August 2021: The Devices Issue by Aesthetics & CCR

VOLUME 8/ISSUE 9 - AUGUST 2021

#INJECTORSOFTHEREVOLUTION

THE SPHER SPHERICAL REVOL REVOLUTION HA BUT NOT AS YOU KNOW IT SMOOTH RESULTS BY INJECTORS WITH FLAIR

CPD: Treating Hyperhidrosis

Two dermatologists present the management of primary hyperhidrosis

Addressing Acne Scars with Lasers

Practitioners discuss their approaches to improving acne scars

Thinning Temples in Women

Mr Greg Williams explores the common causes of hair thinning

Working with Sales Reps Vanessa Bird discusses how to have a partnership with sales reps

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Contents • August 2021 06 News The latest product and industry news 14 The Big Aesthetics Reunion at CCR An overview of the exciting agendas on October 14-15 16 News Special: Recognising Body Dysmorphic Disorder Aesthetics looks into the importance of being able to identify when a patient

might be suffering from BDD

CLINICAL PRACTICE 18 The Art of the Consultation Dr Emma and Simon Ravichandran discuss the consultation process 21 Special Feature: Addressing Acne Scars with Lasers Practitioners discuss their approach to improving acne scarring

News Special: Recognising Body Dysmorphic Disorder Page 16

27 CPD: Primary Hyperhidrosis Dr Rakesh Anand and Dr Emma Craythorne present the diagnose and

management of primary hyperhidrosis

32 Treating the Abdomen with Cryolipolysis Dr Claire Oliver shares two body contouring case studies 37 Thinning Temples in Women Mr Greg Williams explores causes for hair thinning in the temples 41 Assessing and Augmenting Lips Two practitioners present their five principles to lip assessment 45 Using RF in the Periorbital Area Dr Sheila Nguyen uses radiofrequency to enhance and rejuvenate the eye 49 Offering CO2 Lasers in your Clinic Mr Ali Ghanem provides considerations for adding CO2 lasers to your

treatment offering

52 The New Standard in Microneedling Introducing the developments in radiofrequency microneedling 53 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 55 Introducing Ultrasound to your Clinic Dr Kim Booysen explains introducing ultrasound into your clinic 58 Working With Sales Representatives Vanessa Bird discusses how to have a good relationship with a sales rep 61 Combination is Key Aesthetic nurse Anna Gunning explains investing in devices for

optimum results

62 Enhancing Your Facebook Advertising Richard Gibbons outlines the problems and solutions of Facebook ads 65 In Profile: Dr Nestor Demosthenous Dr Nestor Demosthenous discusses why aesthetics is more than fillers 66 The Last Word: Model Sharing Dr MJ Rowland-Warmann debates live model sharing NEXT MONTH IN FOCUS: Professional Development • Upper Eyelid Rejuvenation with HA • Understanding Gynaecomastia

Special Feature: Addressing Acne Scars with Lasers Page 21

Clinical Contributors Dr Rakesh Anand is a London-based consultant dermatologist and fellow in Mohs micrographic surgery at the St John’s Institute of Dermatology. Dr Anand believes in a holistic approach for achieving and maintaining healthy skin. Dr Emma Craythorne is a consultant dermatologist, dermatological and laser surgeon and Mohs micrographic surgeon at the St John’s Institute of Dermatology at Guy's and St Thomas' Hospital NHS Trust. Dr Claire Oliver is the medical director and founder of the multi-award-winning Air Aesthetics Clinics in Warwickshire and Birmingham. She has more than 18 years’ experience in aesthetics and eight years of experience treating patients with cryolipolysis. Mr Greg Williams is a hair transplant surgeon and member of the British Association of Aesthetic Plastic Surgeons (BAAPS). He has more than 15 years of experience in hair restoration for hereditary male/ female pattern hair loss. Dr Ayad Harb is a world authority in non-surgical nose correction and has published seminal papers and book chapters on this subject. Dr Harb is involved in training, being a global KOL in facial aesthetics and director of Aesthetic Intelligence. Dr Yalda Jamali is a UK trained medical doctor, holds a Level 7 postgraduate qualification in aesthetic medicine and is currently completing a master’s in clinical dermatology. She is an experienced aesthetics trainer and is the owner of Dr Yalda Clinics in the UK. Mr Ali Ghanem is a consultant aesthetic and plastic surgeon. He is the director of the Ghanem Clinic London – Bahrain, Rae Clinic London, and the Cranley Clinic London. He is a senior clinical lecturer in plastic reconstructive aesthetic surgery at the School of Medicine and Dentistry.

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Editor’s letter Injectable treatments like dermal fillers and botulinum toxin are recognised as the ‘bread and butter’ of the specialty and are usually what aesthetic practitioners will train in first as they enter the field. However, aesthetic devices play a huge part in further enhancing your practice as well as your results. That’s why we focused this issue on all things devices!

Shannon Kilgariff Acting Editor & Content Manager @shannonkilgariff

In this issue you can learn about lasers for acne scarring (p.21), cryolipolysis for fat reduction (p.32), radiofrequency for rejuvenation around the eye (p.45), CO2 lasers (p.49), and how to incorporate ultrasound devices into your practice for reducing and managing dermal filler complications (p.55). You can also get to grips with making the most of your sales representative when you are purchasing your devices – read these top tips on p.58! Of course, if you are looking to onboard a new device, where better to start than CCR where there will be 150 aesthetic

companies under one roof? I’m delighted to announce that free registration to attend CCR at ExCeL in London on October 14-15 has now opened. This year we have so much going on – Galderma is Headline Sponsor with some great launches, the ACE Group World is doing a conference on complications (tickets are available online) and the International Society of Aesthetic Plastic Surgery and the British Cosmetic Dermatology Group are both being hosted at CCR. Read more and register on p.14. Finally, Aesthetics Awards entry will open at the end of September! Stay tuned for more updates soon, and remember if you would like to receive feedback from your entry last year do get in touch before the end of August: contact@aestheticsjournal.com As always, we would love to hear from you about your thoughts on this issue and what you would like to read about next. Get in touch via email: editorial@aestheticsjournal.com or tag us on Instagram @aestheticsjournaluk. Happy reading!

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

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

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

Dr Raj Acquilla has more than 12 years’ experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer for botulinum toxin and dermal fillers.

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

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

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

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

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

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

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

ARTICLE PDFs AND REPRO

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

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Industry

Talk #Aesthetics

APPG releases final report on aesthetics regulation

The All Party Parliamentary Group on Beauty, Aesthetics and Wellbeing (APPG) has published its final report into botulinum toxin, dermal fillers and other aesthetic non-surgical cosmetic treatments. The group made 17 recommendations for Government to aid the regulatory gap. These included making dermal fillers prescription only, mandate practitioners to hold a regulated qualification in line with national standards, place advertising restrictions on dermal fillers and other invasive aesthetic treatments, and require social media platforms to curb misleading ads and posts promoting these treatments. The APPG also outlined in point five of its recommendations that on-site medical oversight should be made mandatory for aesthetic non-surgical cosmetic treatments using prescription-only medicines, where the treatments are performed under the oversight of the prescriber who has gained the accredited qualifications to prescribe, supervise and provide remedial medicines if necessary. They suggest that initial face-to-face consultation with the person providing the medical oversight (the prescriber) must also be made mandatory prior to any treatment. Co-chairs of the APPG, Carolyn Harris MP and Judith Cummins MP, commented, “We launched this inquiry as we were deeply concerned that as the number of advanced treatments on the market continues to grow, the regulations remained fragmented, obscure and out of date which puts the public at risk. We urge the Government to implement the recommendations in our report and to take action to improve the situation for the benefit of the industry and public safety.”

#BeyondBeauty Anna Baker @annabakeraesthetics Thank you @beyondbeauty_mag for this opportunity alongside esteemed colleague @drsouphi #botulinumtoxin #Celebration BCAM @britishcollegeofaestheticmed Thanks to everyone who joined us for the launch of our new branding, website and logo – what an achievement in the college’s 20th anniversary year! #Education Dr Simon Zokaie @drsimonzokaie Hard at work training medical professionals in our dermal filler masterclass @harleyaesthetictraining with our sponsors @relife_company #training

#Aestheticsjournal Dr Aileen McPhillips @draileenaesthetics Privileged to have another educational article published in this month’s Aesthetics journal #education

#Book Dija Ayodele @dija_ayodele It’s official… I wrote a book! My book Black Skin – The Definitive Skincare Guide is everything you’ve ever wanted to know about black skin and beauty identity #publication

Dermatology

Croma-Pharma to offer anaesthetic cream Aesthetic manufacturer Croma-Pharma has entered a licensing agreement with dermatology company Crescita Therapeutics for the rights to Pliaglis. Pliaglis is a topical local anaesthetic cream which aims to provide effective dermal analgesia on intact skin prior to procedures such as dermal filler, facial laser resurfacing and pulsed dye laser therapy, explains Crescita Therapeutics. Croma explains that it will promote Pliaglis directly to practitioners through its sales network consisting of 130 members across the nine countries, including the UK, Ireland, Germany, Switzerland, Brazil, Romania, Belgium, the Netherlands and Luxembourg. Crescita will be the sole supplier of Pliaglis under the agreement at a price per unit including a profit margin, whilst Croma expects to launch Pliaglis to most of these countries throughout 2022. Croma managing director, Andreas Prinz, commented, “We are looking forward to collaborating with Crescita on Pliaglis which complements our portfolio of aesthetic injectable products, right at a time when we are about to enter the market of pharmaceuticals. We are delighted to launch Pliaglis in some of our most important markets where it will certainly become an important pillar within Croma’s product family.”

