and assertiveness.16-19

Bio-identical hormones (BHRT) are hormone preparations which are identical molecules to those produced by the body. In practice, the term is used for preparations made by

compounding chemists which are claimed to be safer than ‘traditional’ hormones used in HRT. In fact, some traditional HRT preparations are ‘bio-identical’, using oestradiol 17-beta which is the natural human oestrogen, or micronised progesterone capsules which is the natural human progesterone. These are generally referred to as ‘body-identical’ in the UK.16-19 A benefit of compounded BHRT is that the hormones are specifically tailored to the individual, so many of the side effects associated with a one-size-fits-all approach of conventional HRT can be eliminated.16-19

Menopause today

As a society, our perception of women in their 50s and beyond is changing, as are expectations of them. A few decades ago, menopause was regarded as something that occurred towards the end of life. With the population living longer, healthier lives, women can spend one third to a half of their lives in the peri- and post-menopausal period. Women in their 50s are now considered to be in the prime of their lives. It is therefore important to minimise the negative effects of menopause, allowing women to continue to enjoy all aspects of life.14,20

As such, it is encouraging to see menopause taking a front seat in discussions ranging from healthcare provision to media representation, and from workplace policies to politics. However, despite recent progress in how we talk about the menopause, there is still a long way to go. Despite the efforts of campaigns such as the Menopause Revolution and the Menopause Mandate, we have recently seen the rejection of recommendations to make menopause a protected characteristic, plans to introduce mandatory training for GPs on menopause and of proposals to introduce menopause leave in the workplace (as it could be discriminatory to men).21

Despite the Government introducing a single prescription charge in England for HRT from April this year (prescriptions for HRT in Wales, Scotland and Northern Ireland are already free), there is still inequality in HRT access for deprived populations, and nationwide shortages mean that even when women overcome the hurdles of being prescribed HRT, they are unable to get hold of their medication.22

Looking to the future

Awareness of menopause is increasing, and patients are more informed of its impact. As medical practitioners looking after these women in our clinics, it is essential that we are

familiar with menopausal symptoms so we can treat them to the best of our abilities and signpost them to services that could be beneficial.

Even though menopause is a physiological condition and not a disease, it has significant morbidity. Besides the increased risk of osteoporosis and fractures, risk of heart disease can also increase.23 In addition, menopause symptoms are poorly tolerated and can lead to poor quality of life.24 However, it must be remembered that any treatment options provided should be evidence-based and safe.

As the focus of aesthetic medicine moves towards longevity and age management, our understanding of cellular ageing is improving, and knowledge of the effects of hormone depletion is increasing. Menopause provides an opportunity to implement strategies to reduce the risk of cardiometabolic disease, and enable women to live longer and healthier lives.

Changing attitudes

Despite being something which inevitably affects over half the population, menopause has, until recently, been the subject of shame and stigma. The worth of women has historically been measured in terms of their reproductive function and this attitude must change. Menopause is not an end but a new beginning, and if managed effectively, can be a rich and fulfilling time.

Dr Shirin Lakhani is a cosmetic practitioner specialising in advanced aesthetic treatments, intimate health and HRT for men and women. Dr Lakhani appears regularly on television and in the press, as well as contributing to articles and speaking at conferences both in the UK and internationally. She is currently involved with the APPG for menopause.

Qual: MBBS, MRCA, MRCGP, DRCOG

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Restylane offers the world’s most diverse range of individually engineered hyaluronic acid (HA) fillers and skinboosters so you can bring bespoke looks to life.1-3 With more than 55 million treatments worldwide since its launch 26 years ago, Restylane offers a heritage you can trust, as showcased in more than 160 publications and safety data reported from more than 400,000 patients.4,5 Let’s shine the spotlight on the 2023

Aesthetics Award High Commendation for The Silkann Cannula Award for Injectable Product of the Year, Restylane Lyft.

What is Restylane Lyft?

Restylane Lyft is a firm HA gel with the highest G’ prime in the Restylane range, designed to deliver projection and structure without volumisation.3,6 Providing a pronounced effect and desired lifting in the treated areas of the face, Restylane Lyft contains 20mg/ml of HA and 3mg/ml of lidocaine.7-9

Where can I use it?

Restylane Lyft can be used in the cheeks, nose, jawline and chin for sharp and sculpted results without adding volume.10 Patients could expect to see more defined cheeks, sharper jawlines, projected chins and improvements to the nose that enhance the overall profile.

What is the technology?

The Restylane range is made up of two complementary technologies:

• NASHA: Firm gels that provide targeted tissue integration with minimal distribution, providing precise results that resist the forces of facial dynamics.11,12

• OBT: Soft and flexible gels that allow for distributed tissue integration to

Restylane: Your Expertise, Meets Ours

Discover Restylane Lyft to enhance your aesthetic practice

What results can I expect?

35-year-old patient treated with Restylane Lyft:

• Nose: 1ml

• Cheeks: 2ml

• Chin: 1ml

• (Lips also treated with Restylane Kysse)

Restylane Lyft can be purchased from Galderma’s preferred provider, Medfx, who is currently offering 15% off the Restylane portfolio.

achieve contouring and volumisation while maintaining natural dynamic movement.8,13,14

Restylane Lyft is NASHA technology. The NASHA technology aims to deliver precise results, allowing targeted placement due to the firm gel texture, with low distribution and integration into surrounding tissues.11

How long will the results last?

Results with Restylane Lyft can last up to 24 months* – a real plus for patients seeking non-surgical rhinoplasty treatment who often desire a long-lasting result with less downtime vs. surgical rhinoplasty.15

What do patients say?

• 96% of patients said they would have the treatment again17^

• 98% said they would recommend the treatment to a friend17^

• 100% of patients said their results were natural looking at four and eight weeks post-treatment16^^

• 88% of patients felt their results were still improved at 12 months17^

events can be reported via HPRA Pharmacovigilance, www. hpra.ie Adverse events should also be reported to Galderma (UK) Ltd. Email: medinfo.uk@galderma.com Tel: +44 (0)300 3035674

What is the safety profile?

Restylane Lyft has a well-established safety profile which has been shown in more than 20 publications including more than 1,500 patients.18,19 Injection-related reactions (including bruising, erythema, itching, swelling, pain or tenderness at the implant site) might occur after treatment. These reactions consist mainly of mild to moderate inflammatory symptoms that resolve spontaneously within a few days or up to two weeks.**9

This advertorial has been written and supplied by Galderma.

UKI-RES-2300052 DOP March 2023.