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Event

CCR registration opens The registration for CCR has officially opened with pharmaceutical company Galderma as headline sponsor. Galderma will also be sponsoring the networking hub at CCR with its exclusive distributor Med-FX sponsoring the networking drinks, situated on the main show floor at the ExCeL in London. Joanna Neal, brand manager at Galderma, said, “We are thrilled to be headlining at CCR 2021 and are delighted Med-FX will also be joining us there and taking sponsorship of the networking drinks at the Galderma sponsored networking hub. For us, this year’s CCR is a must-attend event and we always look forward to hearing about the latest developments within the industry. This is the first event that Galderma will have Sculptra as part of our portfolio since we announced our takeover of the brand in February 2020, and we can’t wait to showcase this at the event.” Aesthetics and CCR event manager Courtney Baldwin commented, “We are so excited for both Galderma and Med-FX to be sponsoring our networking hub! Networking is an important aspect of CCR with industry professionals being able to discuss new developments, trends, share knowledge and search for the latest products on the market. We can’t wait to welcome you back to CCR and to see everyone in-person once again.” To register free for CCR, go to the QR code on p.15. Networking

Cutera to host educational and networking event

Vital Statistics In a survey of 1,000 men and women, 39% reported an interest in non-surgical aesthetic treatments (AEDIT, 2021)

48% of 1,403 men in the US felt less conﬁdent in the workplace due to hair loss (Hims Survey, 2021)

In a survey of 2,500 facial plastic surgeons, 40% agree that patients have an increased interest in eye procedures due to wearing face masks (AAFPRS, 2021)

Aesthetic technology manufacturer Cutera is hosting an event with a CPD-approved agenda on September 27. The event will be a learning and networking experience focused on trending discussion points from within the aesthetics specialty, with topics to be announced soon. The speakers at the event include aesthetic practitioners Dr Anna Hemming, Dr David Eccleston, Dr Nestor Demosthenous, Dr Julia Sevi, Dr Tatiana Lapa and Dr Tapan Patel. The event will take place at the Castle Hotel Windsor at 10am GMT. You can register for the event through the Cutera website now. Filler

Prollenium launches Revanesse in the UK Medical device manufacturer Prollenium has launched its new dermal filler brand Revanesse in the UK. According to the company, the dermal filler is made in Canada with approval from the US Food and Drug Administration (FDA). Plastic surgeon and aesthetic trainer Dr Arthur Swift will officially launch the range at CCR in October. Katie Bennett, head of marketing UK at Prollenium, commented, “We are so excited to launch Revanesse in the UK. Working with such high-quality products and a company that truly listens to its customers is refreshing and it is thrilling to be part of this forward-thinking team.” Revanesse is available to buy from Healthxchange now.

10 million people in the UK struggle with their mental health due to a skin condition (E45, 2021)

56% of 1,000 men in the UK were guilty of ‘stealing’ their partner’s skincare products (Clarins, 2021)

In 2020, the most popular cosmetic surgery amongst women in the UK was breast augmentation, with more than 4,600 procedures being carried out (Statista, 2021)

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Events Diary 3rd September 2021 International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) symposium iapcam.co.uk

4th-5th September 2021 13th 5CC Virtual World Congress www.5-cc.com/en/2021/home/

10th-11th September 2021 British College of Aesthetic Medicine (BCAM) second virtual conference bcamconference.co.uk/

20th November 2021 Aesthetics United Charity Conference 2021 aucc.co.uk

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Sun protection

Medik8 releases new sunscreen Skincare company Medik8 has added the new Advanced Day Ultimate Protect SPF 50+ sunscreen to its portfolio. According to the company, the sunscreen has been formulated to deliver protection in a daily moisturiser format which is suitable for all skin tones. The sunscreen offers protection from blue light by containing blueberry seed oil, which aims to absorb the light to aid against hyperpigmentation and free radical damage. The product also contains marrubium vulgare extract, carnosine and glycation to prevent the loss of collagen and elastin, whilst protecting against infrared and pollution on the skin, explains Medik8. Director of research at Medik8, Daniel Issacs, commented, “For those that want ultra-high sun protection in a daily moisturiser format, Medik8’s new Advanced Day Ultimate Protect is the complete sunscreen offering. The sunscreen not only protects the skin, but it also repairs DNA damage derived from UV whilst you wear it.” Digital

New app launches to connect providers and patients 14 & 15 October, ExCeL www.ccrlondon.com

Training

Lynton introduces business programme Laser and IPL manufacturer Lynton has introduced a programme to help practitioners launch a new device into their clinic. The programme consists of six virtual sessions where Lynton’s marketing team will coach practitioners through the launch process of an aesthetic device. The sessions include topics such as email marketing, how to run a successful launch event, enhancing SEO, increasing social media followers, building databases, how to optimise your website and how to create a content hub. Lynton explains that the programme will provide all the tools, information and teaching that practitioners will need for introducing a new device. The next dates for the business programme are due to be released. The programme is free for all current and future Focus Dual users.

Software and application development company MeTime Corporation has launched a new app to match patients with medical aesthetic services. The patient-facing app allows users to select their areas of concern, find treatments, and upload their own photos. They can also select their preferred type of specialist, expertise and price range accordingly. Once submitted, practitioners who have registered on the MeTime platform will receive matches and begin the conversation, the company explains. Dr Peter Prendergast, aesthetic practitioner and medical advisor for MeTime Corporation, commented, “The reaction of my patients who connect and chat through MeTime has been remarkable. No more back and forth with emails. It’s seamless and makes the flow of interacting with patients much easier. They love how simple it is to connect and get advice before booking treatments.” Providers can register for free on the MeTime website and share a unique link with their patients to make it easier to start a conversation. All patients who download the app for free can connect with providers in their area. Achievement

Cynosure marks 30-year anniversary Laser manufacturer Cynosure commemorated its 30-year anniversary in July with a month-long celebration. The company explains that the celebrations recognised the significant contributions of partners around the world, offered special promotions, and hosted celebratory events for customers and employees. Cynosure has also launched a new consumer website and brand identity centred around the concept of ‘beautiful energy.’ The mission was to partner with healthcare providers around the world, providing them with skincare science, innovation and expertise, to release the beautiful energy within everyone, stated Cynosure. Todd Tillemans, chief executive officer at Cynosure, commented, “Our rich, 30-year history of technology, innovation and pioneering spirit has established Cynosure as the leader it is today. We look forward to bringing new surgical innovations to the market, as well as furthering our commitment to provide patients with outstanding clinical results.”

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Education

Merz reveals three new Innovation Partners Global pharmaceutical company Merz Aesthetics has introduced three new Merz Innovation Partners (MIP) as part of its educational team. The new partners include aesthetic practitioners Dr Chris Hutton and Dr Dev Patel and dermatologist and hair restoration surgeon Dr Max Malik. The Merz Innovation Board (MIB) and MIP team are a group of clinical educators and ambassadors who deliver a wide variety of medical educational resources across the Merz portfolio, explains Merz. Merz is due to launch Merz Associates in the coming months, which will be a community of healthcare professionals who Merz support and develop through relationships. The Merz Associates will enable Merz to provide increased peer-to-peer support for customers and enhance the overall medical programme.

What Are ‘Filler’ Images?

Photographer Hannah McClune’s monthly tips on how to strengthen your business through branding ‘Filler’ images are the mood-setting, and contextual type of photos that every business needs.

Research

Industry report on aesthetics to be released An industry report on the UK aesthetics market is to be released by Aesthetics Media and CCR to gather and share vital information on the sector. The report will survey aesthetic practitioners to discover key information such as how many aesthetic procedures are being performed, as well as the popular trends occurring in the industry. In addition to practitioners, consumer data will also be gathered to learn more about patient age ranges, treatment trends, and the reasons why patients seek out aesthetic procedures. Acting editor of the Aesthetics journal and Beyond Beauty, Shannon Kilgariff, said, “In this unregulated market, it’s important that we gather data and use this to better the field. We believe these findings will be of huge benefit for practitioners to gain a clear understanding of their patients’ individual requirements when seeking procedures. We want to distribute the survey as widely as possible across the sector, using the reach of the CCR and Aesthetics databases and from our trusted partners.” The insights will be released at CCR on October 14 and published in the Aesthetics journal and Beyond Beauty magazine. They will also be shared with the wider industry and media outlets. Development

Clinisept+ rebrands Product manufacturer Clinical Health Technologies is updating the name and packaging for the Clinisept+ aesthetics range in early autumn. To mark the fifth anniversary of Clinisept+, the Prep and Procedure and Aftercare will both be renamed to Clinisept+ Skin. The product will still be available in the large 490ml bottle as well as the 100ml take home size. The 490ml bottle has been updated with an improved pump dispenser, allowing for better controlled dispensing, explains the company. The products also have new labelling displaying additional information regarding the products, to help practitioners easily explain them to their patients.

A filler photo to attract those considering treatments ahead of their wedding

Break up your images!

Filler photos can be scattered throughout your website or used to break up a social media page. They help space out busier and important pictures to achieve a balanced look. The photos can give a smoother transition, resulting in what you share becoming varied and interesting. Filler photos can feature your printed marketing, products, or a variety of props that fit your brand aesthetics.

Get planning

If you choose to have content created professionally, you need to complete a brief to share your brand information – then simply step back and let your photographer get creative with the set up and styling, without needing to be at the shoot yourself! Alternatively, if you or someone in your team is great at photography, then think ahead to what upcoming messages you have, and start planning a content shoot day. List the intentions behind each set up, gather your products and props then shoot away! Whether the images you choose will be used to support educational or fun pieces – they will help get your ideal patient’s attention. Please get in touch if you would like to see examples and learn about how you can start your filler photography with quality photos.

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

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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BACN UPDATES A round-up of the latest news and events from the British Association of Cosmetic Nurses

The BACN has updated its Code of Conduct by offering its members a thorough framework to understand their responsibilities as aesthetic nurses. An aesthetic nurse conducting medical aesthetic treatments is required to exercise a unique and multi-faceted clinical judgement and skillset, often in complex scenarios, which are unique to the aesthetic specialty. Considering the paucity of a robust, recognised medical model within the aesthetic specialty, it is the BACN’s intention that the principles within the code underpin the broad scope of practice and clinical skillset which aesthetic nurses are required to develop. This does not replace the NMC code which still must be adhered to. Within the new code are several contemporaneous references to current legislative and statutory guidance. The project was led by Anna Baker, nurse prescriber and one of the BACN management committee members and is available for all members on the website along with a downloadable copy.

AUGUST EVENTS The BACN is working with Galderma for its August events focusing on the European re-launch of the collagen stimulating injectable Sculptra. • In Conversation With – A KOL for Galderma will be discussing with the BACN about Sculptra and its use in your aesthetic toolkit – 10th August • InFocus Digital Webinar – An overview of the original Sculptra to activate your patients’ skin sponsored by Galderma – 17th August • Peer Review – Full agendas and details can be found on the events page of the BACN website – 19th August

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Industry

Healthxchange to supply Intraline products Aesthetic supplier Healthxchange has partnered with aesthetic company Intraline to supply its line of lifting and rejuvenating PDO threads as well as the brand’s dermal fillers. Intraline will also be offering training in partnership with Healthxchange with dates to be announced soon. Terry Fraser, president at Intraline, said, “We are thrilled to announce Healthxchange as an approved pharmacy partner; their dedication to customer service, quality and support for their clients is exceptional. At Intraline, we are working to raise the safety standard in the industry and working with partners such as Healthxchange aids in that growth.” Marketing and technology director at Healthxchange, Steve Joyce commented, “PDO threads are a terrific treatment option for patients looking to combat the signs of ageing. We are delighted to announce that we stock Intraline’s comphrensive range of PDO threads for both rejuvenation and lifting.” Health

TV programme on skin diseases launches UK charity The British Skin Foundation (BSF) and production company ITN Productions Industry News have co-produced a programme called More Than Skin Deep. The production aims to raise awareness and understanding of the different types of skin diseases, the mental and physical scars they can cause, and the importance of research into the advancements of new treatments and cures, explains ITN Productions. During the programme, ITN Productions presenter and reporter Mary-Ann Ochota explores the increasing awareness of the effects of skin conditions on mental health, the latest developments in dermatology and the research into skin diseases within the BSF’s work. The programme also features CEO of the BSF Matthew Patey, who discusses the science behind skin treatments and the vital role of research. More Than Skin Deep is available to view on demand on the BSF’s website. Skincare

FAREWELL TO TARA The BACN is sad to announce that the BACN events manager Tara Glover will be leaving in August after more than four years working for the association. Throughout her time at the BACN, Tara focused on transforming the events programme, ensuring educational content was at the forefront of the regional events structure, and developed strong working relationships with members. Her departure means a restructure of the BACN head office, and members will be kept up-to-date with any changes. This column is written and supported by the BACN

GetHarley partners with Spectacle skincare Skincare platform GetHarley has teamed up with Spectacle skincare to offer practitioners the opportunity to sell and send the Spectacle Performance Crème directly to their patients’ homes. According to the company, the gel/cream hybrid contains a blend of amino acids, polyphenols, encapsulated retinoid complex, and essential lipids that aim to protect and hydrate the skin. Olivia Falcon, founder of Spectacle skincare, commented, “We have partnered with GetHarley so that practitioners are able to easily recommend and sell Spectacle to their patients. Spectacle is the ideal product to add to any skincare regime to deeply hydrate, protect and soothe skin, and we trust in GetHarley’s premium service and reliable replenishment system.”

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Anniversary

BCAM celebrates new branding launch BCAM has unveiled its updated logo, new website and branding as part of its 20th anniversary celebrations. The digital event was hosted by BCAM’s president Dr Uliana Gout, who expressed her “Immense excitement about this huge step forward for BCAM.” The event was also attended by BCAM founding members Dr Rita Rakus and Dr John Curran. The new branding and website project has been in the pipeline since February 2020, says Dr Gout, who stated, “It is an important step towards modernising the organisation and improving its processes and procedures.” BCAM trustee Dr Bhavjit Kaur, explained the new logo design, “The new logo recognises BCAM’s past, but it also highlights our aspirations for the future.” Dr Rakus also commented on the new logo, expressing her excitement at being involved in the first new logo in the college’s history. Charity

Conference launches business initiative The Aesthetics United Charity Conference (AUCC) 2021 taking place in November has announced it will feature a business ‘speed dating’ event. The event will aim to match practitioners with a panel of industry business professionals to discuss aspects of their business including their brand, marketing, patient management and business model. Each attendee who registers will spend six minutes with each speaker in this event. Speakers include director of The Consulting Room Ron Myers, directors of Glowday Hannah and Joby Russell, and PR consultant Sophie Attwood. Dr Lara Watson, co-founder of the AUCC, commented, “Our speed dating with the experts initiative offers attendees of AUCC the chance to receive a full MOT of their aesthetics business plan or model with some key industry experts. This is valuable to anyone looking to jumpstart their career in aesthetic medicine.” The AUCC 2021 will also deliver clinical education and will take place on November 20 at the Hotel Sofitel London. Sun

SkinCeuticals unveils new SPF Professional skincare and antioxidant company SkinCeuticals has launched the Oil Shield UV Defense SPF 50. According to the company, the sunscreen delivers high broad-spectrum protection with a dry-touch finish to the skin. The UV defence filtering complex combines a mineral filter with organic filters to help stabilise the formula for optimal protection against UV rays. The formula contains silica to help absorb excess oil and provide a mattifying effect. Dr Jonquille Chantrey, aesthetic surgeon and winner of the AlumierMD Award for Best Non-Surgical Result at the Aesthetics Awards 2021, commented, “This is a welcome, mattifying addition for my patients with oily skin and acne. When paired with the hero product Silymarin for this skin type, this new SPF can help to further protect against harmful free radical production through sun exposure and lipid peroxidation.”