REFERENCES 1. Öhrlund Å. J Cosmet Dermatol Sci Applic. 2018; 8(2): 47-54. 2. Data on file MA-34483. 3. Nikolis A et al. Aesthetic J Surg Open Forum. 2020; 2(1): ojaa005. 4. Galderma. Data on File. MA-48087. 5. Galderma. Data on File. MA-39680. 6. Galderma. Data on File. MA-43049. 7. Weiss R et al. Dermatol Surg 2016; 42: 699709. 8. Gregario G et al. Clin Cosmet Investig Dermatol 2022; 15: 681-690. 9. Restylane Lyft Lidocaine IFU 10. Kablik J et al. Dermatol Surg 2009; 35(Suppl 1): 302–312. 11. Data on file MA-33947. 12. Lundgren B et al. J Drugs Dermatol 2018; 17(9): 982-986 13. PhilippDormston WG et al. Dermatol Surg 2018; 44: 826-832. 14. Talarico S et al. Dermatol Surg 2015; 41: 1361-1369. 15. Huang S and Tsai T. J Drugs Dermatol 2020; 19(9): 836-842.16. Nikolis A. AMWC poster 2022 17. Data on File. MA-40091 18. Data on File. MA-43602. 19. Sadeghpour M et al. Dermatol Surg 2019; 45(8): 1085-1094.

*With 1 retreatment ** For full information please consult the product instructions for use. ^ In a study of 100 Asian patients assessing facial aesthetics appearance after treatment with Restylane and Restylane Lyft in the upper cheeks, nasolabial folds, temples, nose and chin. ^^ 30 patients treated with Restylane Lyft and Restylane Volyme in the mid face.

Figure 1: 35-year-old patient treatment with Restylane Lyft

Adverse events should be reported. For the UK, reporting forms and information can be found at www.mhra.gov.uk/yellowcard Or search for MHRA Yellow Card in the Google Play or App Store. For Ireland, suspected adverse

A summary of the latest clinical studies

Title: Microtoxin for Improving Pore Size, Skin Laxity, Sebum Control, and Scars: A Roundtable on Integrating Intradermal Botulinum Toxin Type A Microdoses into Clinical Practice

Authors: Fabi S, et al.

Published: Aesthetic Surgery Journal, March 2023

Keywords: Botulinum Toxin, Fine Lines, Skin Quality

Abstract: In the aesthetic clinical practice, botulinum toxin type A (BoNT-A) is best known for its use as a neuromodulator for the treatment of dynamic facial lines; however, when injected intradermally as microdroplets, BoNT-A can improve skin quality and overall skin appearance. This study discusses key aspects of microtoxin use in clinical practice and provides expert guidance on use. As part of a Continuing Medical Education (CME) lecture series and roundtable, the authors discussed key aspects of microtoxin patient selection, injection technique and safety. The experiences of expert faculty are shared here. Microtoxin can be used to reduce pore size, sebum production, rosacea, acne, and fine lines, and to improve jawline and neck definition. Intradermal injection can also be used for the improvement of transverse neck lines, as well as for the safe prevention and management of scars and keloids. Expanding the use of BoNT-A, a predictable, minimally invasive and affordable treatment to address commonly encountered complaints, is appealing. The authors have found that making patients aware of microtoxin as a treatment option results in more interest, increased use of BoNT-A and high satisfaction among appropriately selected patients.

Title: Multiplanar Breast Augmentation: A Personal Surgical Concept for Dynamic Implant-Tissue Interaction Providing Sustainable Shape Stability

Authors: Mackowski M, et al.

Published: Journal of Craniofacial Surgery, March 2023

Keywords: Breast Augmentation, Multiplanar Procedure, Shape Stability

Abstract: In aesthetic breast augmentation, long-term shape stability and natural appearance remain an ongoing challenge. The authors found that to reduce the incidence of secondary deformity and increase natural feel and appearance, a standard multiplanar procedure combining a subfascial and dual plane approach with fasciotomies will provide long-term stability and aesthetic quality. The technique involves a submuscular dissection and release of the infra-nipple portion of the pectoralis muscle, combined with the wide subfascial release of the breast gland and scoring of the deep plane of the superficial glandular fascia. For long-term stability, a firm fixation of the glandular fascia at the inframammary fold to the deep layer of the abdomino-pectoral fascia is critical. Postoperative measurements proved the intrinsic balance of the breasts without significant changes over time. Shape stability was observed over 10 years in more than 95% of the patients. Unsightly muscular animation could be avoided in almost every patient. Results indicate that a technique of multiplane breast augmentation –combining well-established techniques of a submuscular dual plane, additional shaping through a controlled deep fasciotomy and stable inframammary fold fixation – provides long-term stability and aesthetic quality.

Title: Time and Dose-Dependent Effects of Hyaluronidase on the Degradation of Different Hyaluronan-Based Fillers In Vitro

Authors: Buhren B, et al.

Published: Plastic and Reconstructive Surgery, March 2023

Keywords: Complications, HA Filler, Hyaluronidase

Abstract: Hyaluronidase (HYAL) is regarded as the standard for the management of complications associated with hyaluronan (HA)-based fillers. Therefore, understanding of interactions of HA fillers and HYAL is essential. Nine different commercially available HA fillers (Belotero, Juvéderm and Restylane) with varying degrees of cross-linking were used for the analysis. Fluorescently dyed HA fillers were individually incubated with varying doses of HYAL or sodium chloride and monitored by time-lapse microscopy. HA filler degradation was assessed as a decrease in fluorescence intensity of HA filler plus HYAL compared to HA filler plus control, quantified by computerised image analysis. HA fillers show significant differences in their reaction to HYAL. Levels of degradation of HA fillers are positively correlated with increasing concentrations of HYAL. At the highest concentration of HYAL (20 U/mL), all fillers except one (Belotero Volume) reached a significant level of degradation at five to nine hours. In this study, the authors show that most HA fillers can be dissolved by HYAL in a dose- and timedependent manner. Of note, the fillers’ technology and degree of cross-linking seem to exert stronger effects on the degradability by HYAL as compared to the concentration of HA.

Title: Embellishing Emotrics for a More Complete Emotion

Analysis: Addition of the Nasolabial Fold

Authors: Ein L, et al.