J O I N U S AT CCR The surgical and non-surgical aesthetic disciplines are uniting to raise industry standards at CCR 2021! Join us at CCR on October 14 & 15 at ExCeL, London to share and learn best practice, discover the latest clinical developments and source new products from 150+ leading brands. The UK’s leading surgical and non-surgical medical aesthetic exhibition and conference will be packed with two full days of CPD training, live demonstrations, world-class speakers, and that’s not all… We have added a whole host of NEW features to CCR this year: • Galderma, one of the world’s leading pharmaceutical companies, is this year’s headline sponsor. In addition to providing the latest news and exceptional educational resources, Galderma will play host to a dedicated networking hub for you to make incomparable connections in the aesthetics specialty. • The ISAPS Symposium UK and the Aesthetic Complications Expert (ACE) Group World Conference will both be co-located at CCR, uniting the biggest players in the surgical, dermatological and aesthetic professions. • The CCR exclusive Press Conference, hosted by CCR press ambassador, Francesca White (Tatler’s Health and Beauty editor-at-large) will share cutting-edge research and pioneering advancements in the aesthetics market. You will learn about the latest trends across all medical aesthetics specialities, develop your skills through shared knowledge, and how to find the very best solutions on the market. • An exclusive anatomy and cadaver masterclass with world-renowned aesthetic practitioner Dr Tapan Patel will be held on day two of CCR, covering injection techniques with video cadaver demonstrations. ...And so much more! Make sure you’re there on October 14 & 15 for the unmissable aesthetics event of the year. Find out more and register now at

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Training

Eden Aesthetics collaborates with Cosmetic Courses Skincare distributor Eden Aesthetics has partnered with training provider Cosmetic Courses to offer polydioxanone (PDO) thread training for N-Finders as well as the brand’s dermal fillers. Eden Aesthetics is the UK distributor for N-Finders PDO threads, made in Korea, which are approved by the KFDA (Korean Food and Drug Association) and are CE marked. According to a study conducted by the department of dermatology at the Korea University Ansan Hospital, a total of 31 thread lifting procedures were performed to improve the nasolabial folds, with 87% of patients considering their results satisfactory. The training is available monthly from the company’s two locations in Princes Risborough and Nottingham, both of which are registered with the CQC. Achievement

NMC members increase The Nursing and Midwifery Council (NMC) has grown by 15,000 members since March 2020. The NMC’s annual registration data report showed that the number of people on its permanent register has grown by 15,311 to an overall total of 731,918. This included 11,673 more nurses, 1,152 more midwives and 2,660 more nursing associates. The register also highlighted the number of people whose initial registration was in the UK has increased by 8,421 over the past 12 months, although the rate of growth has slowed compared with previous years. Andrea Sutcliffe, chief executive and registrar at the NMC, commented, “Our register shows welcome and much needed positive UK growth overall. The pandemic has driven a surge of interest in our wonderful professions. It’s now the responsibility of all of us as leaders across the health and care system to heed the underlying pressures and work together to develop, support and sustain the nursing and midwifery workforce to cope with the future challenges ahead.” Patient demand

Caution over rise in cosmetic treatments Aesthetic practitioner national register Save Face has issued a warning to patients as new figures reveal an increased demand for cosmetic treatments is expected over the summer. Figures from Save Face revealed a 37% increase in people researching non-surgical treatments such as lip fillers and botulinum toxin after the UK government announced their roadmap for lifting lockdown earlier this year. In addition, the British Association of Aesthetic Plastic Surgeons (BAAPS) reported that UK plastic surgeons saw a 70% rise in consultation requests during 2020, linked to an increased focus on our appearance during video calls in lockdown. Despite this, BAAPS issued a warning to consumers to check the credentials of their practitioner before going ahead with any treatments. Independent insurance company Policy Bee have supported Save Face’s caution and believe it is important that practitioners have completed accredited training and are fully insured. With a rising demand for cosmetic procedures, Save Face also logged more than 2,000 patient-reported complaints last year, a 22% increase on 2019 figures, which has led to a rise in the number of corrective treatments required, according to the company.

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Dr Marwa Ali, from Harrods Wellness Clinic and Lumenis Ambassador for the Stellar M22 What does the Stellar M22 treat? It can treat more than 30 skin conditions as well as hair removal, and is especially known for its efficacy in treating different types of pigmentation, such as sun spots, melasma, and all kinds of dyschromia. It has four light/laser modalities, and combining them in the same session helps get optimal results. The Photofractional treatment, for example, combines IPL and ResurFX™ – a non-ablative fractional laser, and is ideal for managing tone and texture in just one setting. The results that we have seen from the Stellar M22 are incredible due to its combined different modalities where a treatment plan can be created that is bespoke to each patient’s needs, skin type and lifestyle. Can you tell us a little more about the science behind the Stellar M22 and how it gets results? In four innovative technologies, the Stellar M22 offers: a versatile IPL applicator to treat more than 20 skin conditions, including acne, rosacea, pigmented lesions and vascular lesions, reduction of age spots and hair removal; a MultiSpot™ Nd:YAG to deliver precise treatment of vascular and leg vein lesions on all skin types; a Q-Switched Nd:YAG for the treatment of pigmented lesions and dark tattoo removal; and a ResurFX™, a fractional laser with non-ablative scanner for a high-end treatment of stretch marks, scars and skin rejuvenation. Any last thoughts on the new platform? We’re very proud to offer one of the newest and most innovative treatments available on the market and are therefore thrilled to be adding the Lumenis Stellar M22™ to our Harrods Wellness Clinic menu. I’m very excited by the capabilities of this system as some of the conditions it combats have previously been deemed untreatable. I can’t wait to introduce my patients to the Stellar M22™ by Lumenis and to use it to its full potential.

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Complications

ACE Group World Conference programme revealed The Aesthetic Complications Expert (ACE) Group World has unveiled its completed programme for CCR on October 14 2021. The conference will take place in two sessions, with the first hosted by nurse prescriber Liz Bardolph. Bardolph will open the conference and introduce the ACE Group World to delegates, as well as the current challenges facing aesthetic practitioners. The first session will feature talks from aesthetic practitioners Dr David Eccleston on botulinum toxin complications, Dr Xavier Goodarzian on chemical peel complications, consultant vascular physician Dr Steve Tristram on sclerotherapy complications, and director of the ACE Group World Dr Martyn King on the management of delayed onset nodules. The second session will be hosted by nurse prescriber Helena Collier. It will involve founder of the International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) Dr Beatriz Molina discussing lip complications and vascular occlusions, ENT surgeon Mr Ash Labib on nose complications and hyaluronidase, oculoplastic surgeon Mrs Sabrina Shah-Desai on eye complications and dermatologist Dr Harryono Judodihardjo explaining what skin lesions should not be missed when performing aesthetic treatments. The conference will end with a Q&A session. The ACE Group World conference will take place at 13.30-19.30pm at CCR at ExCeL in London. To register for CCR and to secure your ACE Group World tickets, scan the QR code on p.15. Distribution

AestheticSource to stock Clinisoothe+ Skin Purifier Clinical distributor AestheticSource has added the Clinisoothe+ Skin Purifier to its portfolio to retail to patients. The Clinisoothe+ Skin Purifier provides gentle antimicrobial cleansing whilst protecting the skin from pollutants and impurities, preventing breakouts and promoting rapid recovery to the skin, explains AestheticSource. The company explains that the Clinisoothe+ is suitable for patients who may be prone to eczema, psoriasis, dermatitis, rosacea and acne. Vikki Baker, marketing manager at AestheticSource, said, “Clinisept+ has been popular with both practitioners and patients. The new Clinisoothe+ Skin Purifier consumer packaging presents a product for practitioners to retail to their patients with clear product benefits.” Diversity

Transform Hospital Group supports LGBTQ+ community Healthcare provider Transform Hospital Group has created a team of LGBTQ+ ambassadors to undergo training with the LGBT Foundation. The group was set up as part of a wider pledge which aims to achieve LGBTQ+ inclusion in the workplace as well as the wider society. Five team members based at different locations have been selected from numerous volunteers to act as ‘champions’, helping create future activities and initiatives. The team includes clinical services director Christine Mozzamdar, group HR manager Korina Cook, brand executive Jenna Robertson, reception and administration manager Karen Barlow, and surgeon assistant Joanne Williams. Before embarking on their new roles, the team enrolled in the LGBT Foundation Champion programme as part of the LGBT Foundation’s Training Academy. The academy aims to increase people’s knowledge and confidence of LGBT inclusion at home, work and in the community.

News in Brief Dija Ayodele launches skincare guide for black skin Aesthetician and founder of Black Skin Directory Dija Ayodele is launching a new book for black patients. Ayodele explains that Black Skin: The Definitive Skincare Guide will be a comprehensive guide for black women to care for their skin as well as provide social and historical insights into beauty and the concept of blackness. The book will be available in hardback, audio and eBook in November 2021 and is currently available to pre-order at Amazon and Waterstones. Lumenis hires new sales manager Aesthetic device company Lumenis has appointed Andrew Snaddon as its new national sales manager for the UK and Ireland. Snaddon has worked in the aesthetics sector for 17 years and has gained an essential understanding of all aspects of the laser industry including product development, engineering/service, marketing, corporate finances, budgeting and new product launches, explains Lumenis. Snaddon commented, “I am privileged to join such a dynamic company which provides scientifically proven solutions designed specifically for our customers.” Vycel unveils new device to kill viruses in clinics Technology company Vycel has introduced the Electrostatic Sprayer, designed to remove viruses and bacteria from clinics. According to the company, the device projects a fine mist up to two metres across the room which aims to disinfect surfaces and clean the air it passes through. The device is compact and is battery powered, explains Vycel. Ken Parker, CEO of Vycel, explained, “Protecting patients and staff from viruses has never been more important, and thanks to their strict deep cleaning regimes, many clinics are cleaner than hospitals.” Epionce announces new KOL Skincare distributor Eden Aesthetics has appointed aesthetic practitioner Dr Carla Devlin as its KOL for skincare line Epionce. Dr Devlin has been working within aesthetics for 15 years, trained with training provider Harley Academy, and has worked with Epionce for more than four years. Dr Devlin commented, “I am delighted to become the new UK and Ireland KOL for Epionce. I will continue to evolve treatment plans for all skin types based on the wide range of Epionce products.”

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COUNTING The entire medical aesthetics community isDOWN TO THE reuniting at CCR 2021: are you ready? BIG AESTHETICS REUNION AT CCR 2021 14 + 15 October | ExCeL London, UK

Join the surgical and non-surgical disciplines at the UK’s leading event for education and raising industry standards. 14 + 15 October 2021 | ExCeL London Headline sponsor

CCR provides the central hub for exhibitors and organisations of both the surgical and non-surgical disciplines. CCR is proud to be the first large scale exhibition to be reopening CPD points | CCR Exclusive Press Conference | …And so much more! its doors and reuniting a booming industry which is set to bounce back quickly. This year, the conference hosts the International Society of Aesthetic Plastic Surgery (ISAPS), the British Cosmetic Dermatology Group (BCDG) and Aesthetic Complications Expert (ACE) Group REGISTER NOW! World. In a unique one-off, www.ccrlondon.com annual event, these organisations and others, come together to share information with the aesthetics community and inform and address thousands of visitors over the two-day show.

demonstrations | 150+ Leading Brands | In Practice Advice | 7 CPD Conferences & 80

Back to school As always, this year’s show will incorporate an unparalleled and comprehensive educational programme, all of which is CPD approved. October’s educational highlights include a one-day videoed cadaver training course with industry guru Dr Tapan Patel of London’s renowned PHI Clinic. Dr Tapan says: “I’m so proud to be returning to CCR this year to carry out a full-day cadaver course during which I will be demonstrating a range of educational techniques utilising a cadaver. Attending the course is a fantastic way to really study how to best treat your patients; the correct placement of filler and how and why complications might occur (and how to avoid them!) I’m so excited to share my experiences with my peers and to talk about how I administer treatment to achieve beautiful, natural-looking results.” There is an additional cost for this highly sought-after conference, but there are a large number of conferences that will be free-to-attend. Also, look out for the much-anticipated clinic management focus this year, which will provide some much-needed advice to help get aesthetic businesses back on track during the busy months that lie ahead. Acting Editor and Content Manager Shannon Kilgariff, who is co-ordinating CCR’s In Practice business conference comments: “After such a hard year for everyone within the specialty we want to offer as much advice as possible from as many viewpoints to our delegates, to make sure they feel they are well-armed to take on a post-Covid world. ‘In Practice’ will cover everything from mental health to social media platforms – we know that there will be something in there for everyone.”

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course as part of CCR’s agenda to improve patient safety and to provide a platform for discussions about the latest industry developments with the prevention and management of complications occurring in practices. There will be a paid-for part of the conference led by Dr Martyn and Sharon King which CCR expects to sell out quickly, and therefore encourages delegates to book their tickets as soon as possible. Furthermore, ISAPS will be producing two full mornings of surgical content which will be open to all surgeons and healthcare professionals. CCR is proud that along with the above revered organisations, the BCDG will also have a presence at the event. CCR is absolutely thrilled that Swiss pharmaceutical brand Galderma will be headlining as a sponsor and will come armed to the conference with some exciting news of their own. Galderma is the world’s largest independent dermatology company, present

New partnerships The ACE Group World, who are newly relocating their Conference to CCR, will also be hosting a half-day complications

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Swift who will be attending as a guest of Prollenium. Furthermore, CCR will be hosting other fabulous symposiums by Allergan, Galderma, Relife, Vivacy and Lumenis.

in approximately 100 countries. Their innovative, science-based portfolio ― of sophisticated brands and services across aesthetics, consumer care and prescription medicine ― makes them an ideal partner for the conference and their news is awaited with great anticipation. The brand will be celebrating 25 years of Restylane, as well as bringing Sculptra under the Galderma umbrella. Of their involvement in the event, Joanna Neal, Galderma’s brand manager comments: “We are thrilled to be headlining at CCR 2021. For us, this year’s CCR is a must-attend event, and we always look forward to hearing about the latest developments within the industry. Our brand is ever-evolving, and we are so excited to be sharing our news to all of the CCR attendees – we’ve missed attending events such as these and can’t wait to be face to face with old friends and colleagues once again!” This year CCR’s Surgical Arena will incorporate the ISAPS Symposium UK, which will bring to life a surgical agenda, presenting cutting edge, innovative surgical procedures focusing on breast and body. The Symposium will be open to all plastic surgeons for whom a dedicated networking lounge will be available where exhibitors can also access and meet with the delegates. This new addition to the UK’s leading medical aesthetics event will unite the UK’s aesthetic plastic surgeons under one roof, integrating surgical education and networking into CCR to enable true cross-fertilisation of knowledge between surgical and non-surgical practitioners. The programme, which will be curated by Mr Naveen Cavale, ISAPS National Secretary and Mr Mo Akhavani, ISAPS Assistant National Secretary will involve presentations by both international and local speakers. Mr Cavale and Mr Akhavani will also be curating the content for the Face and Eyes section of the CCR Surgical Arena alongside the CCR conference team. CCR will also be hosting a number of incredible, world-renowned speakers including esteemed educator and innovator Dr Arthur

Hot off the press! CCR welcomes back Press Ambassador Francesca White, Tatler Beauty Editor at Large and Editor of the Tatler Beauty & Cosmetic Surgery Guide, and NEW for this year, Francesca will take on an additional role as Master of Ceremonies and compere for the first ever CCR Aesthetics Press Conference. On her role, Francesca comments: “I am thrilled to have been invited to be this year’s CCR press ambassador once again. It’s truly an honour and a privilege to be involved in THE show for both the surgical and non-surgical disciplines and to work with the most eminent practitioners in their fields. The new press conference element that I will be chairing for this year is hugely exciting and will provide the first and only press-specific closed event to obtain news of all the pioneering and most cutting-edge research, launches and advancements in the aesthetics market. I expect it to be a hot ticket for 2021 and the subsequent years!” With an unprecedented amount of media interest at CCR in 2019, including representatives from BBC Breakfast, Talk Radio, This Morning, The Guardian, and BBC Radio to name a few, CCR has developed a more structured press briefing format, open to any registered journalists. We now have a unique closed event for consumer and trade health and beauty journalists to get a concise briefing at the CCR Aesthetics Press Conference. Press can learn about what’s new and hear about those procedures and research papers that are making waves in Aesthetics. With a Q&A session to follow involving some of the industry’s most recognisable names, CCR is set to provide a completely unique and interactive forum to update and inform key, influential journalists. Courtney Baldwin, event manager at CCR and Aesthetics says: “We are honoured to welcome so many distinguished brands and prominent industry bodies to CCR this year. The event has always brought the entire medical aesthetics community together and 2021 is no exception. Our conference will be the first educational meeting this year to unite all specialties, and we can’t wait!”

Scan the QR code to register!

ccrlondon.com use invitation code 1125

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Identifying possible BDD Aesthetic practitioner Dr Reena Jasani recommends that practitioners implement routine screening during all initial consultations. She says, “Questions that practitioners can ask would include: which area(s) would you like treating and why? How frequently do you check or look at that area of your body? Have you had any previous cosmetic treatment and how satisfied are you with your previous treatment?” Miss Payne also suggests asking whether the treatment will increase the patient’s self-confidence and self-esteem. If there are concerns that the patient may have symptoms relating to BDD, Dr Jasani then recommends specific screening tools and questionnaires, such as the BDD QuestionnaireDermatology Version (BDDQ-DV). “By completing these questionnaires and having a consultation with the patient, the aesthetic practitioner will have a better idea of patient concerns, motivations and expectations. If BDD is suspected, a referral for psychological assessment would be an appropriate step to take for formal diagnosis,” she adds. Dr Jasani also emphasises that BDD should not be confused for insecurity, and vice versa, for which aesthetic procedures can be hugely beneficial. “From my own experience, the level of insecurity can range Aesthetics looks into the importance of being from someone being mildly self-conscious about the able to identify when a patient might be part of their body to being severely impacted by it suffering from BDD (but still may not have BDD),” she says, adding, “Their level of insecurity depends on multiple factors such Body dysmorphic disorder (BDD) is a psychological condition as their overall confidence in themselves, any recent significant life continually gaining more recognition in the aesthetics specialty. It’s events (such as a breakup or divorce), whether their flaw/concern is been estimated that around one in eight patients who present to facial also noticed by others – amongst other considerations. In the majority plastic and reconstructive surgery settings suffer from the disorder, of these cases, I find patients often feel empowered after undergoing although it’s likely to be underreported.1 In terms of the general cosmetic treatment. They feel better in themselves, have increased population, it is thought to affect 0.5% of people in the UK.2 Recently, self-esteem and confidence, and the results are satisfactory to both the reality star Katie Price stated that BDD could be the reason behind her practitioner and patient.” latest round of plastic surgery, having already undergone around 20 surgical procedures as well as numerous non-invasive treatments.3 Potential impact on practitioners Obsession with both invasive and non-invasive aesthetic procedures One study of the literature indicated that having a mental illness is and increased insecurity isn’t an unusual occurrence, and has led to often linked to dissatisfaction following cosmetic procedures.5 This is patients putting themselves in danger. One extreme example includes a main focus of the BAAPS course, and Miss Payne notes that a lot former model Hang Mioku, who injected herself with cooking oil after of the content will be aimed at how to manage patient expectations. practitioners refused her any further procedures.4 Therefore, it’s not She comments, “There is the patient who will go from practitioner only important for practitioners to be able to identify the condition, but also to be aware of how to get the patient correct support. The British Association of Aesthetic Plastic Surgeons (BAAPS) recently highlighted the importance of practitioner knowledge and skills in this area by launching a new psychology course for its members, aiming to equip surgeons with the necessary skills to respond to psychological factors in patient consultations. Plastic, cosmetic and reconstructive surgeon and BAAPS board member, Miss Caroline Payne commented, “BAAPS has run psychology courses before, but we have changed the emphasis in this new course to enhance the psychological skills of the surgeon in helping patients. BDD is a spectrum of symptoms and can be very mild to quite unsettling for the patient, so for those that work in the aesthetics industry, knowing how to unpack a patient’s needs and Miss Caroline Payne desires and isolate targeted goals can help us decide whether a patient has actual symptoms of BDD.”