Published: Facial Plastic Surgery and Aesthetic Medicine, March 2023

Keywords: Emotrics, Facial Paralysis, Nasolabial Fold

Abstract: The nasolabial fold (NLF) greatly contributes to facial aesthetics; changes to NLF depth and vector are disfiguring in patients with facial paralysis (FP). NLF parameters are integral to clinician-graded outcomes, but automated programmes currently lack NLF identification capabilities. This study aimed to incorporate an automated NLF identification and quantification function into the facial landmark programme Emotrics, and to compare new Emotrics-derived NLF data to clinician-graded electronic facial paralysis assessment (eFACE) data for accuracy. Photographs of 135 patients with FP were marked bilaterally, using identification markers manually placed on each NLF. A machine learning model was trained to automatically localise the markers using this data. Once Emotrics accurately identified the NLF and its corresponding vector, photographs of 20 additional patients who underwent facial reanimation procedures were assessed by the algorithm. The enhanced Emotrics algorithm successfully identified the NLF and measured the vector from midline in a series of patients with FP. NLF vector data closely matched corresponding eFACE parameters. Furthermore, changes in NLF presence and vector were detected following facial reanimation procedures. The Emotrics programme now provides critical NLF data, providing objective parameters for clinicians interested in changing NLF dynamics after FP.

Greenwashing in Aesthetics

Issues around climate change and sustainability are reported daily in the media. Every year there is increasing pressure from both the Government and consumers for businesses to show they are operating in a more sustainable way. Unfortunately, this can lead to false or misleading sustainability claims that make it confusing for consumers to understand and weed out those that are feigning being environmentally friendly from the ones that are genuinely dedicated to sustainable practices – namely, who is greenwashing and who is not. The term greenwashing is used to refer to businesses that are making false or misleading statements about their sustainable practices to encourage consumers to spend more money on their products or services, without actually making any notable efforts to be more environmentally conscious.1 In some cases, greenwashing may describe a company’s attempts to emphasise sustainable aspects of a product to overshadow the company’s involvement in environmentally damaging practices.1 It is frequently seen as a play on the term whitewashing, which means using false information to intentionally hide wrongdoing or errors in an attempt to make something seem less bad than it is.1

If businesses engage in greenwashing,

either knowingly or unknowingly, they run the risk of being reported to advertising watchdogs concerning misleading claims, causing potential damage to their reputation and credibility.2

Changes are happening in our sector, with the British Beauty Council forming the Sustainable Beauty Coalition of industry experts, brand owners and beauty industry body representatives to educate both the specialty and consumers on sustainability issues.3 This could prove relevant to the skincare brands you sell in your clinic. The Coalition has made a number of pledges, including a net zero emissions goal by 2050, indicating that it will become increasingly important to consider sustainability when choosing which skincare products to promote.3

In this article, I explore what greenwashing is and why sustainability issues around skincare marketing in particular are relevant to our specialty as patients become more in tune with protecting the planet. Because the skincare market is so huge, it’s my view that the most visible sustainability changes in this specialty can be made here.

Skincare and sustainability

Topical skincare is seen as an important adjunctive component in achieving optimum

results for patients seeking facial rejuvenation procedures in aesthetic clinics, while also providing an attractive ongoing revenue stream for practitioners’ businesses. However, competition for the loyal skincare patient is fierce, with hundreds of different skincare brands promoted via high street retailers and online portals which threaten to draw away patients with the greater choice and smaller price tags. Over the last 20 years, many clinics have differentiated themselves from high street skincare by choosing medical-grade cosmeceutical brands that have been promoted specifically to aesthetic clinics.

Although there is currently no comprehensive or legal definition of the term cosmeceutical, such products are often marketed by aesthetic suppliers as skincare products that have higher levels of active ingredients, with more clinical evidence of efficacy for specific skin problems than most widespread high street brands.

Skincare in the aesthetics specialty has been driven primarily by promoting results-orientated products to complement and maintain in-clinic treatments. However, consumer attitudes are changing, and patients are increasingly considering sustainability issues when purchasing skincare products. Market research company Mintel has reported that the concept of beauty eco-lution – where consumers are increasingly considering co-ethical considerations when making purchases in the beauty sector – has become a more prominent focus for patients since the COVID-19 pandemic.4 In particular, Millennials (those born between the early 1980s and mid 1990s) – who number more than 14 million and are now the largest generation cohort in the UK5 – and the younger Gen Z (born between the late 1990s and around 2010) are far more environmentally conscious than previous generations.6

This means that efficacy claims companies or clinics make regarding the skin health benefits of various products also need to take into consideration protecting the environment. This is a trend that is here to stay, and it must be made a priority in order to appeal to a diverse and sustainability conscious patient base.

Sustainability claims

It can already seem difficult enough for consumers to understand the array of ingredients linked to skin improvements in skincare, but there is now another layer of sustainability-driven messaging that can be

Business coach Ron Myers introduces the phenomenon of greenwashing in cosmeceutical skincare and explains why sustainability is so important in medical aesthetics

equally confusing. While this messaging can often be substantiated by real sustainability efforts, brands can sometimes include buzzwords in their messaging, such as those from the United Nations’ 17 Sustainability Development Goals (SDGs), without sufficient actions to justify them.7 These SDGs, which were introduced in 2015 in order to encourage member states – including the UK – to incorporate areas of sustainability into their policies, include protecting the safety and biodiversity of water sources, disposing of chemical waste responsibly, preventing exploitation of natural resources in the manufacture of products and promoting understanding of sustainable living among consumers.7,8 Occasionally, companies include goals such as these in the marketing of their products because they know they will resonate with consumers, rather than because they are committed to achieving them. Clean, green, natural, organic, botanic, fairtrade, palm oil free, biodegradable, reef-friendly, vegan, cruelty-free, plastic-free, recyclable, waterless beauty and carbon neutral are all terms that are increasingly used by different brands to attract the environmentally conscious skincare consumer.9 Unfortunately, these terms can sometimes be misleading, unsupportable or not entirely transparent, essentially amounting to greenwashing. Hence, it’s not surprising that of 1,500 people surveyed, four in every five consumers have difficulty trusting the sustainability and social claims made by companies in the beauty industry.10

Education is key

Educating yourself is crucial if you are to advertise yourself and your practice as being sustainable in a knowledgeable and trustworthy way. You can do this by making actionable changes to the way your clinic runs, but you can also check the sustainability profile of the brands and products you work with by asking the companies for evidence-based data substantiating their eco claims and initiatives.11 Practitioners may feel they want to signpost their patients to various resources to substantiate the sustainability claims of their practices and the products they stock. This action can encourage confidence among your patients that you’re making genuine efforts to be environmentally responsible, as long as you have evidence to back this up.12 There are now multiple sources available for sustainability-orientated consumers to both educate themselves about potential sustainability issues and understand the

difference between greenwashing and genuine claims made by skincare brands who are actively using sustainability messaging in their marketing. These resources include Ethical Consumer, Provenance, the Leaping Bunny Programme and People for the Ethical Treatment of Animals (PETA) for vegan products or the Soil Association for organic skincare, and can be useful for identifying whether companies’ sustainability claims are genuine.13-17 However, predominantly high street brands are listed within these resources, so direct communication with cosmeceutical companies regarding their sustainable practices is advised.

What should you do?

For many clinic owners, evaluating skincare manufacturers’ claims about efficacy and safety can be challenging enough, but as consumers become more concerned and better educated on greenwashing and sustainability claims, you are going to have to be prepared to answer their questions about products promoted in your clinic. These questions could cover a range of criteria, such as vegan ingredients, the recyclability of plastic or other packaging used and carbon footprint data.

Another example could be whether the brand(s) of SPF that you promote are coral reef friendly. Many chemicals used in SPF products, such as oxybenzone, are known to be toxic to marine life.18 So-called ‘reef-safe’ sunscreens aim to avoid a host of other chemicals including nano particles of zinc and titanium dioxide, and it may be beneficial to know whether the products you sell fall under this category so you can promote this fact and educate your patients further.19

You may want to consider sourcing skincare from manufacturers that are B Corp certified and have sustainability at the heart of their operations.20 B Corp certification is a designation which certifies that a business is meeting high standards of verified performance, accountability and transparency on factors from employee benefits and charitable giving, to supply chain practices and input materials.20

Another option that has been embraced by an increasing number of clinics in the UK is to formulate your own skincare range and incorporate sustainable principles and claims into the foundations of your brand. Whilst this is not the right decision for all due to varying levels of expertise, qualifications and budget, for some, it can provide agency in both skin health results and sustainability, which can really add to your individualised clinic offering.

Creating trust

To build a long-term, trusted skincare relationship with your patients, marketing and communication has to be ethical, transparent and truthful about both performance claims and any sustainability messaging used. If in doubt, ask the companies you work with to explain their sustainability initiatives to ensure you and your patients can be confident that the aesthetic practices you promote are good for both the skin and the planet.

Ron Myers is a business coach and mentor who helps aesthetic clinics and suppliers to clarify their business strategy and maximise profits. With a proven background in identifying and capitalising on aesthetic trends, and with a love of the natural world, Myers is keen to champion and incorporate sustainability issues in the aesthetic arena.

REFERENCES

1. Edwards C. ‘What is Greenwashing?’ Business News Daily (2023) <https://www.businessnewsdaily.com/10946greenwashing.html>

2. ‘Advertising Guidance - misleading environmental claims and social responsibility’ Advertising Standards Authority (UK: ASA, 2022) <https://www.asa.org.uk/resource/advertising-guidancemisleading-environmental-claims-and-social-responsibility.html>

3. ‘About the Sustainable Beauty Coalition’ British Beauty Council <https://britishbeautycouncil.com/sustainable-beauty-coalition>

4. Mintel Press Team. ‘Mintel Announces Global Beauty and Personal Care Trends for 2021’ MINTEL (2021) <https://www. mintel.com/press-centre/beauty-and-personal-care/mintelannounces-global-beauty-and-personal-care-trends-for-2021>

5. ‘Millennial population of the United Kingdom in 2020, by age’ Statistica (2020) <https://www.statista.com/statistics/630938/ukmillennial-population-by-age/>

6. Petro G. ‘Gen Z Is Emerging As The Sustainability Generation’ Forbes (2021) <https://www.forbes.com/sites/ gregpetro/2021/04/30/gen-z-is-emerging-as-the-sustainabilitygeneration/?sh=4c7665448699>

7. ‘The Global Goals for Sustainable Development’ United Nations (2015) <https://www.globalgoals.org/>

8. ‘Implementing the Sustainable Development Goals’ UK Government (UK: Government, 2021) <https://www.gov.uk/ government/publications/implementing-the-sustainabledevelopment-goals/implementing-the-sustainabledevelopment-goals--2>

9. Gleeson-Allured J, Grabenhofer R. ‘Clean Beauty Decoded’ Cosmetics & Toiletries (US: Cosmetics & Toiletries, 2019) <https:// www.cosmeticsandtoiletries.com/research/methods-tools/ article/21837397/clean-beauty-decoded>

10. ‘Provenance Skin Deep Beauty Report 2022’ Provenance (2022) <https://25866765.fs1.hubspotusercontent-eu1.net/ hubfs/25866765/Skin%20Deep%20Beauty%20Report%20 2022.pdf>

11. Waters R. ‘Implementing Sustainability in Your Clinic’ Aesthetics (UK: Aesthetics, 2022) <https://aestheticsjournal.com/feature/ implementing-sustainability-in-your-clinic>

12. Myers R. ‘Becoming a Sustainable Clinic’ Aesthetics (UK: Aesthetics, 2022) <https://aestheticsjournal.com/feature/ becoming-a-sustainable-clinic>

13. ‘Health and Beauty’ Ethical Consumer (2023) <www. ethicalconsumer.org>

14. ‘Shope your Values’ Provenance (2023) <www.provenance.org>

15. ‘Compassionate Shopping Guide’ Leaping Bunny Program (2023) <www.leapingbunny.org>

16. ‘Our Mission Statement’ PETA (2023) <www.peta.org>

17. ‘Organic Beauty and Wellbeing’ Soil Association (2023) <www. soilassociation.org>

18. KMadhusoodanan J. ‘A common sunscreen ingredient turns toxic in the sea — anemones suggest why’ Nature (2022) <https://www.nature.com/articles/d41586-022-01271-4>

19. ‘Reef Safe Sunscreen Guide’ Save the Reef (2023) <https:// savethereef.org/about-reef-save-sunscreen.html>

20. ‘About Our Standards’ BCorp (2023) <www.bcorporation.net>

Building Your Personal Brand

Now might be time to put any old social accounts on private and delete anything you don’t want associated with your brand. If you find something negative about yourself published online, consider reaching out to the author to have it removed. In some cases, you can request negative content that violates Google’s guidelines to be permanently removed – but overall, being aware of what’s out there gives you the power to do something about it.1 It’s not always possible to remove content from Google search results, but over time, previously published content is likely to be pushed down and ‘suppressed’, meaning it’s less likely to be seen.

Building your personal brand

Work on your elevator pitch

Everyone has a personal brand, whether you choose to nurture it or not. This personal brand is formed based on your public image, both online and offline. The way you present yourself and the perception you give others offline is easier to control. You decide which parts of your story, personality, conversation topics, outfit and schedule you share, as well as the people you network with. However, your online persona is a different ball game. Anyone from anywhere in the world can search for you online, and anything you’ve published or been mentioned in can be pulled up via a Google search in seconds.

In this article, I will be exploring why personal branding is important in aesthetics, and will share some tips on how you can build your brand to stand out from the crowd.

Why is your personal brand key to success?