Recognising Body Dysmorphic Disorder

"We must be there to help patients in the understanding of their expectations and whether they can be realistically achieved"

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to practitioner until they eventually see someone who will operate and then consequently you end up with an unhappy patient. We have to get the message across to practitioners that not all patients are suitable for surgery or other cosmetic procedures. If a patient comes to you after seeing multiple surgeons/practitioners, you should recognise that it’s highly likely that whatever you say will still not be acceptable to them in the long run. It is actually a lot harder to say no to patients than it is to say yes, so this is a skill that people need to equip themselves with.” Dr Jasani adds that where a patient feels that their cosmetic defect has not been addressed it can have a negative impact on the practitioner, as the patient may put pressure on them for further treatment, submit a negative review, raise a complaint, or in some cases, even seek litigation, making recognition at the initial stages important. She notes that she once had a patient attend for dermal filler treatment and then return a week or two later requesting further injections elsewhere on the face. This continued for a few weeks, with the patient pointing out a variety of perceived flaws which distressed her greatly. Dr Jasani explains, “I didn’t realise it at the time, but the patient was presenting with typical signs of BDD. She focused on a perceived flaw, sought treatment for this area and due to the nature of the condition, these compulsions continued as she moved onto other perceived flaws. Now, with my continued experience combined with the use of the screening questionnaire, I am now able to have a better understanding of patient motivations, which enable me to either treat them or refer them to the appropriate care pathway.”

Creating awareness Dr Jasani believes that aesthetic training providers should focus on incorporating mental health into their courses. She says, “I believe that it would be beneficial for BDD to be highlighted more in aesthetic training courses, so practitioners are better prepared when they see BDD patients. Aesthetic practitioners also have the responsibility to do further learning by reading informational websites and articles to increase their awareness of the condition, so a greater understanding can be created. This will allow us to support our patients in the best way possible.” Miss Payne agrees, adding that the role of a practitioner should be about more than just treating the patient based on what they ask for. She comments, “We must be there to help patients in the understanding of their expectations and whether they can be realistically achieved. We must not be there to simply get a consent, operate and leave the patient in psychological distress. After this last year in particular, it is not just the physiological wellbeing of patients, it is also the psychological wellbeing that we should be looking after.” REFERENCES 1. Jacob Dey, Masaru Ishii, Maria Phillis, Patrick J. Byrne, Kofi D. O. Boahene, Lisa E. Ishii, ‘Body Dysmorphic Disorder in a Facial Plastic and Reconstructive Surgery Clinic’ JAMA Facial Plastic Surgery, 17, 2015 2. OCD UK, Body Dysmorphic Disorder, <https://www.ocduk.org/related-disorders/bdd/> 3. Sarah Robertson, 2021, <https://www.thesun.co.uk/tvandshowbiz/14621296/katie-price-mum-amysurgery/> 4. Becky Evans, Woman Refused More Surgery, 2013, <https://www.dailymail.co.uk/news/ article-2320679/Korean-woman-Hang-Mioku-injects-COOKING-OIL-face-refused-plastic-surgery. html> 5. Malick, F., Howard, J. and Koo, J., 2008. Understanding the psychology of the cosmetic patients. Dermatologic Therapy, 21

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create anxiety. If a member of your team brings them in, stand up and welcome them. Be aware of your body language. Be comfortable and confident and, most importantly, smile.

Gather information

The Art of the Consultation Merz Innovation Partners Dr Emma Ravichandran and Dr Simon Ravichandran discuss the consultation and share two different patient journeys verbal behaviours indicative of a

The amount of information you can get out of a patient in just a few seconds is phenomenal. It only takes six seconds to identify non-verbal behaviours indicative of a personality trait, so think about what they are telling you with their words, body language and non-verbal cues. What are their motivations for treatment? It is also really good to think about the interaction from your point of view. What feeling do you get from this person? Do you want to treat them? When you develop relationships with your long-term patients, it is a two-way process. As humans, we often mimic other people’s body language. So if someone walks in and is laid back and relaxed, then instantly, the other person is more comfortable. If a patient walks in and has very closed body language, the natural human instinct is to mimic that body language. One of you needs to be the open one, and it has to be you.

The Calgary trait, sopast think 14 about whatDrs Simon Consultation andpersonality Over the years and Cambridge consultation framework they are telling you with their words, communication body language Emma Ravichandran have created a When you are gathering your information, Providing Structure and non-verbal Building Relationship to the Consultation skills are blueprint for the Clinetix consultation, you need to: cues. What are their motivations for treatment? frequently which combines the Calgary CambridgeInitiating the • Session Establish eye contact: let the patient Explanation and Planning undervalued. In It is alsoframework with a check-in/check-out know you are listening. really good to think about private practice, the interaction process adapted from airlines. • Encourage specificity: get details about from your point Gathering Information Closing the Session our livelihoods of view. What feeling do you get the big picture as well as the small picture. from this person? Do you want to are dependent treat them? Initiating the session • Summarise information: recap, check When you develop on patient satisfaction, so we need to relationships with your long-term for and correct misunderstandings and it is a two-way process. usinginto a mirror lifting They have got to have that luxury enhance the patient journey. There are patients,Before the patient even walks theand physicallymiscommunication. tissues or pointing to the patient’s feel, that emotional engagement. six components to consultation – basedAs humans, room, be organised and prepared. Clear • Practice active listening: respond to we often mimic other face. Always ask for permission We introduce the patient and the thought about and processed these consultation people’s on the Calgary Cambridge the notes from So your patient and visual and verbal cues about distress body language. if previous before touching a patient’s face. next steps to our receptionist and 1 thoughts. someone walks in and is laidGo back have them a conversation framework – with two overarching pillars: clear your mind. out and call the patient and explore further.while any and relaxed, then instantly, the Once you have decided on a transactions occur. Then we take in yourself and guide themtreatment into theplan, room. • Avoid interruption: studies have shown “She has had some tough times other person is more comfortable. you can discuss the them to the door. If they need a taxi, in the and seems less • past Building the relationship Thiswalks breaks down that barrier of having doctors interrupt their patient If a patient in and has very time frame, the downtime, which we order them a taxi. Whenafter they less comfortable than Georgia did but, language, natural you would do first than and the leave the clinic, we want them to • Providing structure to the consultationclosed body to walk into athe clinical room,treatment which can 15 seconds. on the other hand, she still has very human instinct is to mimic that body intervals between treatments. feel like they have just walked out of open body language and is a very language. One of you has to be the Louis Vuitton with a handbag. likeable feel a genuine The person. patientYou journey can be broken downopen one, and it has to be you. Closing the session warmness towards Jac and want to The The Calgary Cambridge consultation framework closing of the session is where Every patient then gets an email further into four parts: help her achieve her goal to be the When you are gathering your patients are often lost. 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If you ever want to shown doctors interrupt their come back and speak to me, just Go out and call the patient in patient after less than 15 seconds. get in touch. Use this QR yourself and guide them into the 3. If you need more time, time code to watch 18 Aesthetics | August 2021 There are several ways in which a room. This breaks down that barrier is good. People who rush into the videos and patient can derail the consultation. of having to walk into a clinical decisions are much more likely hear Georgia and