Your personal brand helps you stand out from competition, positions you as an industry leader and allows you to demonstrate your knowledge and skills.

People buy from people they know and trust, and in an industry where authenticity plays a huge role, personal branding is crucial. In aesthetic medicine, having an effective personal brand can also open doors to

business growth and opportunities such as being invited to speak at conferences and events, becoming a key opinion leader/brand ambassador and winning industry awards. Working on your personal brand involves evaluating how you promote yourself and telling your story to the world. It includes a summary of your professional experience, skills and personality via your website, social media and any other digital communication streams. On a professional level, your personal brand reflects how your audience perceives you. Being aware of and working on your personal brand empowers you and gives you the opportunity to position yourself in the way you want to be seen, rather than ignoring it and letting it unfold organically.

It’s time to think

It’s important to think about what would come up when you do a quick Google search of your name. Likely your Facebook, LinkedIn, Instagram – maybe your Twitter? Would there be news articles, blog posts or other websites which mention your name and expertise? The impression your search results give of you becomes your personal brand – your online reputation and persona; building credibility, character and experience.

It may be worth Googling yourself as part of this exercise to see what already exists online.

Define the ‘why’ that drives your practice, and your key messages/values. An effective elevator pitch is a 30-60 second summary of what you do, who your audience is and why you do what you do. Your pitch should explain why you believe what you do is valuable, and what makes you/your business unique. You may need to call upon your pitch at networking events, speaking on panels, meeting industry professionals or pitching to secure an opportunity – it should be short to maintain attention and pique interest. Taking just a few minutes to define your unique selling points (USPs) will help you explain your services in a more succinct manner; identifying the core values of your services and what’s important to you.

Not sure how to perfect your pitch? Here are a few pointers:

• Short and sweet: keep it brief – 30-60 seconds of snappy info, sealed with a business card for follow-ups

• Keep it interesting: what you say and how you say it matters; keep it compelling, use persuasive language and speak from the heart

• Summarise your skills/goals: share what you bring to the table, what you’re hoping for and what gets you up in the morning. This gives listeners an insight into who you are and your goals – allowing them to decide whether your goals align with theirs, and any opportunities or contacts they may have that you’d be suitable for

• The Ws of elevator pitching: who you are, what you do, why you do it, who you do it for, why it’s important, what you bring to the table and where you’re hoping to go/ what your goals or accomplishments are

PR consultant Lucy Hilson explores why your personal brand is so important and gives tips to make yours stand out from the crowd

Consistency is key

Your personal brand should reflect your identity and shouldn’t be identical to your business brand, but they can be similar. Look at your brand from a stranger’s perspective – is the experience cohesive? Are the messages and brand values reflected across all digital communications? Is your branding consistent and recognisable across social media, website and other marketing assets? Are your qualifications, experience level and current employer/place of work up-to-date?

Get social

Social media is an integral part of our daily lives, therefore, maintaining an effective, positive presence is key. Your social media accounts are like a shop window for potential new patients, who will ‘look in’ and make a snap decision on if they like what they see and want to explore further. An example of this is having a business/clinic Instagram account and a personal one which can show both sides of your personality. Effectively using social media is a fantastic way to get your brand out there and in front of your target audience, demonstrating your expertise, showcasing results/reviews, building brand credibility and positioning you as an industry expert. On your business/clinic account, you can highlight before/afters, images of the clinic and team or reels of you at conferences, whereas your personal account can have behind the scenes of you at events, pictures of your achievements or stories showcasing your everyday life at the clinic.

An important point to consider is recognising and reacting to the differences between each platform. Curate content to maximise its effectiveness. For example, LinkedIn is an important tool in sourcing professional contacts and business opportunities, whereas Instagram is a great platform to identify, attract and onboard new patients with more visual and light-hearted content. As well as considering the different audiences, purposes and uses of differing platforms, it’s important to curate content and have a strategy when it comes to the types of content you are creating. Ensure your feed is a mix of engaging, informative posts with relatability, rather than sales pitches. Educating, informing and empowering consumers with information on the procedures you offer is a way of establishing yourself as an expert in your field. Constantly posting ads, special offers and sales content can put patients off.

Customer views of advertising (particularly on social media) have shifted in recent years, and these negative perceptions aren’t ones you want associated with your brand.

A few other pointers for perfecting your personal brand on social media include:

1. Be aware of what’s out there: clean-up duplicate or outdated profiles, delete old photos/content you don’t want people to stumble across and get profiles looking fresh. Upload a recent, professional image of yourself, check your details are correct, update outdated handles and post from the heart with content that’s authentically you

2. Show up and glow up: be consistent in posting, commenting, being active and creating content. Scheduling tools can help save time and ensure a regular posting schedule, but be sure to show up and reply to comments, like posts and engage in the way you’d like to be engaged with to network effectively

3. Sharing is caring: share your expertise, personality, photos of your work day, what you’re working on, top tips, life hacks or something you’ve learnt recently. As long as the content you share is on-brand and authentic, it’ll work to confirm and contribute positively to your reputation

Put yourself under the spotlight

It’s time to shine a light on you, illuminating your personal brand and experiences. Putting yourself under the spotlight and understanding the importance of PR, press articles, treatment reviews and TV/podcast appearances showcases credibility and positions you as an industry expert. Writing for the Aesthetics journal can be a great way to do this, as it positions you as a trusted figure among your peers. No matter which route you choose, get yourself in front of your audience and get seen!

Speak up

Get your voice heard! Speaking opportunities (such as workshops, masterclasses, webinars, or hosting Instagram lives/Twitter Spaces) relevant to you and your industry can elevate your brand, setting you apart from competitors. Build relationships with brands and practitioners in the field to make yourself known, attend events yourself to get insight and follow relevant contacts on social media. You could even host your own ‘live’ or webinar to get things started – which you

can use in your professional portfolio when pitching for speaking opportunities.

Stand out

You were born to shine! What makes you different? Is your personal brand a reflection of you? Recognise your strengths and USPs and celebrate what makes you different. So, what could make you stand out? Maybe you’ve won awards, you’re known for your outstanding patient results, incredible customer service experience or for your kindness or donating to charity. Looking at the details of your business and the ways you can stand out is crucial – how do they reflect your personal brand? Find your niche and incorporate this into your digital marketing and communications. Entering, winning or being shortlisted for industry awards is an excellent way of elevating your business and building credibility for what you do. In addition, winning awards builds trust between you and your patients, ensuring you stand out from the competition. Consider entering The Aesthetics Awards 2024 in September this year – being a Finalist would look great to patients and colleagues alike.