The Calgary Cambridge consultation framework personality trait, so think about what Providing Structure body language and non-verbal Building Relationship they are telling you with their words, to the Consultation cues. What are their motivations for Providing Structure body language and non-verbal Advertorial Building Relationship treatment? to the Consultation cues. What are their motivations for Initiating the Session Explanation and Planning @aestheticsgroup @aestheticsjournaluk Aesthetics aestheticsjournal.com Merz Aesthetics verbal behaviours indicative of a treatment? It is also really good to think about Initiating the Session Explanation and Planning The Calgary Cambridge consultation framework personality trait, so think about what the interaction from your point they with It is are alsotelling reallyyou good totheir thinkwords, about Gathering Information Closing the Session of view. 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If a patient walks in and has very time frame, the downtime, which we order them a taxi. When they mistake. You have to wipe that slate clean and approach comfortable than Georgia did but, on the other hand, she other person more comfortable. As humans, we is often mimic treatment plan, you can discuss theWe introduce them to the patient door. Ifand theythe need a taxi, face. Always ask permission closed body language, theother natural treatment youfor would dohas first and thebody leave the clinic, want them to patient with completely open mind. In Georgia’s still very open language and isawe ataxi. very likeable people’s body language. So If a every patient walks inaand hasif very before touching a patient’s face. next steps to our receptionist and time frame, the downtime, which we order them When they human instinct is to mimic that body intervals between treatments. feel like they have just Jac walked words, she language, wanted in her own person. 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everything organised. doctor they have ev f you are not ready to book and you decide this is not for you, hat’s ok. If you ever want to come back and speak to me, just get in touch. Us f you need more time, time cod s good. People who rush into the decisions are much more likely hea o regret the outcomes. What Jac nformation do you need to help the you make a decision?

’t just shake their hand and let m go out. Instead, walk them to door.

References: 1. Kurtz SM, results Silverman JD. Teaching and Communication Skills in Medicine. Oxford, UK: Radcliffe with deliver no pressure, and they should beLearningthem we go order them a taxi. walk When they leave may the the patient out. Instead, them to Medical Press, 1998. Merz Aesthetics UK & Ireland is seeking. You can also do this by the door. References: 1. Kurtz SM, Silverman JD. Teaching and Learning Communication Skills in Medicine. Oxford, UK: Radcliffe Medical Press, 1998.

References: 1. Kurtz SM, Silverman JD. Teaching and Learning Communication Skills in Medicine. Oxford, UK: Radcliffe Medical Press, 1998.

M-MA-UKI-1501 Date of Preparation June 2021

Aesthetics | August 2021

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craters, explains Dr Al-Niaimi. Another form of acne scarring is hypertrophic, which presents as thick, raised, and red in colour. These are rarer and often found on the body, as opposed to the face, Professor Al-Niaimi explains. Although understanding the different types of scarring is helpful, Professor Al-Niaimi adds that many patients actually present with a combination of all three types of atrophic scarring, and so your treatment plan will often need to address all three. He notes that there are a range of factors which can result in scarring, stating that it isn’t always predictable. “In terms of severity, acne can be categorised from mild to severe, with the latter being the most likely for causing acne scars,” Professor Al-Niaimi says, adding, “However, this isn’t always an indicator, and a family history of acne and acne scarring can also play a factor, as well as whether the acne was left untreated or whether the patient squeezed or picked at their spots while the acne was active.”

Addressing Acne Scars with Lasers Three practitioners discuss their approach to improving acne scarring using lasers Acne vulgaris is a common skin condition affecting up to 80% of young adults and adolescents, although it can be seen across all age groups.1 According to the NHS, about 3% of adults have acne over the age of 35.2 The presence of acne can come with many side effects and complications, with the most common being scarring. One UK study estimated that 0.7% of people with acne have severe acne scars, but some degree of scarring is estimated to occur in up to 90% of patients with acne.3 Scarring can be treated in a number of ways, for example by using topical skincare, dermabrasion, laser resurfacing, dermal fillers, non-ablative and fractional lasers, chemical peels, or any number of combination treatments. With the constant development of laser technology in aesthetic medicine, Aesthetics spoke to three practitioners about some of the newest devices on the market, as well as their preferred treatment approach for improving acne scarring.

Types of acne scarring When assessing different types of acne scarring, generalised atrophic scars are the most common form seen on the face, explains Professor Firas Al-Niaimi, consultant dermatologist and laser surgeon at the Dr Firas Al-Niaimi clinic, London. He notes that there are three main types of atrophic acne scars (Figure 1). These can be categorised as ice pick scars – small and deep holes in the surface of the skin; rolling scars – caused by bands of scar tissue that form under the skin, giving the skin a crepey appearance; and boxcar scars – round or oval

Icepick scars

Rolling scars

Figure 1: The different formations of acne scars

Boxcar scars

Hypertrophic scars

The psychological impact All three practitioners note that acne scarring can have a significant negative impact on patients, and studies on the psychosocial impact of acne have documented dissatisfaction with appearance, embarrassment, self-consciousness and lack of self-confidence.5,6,7 This has an impact on the consultation and treatment plan, explains Mr Rishi Mandavia, ENT surgical doctor and managing director of the Dr Tatiana Aesthetic Dermatology Clinic. He explains, “Our appearance has a big impact on the way we feel about ourselves, especially nowadays, with the rise in social media. The reason scarring affects our patients psychologically is because it’s something that’s very difficult to cover up, even with makeup. In my clinic, we carry out quality of life surveys and we really do notice a huge difference in the way that our patients feel before and after treatment. It’s something that plays a big factor in self-confidence.” Professor Al-Niaimi advises that this psychological impact is something practitioners should consider when discussing specific treatment plans and methods with their patients. He comments, “Someone might have what a physician would class as a ‘mild form’ of scarring, however it might have a resounding negative affect on the patient’s quality of life. In contrast, there could be someone with severe acne scarring, but they aren’t

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Before

After

“There are so many devices out there nowadays, so when thinking of onboarding a laser device in your clinic, you need to consider what your patient base is” Mr Rishi Mandavia

as affected by it, and so would be happy to receive a gentler treatment with less downtime.” It is important this is discussed with the patient. Dr Marwa Ali, resident aesthetic doctor at The Wellness Clinic, adds that other lifestyle factors also need to be considered. She states, “If you have someone that frequently travels to sunny destinations or is outside in the sun a lot, then they’re likely to not want a period of downtime after the treatment because the skin is very sensitive following a laser treatment. This is a big factor which comes into play – for example CO2 lasers are ideal for more impact and skin tightening, but they’re more aggressive which means a longer downtime. That’s why in-depth consultations are so important prior to the treatment, because it helps you to establish the best course of action for that particular individual. With aesthetics, and acne scarring specifically, there isn’t a one size fits all approach.”

fractional radiofrequency, and picosecond laser. The choice will depend on type/severity of the scars and the patient’s desires.″ For darker skin types, Professor Al-Niaimi explains that there is a higher risk of pigmentation when using ablative methods, so he typically chooses non-ablative fractional lasers as a first option in this instance. Mr Mandavia previously used a CO2 laser alone for treating acne scarring however, he has found that a combination of fractional CO2 laser and radiofrequency (RF) microneedling provides him with optimal results. He comments, “I’ve recently started using the Secret Pro device, which incorporates CO2 laser and RF microneedling all in one. I find that this works best on my patients because it offers a multi-layer approach in which the CO2 skin resurfacing application targets the epidermis, whilst the Secret RF microneedling technology allows you to reach different depths of the dermis layer of the skin. Therefore, you have a complete 3D approach for skin remodelling, Treatment approach and it can all be done on the same day, which is preferable for my patients.” Professor Al-Niaimi explains that there are Mr Mandavia notes that the procedure lasts two main types of lasers used in aesthetic for 40 minutes and results can be seen after medicine for acne scars: fractional ablative and one session. He comments, “This is not to say non-ablative. “Fractional ablative lasers target that the scarring has completely gone away various layers of the skin whilst simultaneously after the one session, but for me it’s all about creating an epidermal injury,” he says, meeting patient expectations and getting explaining, “However for non-ablative you are them to a point that they feel more confident targeting various layers of the skin but without in their skin. The main thing is that the causing any injury to the epidermis. I have predicted outcome has been communicated fractional ablative and non-ablative lasers, with the patient beforehand.” Mr Mandavia adds that the procedure Before After comes with approximately seven to 10 of downtime, which includes an average of five days of peeling. Dr Ali uses the Stellar M22 laser, which she prefers because it has several types of wavelengths which can be used to treat different Figure 2: 30-year-old patient after three sessions of Frax Pro spaced six elements of acne, and these weeks apart. Treatment performed by Professor Firas Al-Niaimi

Figure 3: Patient before and after a combination of CO2 laser resurfacing and radiofrequency microneedling. Treatment performed by Mr Rishi Mandavia

can be combined for different results. She says, “Firstly, you have the StellarIPL which can treat active acne by shrinking the glands used to create sebum, similar to the way that isotretinoin works. Then, there’s the ResurFX non-ablative skin resurfacing laser, which is what I use to treat the scarring. Thirdly, there’s the Q-switched Nd:YAG module, which can help treat the pigmentation that comes alongside the acne scarring, so it’s a great device to help tackle several things at once which gives my patients the best outcome.” A typical treatment session using the M22 ResurFX lasts for 30-45 minutes, Dr Ali explains. In terms of the number of treatment sessions, this varies from patient to patient. She says, “Everyone gets a bespoke treatment plan, and depending on the severity of the scarring, they may need to have three or four sessions, all spaced about six to eight weeks apart. I leave this amount of time between the procedures because it lets me see how their skin is responding to the treatment.”