Remain true to yourself

Keeping the above in mind, I think one of the most important things you can do to effectively showcase your brand is stay consistent and authentic. You want to appeal to your target audience and maximise your visibility by taking advantage of current trends, but this should always be done in a genuine way that remains true to you and your personal brand.

Lucy Hilson is an award-winning PR and business consultant as well as founder and CEO of Cosmetic PR; an international PR agency with offices in London and Dubai. Over the last 18 years, Hilson has worked for some of the world’s leading aesthetic, beauty, and wellness brands taking them from start-up businesses to leading industry and household names.

REFERENCES

1. Local Guides Help, ‘Prohibited and restricted content’, <https://support.google.com/local-guides/answer/7400114?hl=en#zippy=>

Utilising Mentorship Opportunities

Nurse prescriber Julie Scott discusses the importance of mentorship throughout all stages of your career

No matter where you find yourself in your aesthetics career, as someone who has been through it all, I have learned along the way that it is imperative to have a mentor with you at every step.1 Mentors can be called many things and wear many hats – advisors, guides, confidants, counsellors, consultants, therapists, gurus, tutors, trainers, coaches – and can embody all of these along the course of someone’s journey.

From being freshly qualified in foundation toxin and fillers to having a successful clinic and perhaps working with brands and being a key opinion leader, everybody can benefit from someone to guide and challenge them.

What is mentorship?

According to the Cambridge dictionary, mentorship is defined as ‘the activity of giving a younger or less experienced person help and advice over a period of time, especially at work or school’.2 Within aesthetics, it is not just help and advice, but clinical guidance and practical tips as well. Mentors provide different kinds of support at different stages of one’s career, so let me, as both a mentor and mentee myself, breakdown what mentors should provide and what could be gained as a mentee at a few key stages of your career.

Freshly qualified

This is possibly the hardest stage of anyone’s aesthetic career, when you’re newly qualified and trying to find your feet in this oversaturated and competitive industry. Most likely, you are full of insecurities at worst, with thousands of questions at best. If you’re a more experienced practitioner reading this now, cast your mind

back to how you felt when you were newly qualified – perhaps after finishing your training, you felt buoyant and ready to inject anyone! But once you were face-to-face with your own patient and no one watching or assessing you, maybe the penny dropped and you realised that you still needed some guidance. Unfortunately, I know this lack of self-assurance, combined with a beginner’s knowledge of aesthetics, can sometimes lead to spiraling or self-doubt, and in worst cases, poor practice.

I am sure that every single injector in this industry has asked themselves multiple times: ‘Is this a bruise or a vascular occlusion?’ or ‘This patient has a heavy brow but wants their forehead lines treated with botulinum toxin, can I do this without dropping their brow?’ As we gain experience in the industry, these questions become less frequent and answers come more easily and autonomously. However, in the beginning, to provide best practice to your patients, it’s imperative to have someone to ask these questions to. Of course, complication groups such as Complications in Medical Aesthetics Collaborative (CMAC) and Aesthetic Complications Expert (ACE) Group World are invaluable resources, and I’d recommend them to any practitioner, new or experienced. However, one specific, trusted practitioner to turn to time after time, who knows you as an individual and understands your unique style of practice, can provide an important additional layer of support when it comes to safeguarding your patients and providing the best level of service.

Additionally, when you benefit from somebody else’s years of experience, you can avoid the pitfalls they made on their own journey. Common mistakes I find new practitioners making range from being sucked in by trends or splurging on shiny new machines instead of investing in their hands, to approaching treatments like botulinum toxin as a ‘paint by numbers’ exercise. Mentors can not only help practitioners avoid these mistakes, but also help encourage focus, set goals and plug gaps that we all inevitably start off with.

I know it is usually the hardest time to find the finances to invest in a mentor, but in my experience I believe it is crucial to do so. Mentors usually charge by the hour or for a set package, and prices can vary significantly, but you can expect to pay at least a couple of thousand pounds over the course of a year. So instead of buying that new device, perhaps think of what a mentor can bring to your practice and your business instead. In terms of how to find the right mentor, industry conferences like ACE and CCR are a great place to start. Many experienced practitioners offer mentorship and will frequently present at these conferences, so you can listen to them and see if you think you could work well together. If you don’t feel comfortable approaching them in person, check out their social media and see if they have a website you can enquire through. Many of my mentees have found me this way, and it’s always encouraging to hear they connected with me from an audience!

Your step-by-step to finding a mentor

1. Figure out why you need a mentor

2. Establish your needs/pain points

3. Decide who has the experience/qualifications to meet those needs

4. Search for a mentor individual or mentorship services company that is held in high regard

5. If there is someone you really aspire to emulate or who you really relate to, don’t be afraid to approach them

6. Set up a call/meeting to discuss your needs and wants

7. Work out how your mentorship relationship is going to work on a practical level

8. Start the journey together... who knows where it will take you and how long it will last!

Growing your business

Once you’ve landed on your feet and found your stride in clinical practice, you will probably want to grow your business and/or your presence in the aesthetic industry. You are no longer a deer in headlights, but equally you are not yet at the top of your game. Often once we’ve become confident in our clinical ability, the next unanswered questions we have relate to business. These can be questions such as ‘How do you successfully market yourself?’ or ‘How do you say no to patients who try to haggle with you on prices, or have unrealistic expectations?’ And importantly, we need someone to ask the question, ‘What will make you happy?’, because this is the basis of your business, but it is not something we ask ourselves often. When I was at this stage of my practice, I too was more secure in my clinical abilities, but needed help in other areas. I invested in one-on-one sessions and group seminars with business coaches, and it proved instrumental in growing my practice. My business coaches helped me realise that what would make me happy was not more patients, but a less overwhelming workload – I couldn’t do everything I was doing and still be successful. It was time to outsource some jobs and expand my team. Through mentorship, I gained advice on how to do this successfully, and thankfully avoided burnout; separating work and personal phones is a good tip here! I know my business wouldn’t be where it is now without my team’s input at that vital stage, and I’m so grateful I had objective insight and advice into my business at this pivotal point in my career.

In addition to preventing burnout, I most often work with practitioners on how not to fall into the trap of being generic at this stage. We also often work on brand awareness, offering new treatments, pricing (particularly increasing prices and patient spend) and communicating with patients. And of course, we still discuss individual patient cases, as clinical reflection and support is vital for every practitioner, regardless of level of expertise. So, if you are an aesthetic practitioner who is proud of your growth so far, but you’re ready to take that next step, consider how a mentor can help you kickstart the next chapter of your journey. If you still need clinical support, it is best to look solely within the aesthetics industry, but you may find that you can look elsewhere for business coaches and general mentors. Even better, you can look for both in the same person – business and clinical expertise rolled into one. Wherever you search for mentorship, ensure the person is someone you aspire to emulate. If they have specific experience doing what you want to do, they’ll be best-placed to help you reach your goals.

Expert level

I believe there is no such thing as an expert. I’ve been in this industry for more than 20 years, and I still have a mentor myself. There are obviously brilliant practitioners with decades of experience, but even they have something to learn from others. Regardless of the industry one is in, there will always be someone that’s more skilled, and always someone else to bring different qualities to the table. For example, did you know that Oprah Winfrey had a mentor? The late Maya Angelou was a prominent figure in Oprah’s life right until she passed in 2014. Additionally, Mark Zuckerberg was mentored by Steve Jobs, and JJ Abrams calls Steven Spielberg a mentor! No matter how far we progress in our careers or in life, we never stop learning. So, if you’re a highly-qualified and experienced aesthetic practitioner, what can you gain from mentorship? Someone to challenge you, ask you the difficult questions; someone to stop you from hiding in a metaphorical ivory tower. No matter how skilled you are clinically, no human being can be truly objective, and every individual’s practice sometimes needs an objective eye. Challenges are essential for growth, so contrary to what you might think, I believe experts sometimes need mentoring more than anyone! Of course, experienced practitioners in this small field tend to know or know of one another, so this may work out as a more informal and reciprocal arrangement than typical mentoring agreements. Networking will be the most likely way to find a mentor at this stage of your career, and practitioners should look for someone who can both challenge and inspire them.

Take the next step

Everybody has a unique journey to success in this industry, but what we all have in common is that familiar phrase, ‘no man is an island.’ Having a trusted mentor in your life can be the difference between struggling with feeling alone for ages, versus having the support and resources in place to make great strides forward. It is true that new practitioners need different kinds of support than long-established ones, but it is support that everyone needs nonetheless. I learnt this throughout my own career, and I see it time and time again with my mentees. Therefore, regardless of where you are in your career in this specialty, if you are working alone and feel you need to take the next step, I highly urge you to look into mentoring — it could be just the thing you’re missing!

Disclosure: Julie Scott offers a paid-for mentorship scheme

Qual: RGN, NIP

REFERENCES

1. Arjemandfar E. ‘Entering a Mentorship Scheme’ Aesthetics journal (UK: Aesthetics, 2022) <https:// aestheticsjournal.com/feature/entering-a-mentorship-scheme>

2. Mentorship, Cambridge Dictionary <https://dictionary.cambridge.org/dictionary/english/mentorship>

Julie Scott is a registered nurse and independent nurse prescriber with more than 20 years’ experience in the aesthetics industry and has worked with leading plastic surgeons in London. She now practises from her own Essex clinic, Facial Aesthetics.

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Professor Sebastian Cotofana shares his unconventional path into aesthetics and his passion for advanced anatomy

Professor Sebastian Cotofana is a world-leading voice in medical aesthetic excellence, championing patient safety and best practice through anatomy education. Professor Cotofana grew up in Transylvania, Romania, before moving to Germany. Although none of his family had a medical background, his passion for medicine began at an early age. “For me, there was never any alternative to becoming a doctor,” he says. His initial aspiration when he began his medical studies at the Ludwig Maximillian University of Munich, Germany in 2002 was to become a trauma surgeon. However, after qualifying, he decided to further his anatomical knowledge to become an anatomy professor at the Paracelsus Medical University in Salzburg, Austria. “My secret love is still trauma surgery and emergency medicine,” he says, “But while studying anatomy, I fell in love with facial anatomy, driven by clinicians becoming more and more interested in the subject at the time.”

After two years working in trauma surgery, Professor Cotofana decided to revisit anatomy. He says, “I think you can never focus 100% on more than one thing, and when I do something in my work, I invest all my focus into that. That’s what I did when I returned to anatomy.” In his late 20s, he was the youngest anatomist on his team, and was assigned to conduct an anatomy cadaver course for cosmetic injectors to study facial muscle anatomy. His collaborators on the course were physicians from the German Society for Aesthetic Botulinum Toxin Therapy (DGBT). Professor Cotofana notes that he had no knowledge of aesthetics or facial injections prior to the course, commenting, “As a young anatomical assistant, I wanted to prove that I knew my stuff, so I didn’t even think about if I enjoyed the work to begin with. I did lots of additional reading and tried various dissection techniques and it went well, so the DGBT team returned the next year.”

He was then invited to speak at a German meeting of top dermatologists and plastic

surgeons. He shares, “I was incredibly nervous, but I met some brilliant clinicians who asked me to join them on anatomical research projects focused on facial reconstructive surgery. This led to an invitation to dissect at IMCAS 2015, and my work within aesthetic medicine continued from there.”

Professor Cotofana later became an associate professor of anatomy in Dominica in the Caribbean, giving him more scope to invest time into studies on areas including the lip and forehead. After this, requests for international speaking opportunities skyrocketed, and he moved to the US, fuelling more travel and collaboration in the specialty. Since then, he has been involved in studies on a range of facial zones, as well as injectable rheology. Such studies have allowed him to coin the terms ‘injectable biomechanics’ (referring to how injectable products behave once injected) and ‘facial biomechanics’ (emphasising the cruciality of mobility during various facial expressions and ageing).

In 2019, Professor Cotofana joined the Department of Clinical Anatomy at the Mayo Clinic in Minnesota as medical director of the clinical anatomy laboratory and director of the

What you would like to research further…

I’m very into debunking myths in aesthetics, the ultimate goal being an evidence-based rather than eminence-based specialty.

Tips for learning anatomy…

I don’t think attending a cadaveric dissection is beneficial without a trained eye – start with more base-level courses to advance anatomy knowledge.

Source of inspiration in aesthetics…

Plastic surgeon Dr Arthur Swift definitely inspired me – he’s an amazing educator who loves to share and is amazingly patient.

Mayo Clinic body donation programme, alongside teaching as a professor of anatomy. He remains dedicated to furthering the specialty with ongoing research. “I’m currently doing a research project on lip compartments,” he shares. “It appears that we do have compartments within the red portions of the lip, and the size and combination of each compartment determines the shape of the lip. That’s pretty exciting if you think about it, because if the lip has compartments, you can inject very specific areas.”

He believes engaging in research like this is the way forward. “Some great research work is being done, and the scientific component is finally catching up with the clinical,” he explains. “I do think aesthetics is still far behind many other medical fields in terms of research, but together with the industry and some opinion leaders, this trend is being forged that it has to be science first. There is still a long way to go,” he adds.

Anatomical education is another passion of his that he sees advancing in coming years, whatever the baseline knowledge of the practitioner. For example, “I think learning anatomy from plastic or silicone models will become more and more integrated in anatomical curricula in the aesthetic field,” he comments. “I think models are crucial because they simplify the anatomy into digestible pieces of knowledge.” Making anatomy more accessible to beginners will allow more practitioners to understand the ‘puzzle of human anatomy’, as Professor Cotofana explains.

“Aesthetic practitioners shouldn’t forget that they’re still practising in medicine,” he says, noting that injectors must remember their medical responsibility to their patients, emphasising, “you should focus on patient safety first.” He explains this also extends to saying ‘no’ to patients if it is necessary to protect them from harm, concluding, “Medicine, like any other scientific domain, should always be focused on evidence-based knowledge.”

“Medicine, like any other scientific domain, should always be focused on evidence-based knowledge”

The Last Word

Dr Brendan Khong analyses the butterfly lip technique featuring in the consumer media

Katie Price and Lauren Goodger – two celebrities who have featured in the media over the last few weeks having undergone the latest aesthetic trend: the butterfly lip treatment.1,2 Following the publicity, many patients have been posting on TikTok having undergone the same procedure. The butterfly lip is an emerging technique, where tape is used as part of the procedure to structure the lip after injection, aiming to provide a more prominent cupid’s bow.3 While this may seem like a solution to our patients for getting that round, plump, fuller lip, I believe that the technique presents some major issues for patient safety and alternatives need to be considered by medical aesthetic practitioners.

The technique

The overall idea of the technique is that the steri strip tape holds the filler in the desired place following injection and prevents migration, keeping the lips looking full and round. It has been noted that the tape is typically left on for 24 hours after treatment.3 I believe that this presents an issue for several reasons.

Firstly, placing tape over injection points is a clear risk for infection. After filler treatment, the area should always be kept clean and sterile, to avoid any bacteria spreading into the injection sites.4

Secondly, it can hide obvious signs of other side effects and complications. For example, the tape will cover things such as blisters or skin surface irritation around the mouth. A main concern here is the potential for it to camouflage a vascular occlusion. In this instance, you may see a slight bruise on the lip, but with the surrounding area covered it is unlikely that the patient will notice (or may misdiagnose) discolouration to the skin around it. With the tape recommended to stay on for a 24-hour period, by the time the patient removes the tape and views what’s underneath, severe damage may have already occurred.

The use of tape may also increase the risk of asymmetry. It’s unlikely that the tape will stay in place for 24 hours, as the patient will be needing to eat, talk and breathe. As such, it will probably move slightly on either side, and not symmetrically. Therefore, the filler will probably mould in a slightly different way on the right to the left, providing an undesirable appearance.

Worryingly, it’s also been highlighted in the media that when performing this technique, practitioners have been dissolving previous filler and reinjecting new filler on the same day, to completely reshape the lip. There is currently nothing to indicate how hyaluronidase and hyaluronic acid interact at such short intervals, and so while the lips may look good at the time, there may be risks associated with the long term effects.1 Hyaluronidase can take up to 48 hours to develop properly, so this leaves no time to know what the end result will be or how much original filler will be dissolved.5

After elective treatment with hyaluronidase, the patient can be assessed after 48 hours and the treatment repeated if necessary. It might take longer than 48 hours for the post-procedural swelling to subside, however no enzyme activity remains at this time and cross-linked HA may be administered without risk of being dissolved.

However, the Complications in Medical Aesthetics Collaborative recommends waiting a minimum of two weeks until the swelling has settled, longer in the event of significant post-procedural swelling, to ensure a more predictable aesthetic outcome.5

Consider your position

In General Medical Council guidelines, the first rule for practitioners is to ‘do no harm.’6 With this in mind, it is my opinion that the butterfly lip technique should be avoided by all medical aesthetic practitioners, as we have a primary responsibility to ensure patients are cared for and looked after.

However, I also believe it is inevitable that we will get patients coming in and requesting this look, due to the ongoing social media buzz. Therefore, what we need to consider is how to respond to them appropriately. It’s important to remember that as healthcare professionals, we can always say no. Just because a patient is offering us money, doesn’t mean we should agree to whatever they are asking for. In my view, treatments should not be trends-led, but individual-led. So, we should offer an in-depth consultation where we consider the patients’ full-face and individual anatomy, whether a full lip would be appropriate for them, and provide a discussion of solutions. If a patient does want a full lip look, and it can be provided without compromising their natural facial structure – there are other techniques for the practitioner to employ that do not pose the same risks to health and safety. For example, I recommend using conservative dermal filler in the lip, as well as very careful and precise placement of neurotoxins at the vermillion border which can very subtly, but effectively evert the lip so that the lip appears more volumised.

If the patient isn’t receptive to alternative ideas and is adamant on trying the butterfly lip technique, there is no shame in telling them that you are not the right clinician for them, as again I believe you should not compromise your own ethics in return for financial gain.

Going forward

While the butterfly lip trend is becoming more popular, it is important to remember your responsibilities as a medical aesthetic practitioner. To provide your patients with the correct care, I believe you should not be performing any technique that increases the potential for side effects and complications. In addition, we are currently unaware of how such a technique performs long-term and so you are putting your patient at risk if you perform it. As such, it is my view that practitioners should offer alternatives to provide them with their desired look, or refuse treatment altogether.

Dr Brendan Khong is a medical doctor and has practised clinical medicine since 2017. He recently completed his internal medical training at the University of Sheffield. He has gained extensive experience in dermatology, internal medicine and surgery throughout his years in various hospitals.

Qual: BSci (Hons), MBChB, MRCP(UK), PG Cert

REFERENCES

1. Lauren Gordon, Katie Price warned against dangerous trend, 2023, <https://www.mirror.co.uk/3am/ celebrity-news/katie-price-warned-against-dangerous-29312495>

2. Hana Carter, Lauren Goodger reveals new face, 2023, <https://www.thesun.co.uk/ tvandshowbiz/21333118/lauren-goodger-huge-lips/>

3. Dr Tim Pearce, Butterfly lips, 2023, <https://drtimpearce.com/2023/03/02/tiktok-lip-filler-trend-shouldyou-offer-lip-taping-for-butterfly-lips/>

4. Ausen et al., 2021, Applying Unsterile Microporous Tape onto Surgical Wounds, <https://www.ncbi. nlm.nih.gov/pmc/articles/PMC8205218/>

5. CMAC, Guideline for the safe use of hyaluronidase, 2021, <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC8570661/>

6. General Medical Council, Good Medical Practice, 2019, <https://www.gmc-uk.org/ethical-guidance/ ethical-guidance-for-doctors/good-medical-practice>

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