Considerations Mr Mandavia notes that a patient’s ethnic roots will be a deciding factor in skin treatment and outcome. For example, if the patient is Asian or black, he emphasises that it is a lot more difficult to treat acne scarring because of the higher risk of postinflammatory hyperpigmentation, and so it is up to the practitioner to decide how to proceed. He notes, “You can use the Secret RF on darker skin types as long as you ensure you are performing the treatment at the deeper levels of the skin and not heating the more superficial layers of the skin. So for example, by only heating the dermis at 3mm, I am reassured that I am not heating the superficial layers. I can also reduce the

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Before

After

Figure 4: Patient before and after six treatments using the M22. Images courtesy of Dr Olga Yarish

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practitioner you should already be able to predict what you want to use, but it can give that extra confidence, especially to those newer in the specialty.” There are several side effects which can be expected following a laser procedure, which are normal and minimal, but should be communicated to the patient in the consultation, notes Dr Ali. She comments, “Patients will experience redness and peeling following a laser procedure, which typically lasts for about a week. But again, this really depends on the depth of acne scarring the patient has, whether they have dry or oily skin, and the level of pigmentation they have. It’s hard to tell patients an exact period of downtime but we always overestimate to manage patient expectations, and to ensure that they can be prepared for the period following treatment or make an informed decision as to whether they want to proceed.”

Aftercare amount of energy I am delivering to maximise safety. This has to be done with caution, so the most important thing for me to do prior to the treatment is a patch test. This will take place at least a month before the treatment, and it gives me the chance to see whether the patient experiences any complications. If you find that the patient responds well to a patch test, then it is usually safe to perform the full treatment.” Mr Mandavia adds that there have been many times where he hasn’t been happy with the result of the patch test, in which case he decided against proceeding with the treatment. He notes that this can be the case for any patient, and not just those with darker skin types. Dr Ali reminds practitioners that lasers need to be used with caution, as, like most other aesthetic procedures, there are always risks to treatment. She explains that these can include burning, further scarring, and infection, among others. Like Mr Mandavia, she always does a patch test on each patient, and waits at least 24 hours to see how the patient responds. She notes, “Practitioners also need to take their time and really observe the reaction of the patient’s skin throughout the treatment. If it’s used appropriately and properly, there should be no problems. Something I like about the M22 in particular is that it has computerised software where you can input the patient's details, such as skin type and concerns, and it then recommends the wavelength that would be appropriate for use. Of course, if you’re a trained medical

All practitioners interviewed note the importance of ensuring their patient maintains a strict topical skincare regime following the laser treatment. Mr Mandavia comments, “All patients need to be careful of the sun, because the skin will become extra sensitive and at increased risk of post-procedure pigmentation. I ask my patients to wear factor 50 SPF and implement strict sun-avoidance measures such as wearing hats and staying in the shade. For a CO2 laser specifically, I would also prescribe all my patients with antiviral medication and antibiotics to prevent infections. This is for one week prior to the treatment, and one week post-treatment. As always, it’s very important that you communicate the aftercare to your patient clearly, so that they can experience a good recovery after treatment and minimise the risk of developing complications.” Dr Ali also recommends that her patients use sun protection and advises them against using vitamin A derivatives prior to their laser treatment. She comments, “I ask my patients to stay away from anything that can disrupt the skin, for example retinol. They need to use gentle products, which also protect the skin barrier.”

thinking of onboarding a laser device in your clinic, you need to consider what your patient base is. What is the most common concern from the patients that you see, and what device can address these the best?” He explains that it’s also important to research any device extremely thoroughly and look at the evidence for successful treatment in the literature. He adds, “As with anything in aesthetic medicine, the most important thing when treating patients for any skin indication is that we are being safe and giving them the best results possible.” Professor Al-Niaimi adds that laser is a popular and trusted method for treating acne scarring because of the scientific backing it has received in studies and trials. He comments, “The evidence in literature about the results of laser treatments show a high efficacy, making this technology a trustworthy source for providing optimal results, so I think it’s something worth practitioners investing in for the benefit of both the clinic and the patients. The most important thing is to be comfortable and confident with your device, and to ensure you’re keeping yourself up-to date with the latest techniques and developments.” REFERENCES 1. NHS 24, NHS Inform, Acne, <https://www.nhsinform.scot/ illnesses-and-conditions/skin-hair-and-nails/acne> 2. NHS, Acne, <https://www.nhs.uk/conditions/acne/> 3. Professor Hywel Williams, National Institute for Health Research, Treating Acne Scars, 2021 4. Dr Renée Hoenderkamp, Treating Acne Scarring With Filler, Aesthetics journal, 2015, <https://aestheticsjournal.com/feature/ treating-acne-scarring-with-fillers> 5. R Fried et al., The Psychosocial Impact of Post-Acne Scarring, 2015, <https://www.hmpgloballearningnetwork.com/site/ thederm/site/cathlab/event/psychosocial-impact-post-acnescarring> 6. Kilkenny M, Stathakis V, Hibbert ME, Patton G, Caust J, Bowes G. Acne in Victorian adolescents: associations with age, gender, puberty and psychiatric symptoms. J Paediatr Child Health. 1997 7. Magin P, Adams J, Heading G, Pond D, Smith W, Psychological sequelae of acne vulgaris: results of a qualitative study. Can Fam Physician, 2006

Utilising laser in your clinic On adding a laser to your clinic offering, Mr Mandavia advises that practitioners should begin by looking at clinical trials and research. He notes, “There are so many devices out there nowadays, so when

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Treating Primary Hyperhidrosis Dr Rakesh Anand and Dr Emma Craythorne present an overview of the diagnosis and management of primary hyperhidrosis Hyperhidrosis is a common condition that can have a devastating impact on a sufferer. Not only is it underreported and underdiagnosed, but the significance and implications of the condition are often minimised.1,2 This article reviews the literature to help better guide healthcare professionals on the appropriate non-surgical approach to management, considering not only the location of involvement, but the individual as a whole.

Complications of hyperhidrosis Living with hyperhidrosis presents many challenges and impacts many aspects of daily life. The implications hyperhidrosis has on social and professional life, as well as mental and emotional health, cannot be underestimated. In addition, constant moisture from sweating can lead to chronic skin conditions.3,9,12 One study of 2,017 patients found the prevalence of anxiety and depression was 21.3% and 27.2% in patients with primary hyperhidrosis; higher than is reported in the general population.12

Definition Hyperhidrosis, or excessive sweating, is a common condition that can have profound psychological and social implications for the sufferer.3 It is defined by the secretion of sweat in amounts greater than is physiologically needed for thermoregulation. Sweat is produced by the eccrine sweat glands, which are distributed all over the body but are most numerous on the palms and soles.4 Hyperhidrosis can be classified by the presence of an underlying cause (primary or secondary) or by location (focal or generalised). Most commonly, hyperhidrosis is a chronic primary (idiopathic) condition; however, secondary medical causes or side effects of medications need to be excluded (Table 1).4

Prevalence and epidemiology The estimated prevalence of hyperhidrosis ranges from 1-5% of the population.5,6,7 The true prevalence of hyperhidrosis is unknown as it is often underreported by patients and underdiagnosed by healthcare professionals.1,2 The condition tends to start in childhood or adolescence but can occur at any age,8 and males and females are affected equally.9 Hyperhidrosis is uncommon in the elderly, reassuringly suggesting primary hyperhidrosis symptoms often improve with age.10

Some of the challenges and problems associated with hyperhidrosis include:11,13 • Effects on quality of life/impacts on activities of daily living – social embarrassment, relationship difficulties, impaired performance at work/school • Anxiety and depression • Bromhidrosis – unpleasant smell from by-products from bacteria living on the skin • Skin maceration with possible superadded bacterial or fungal infection • Pitted keratolysis – superficial infection on the soles of the feet characterised by pitting

Treatment Before selecting appropriate treatment, the practitioner must begin by considering the location of the sweating and combine this with factors such as the patient’s preference for treatment, as well as other factors such as availability, practicality, side effects, cost, safety, and efficacy. Table 2 outlines the suggested first and second-line therapies for hyperhidrosis dependent on location of involvement.13

Diagnosis Idiopathic hyperhidrosis that is localised to certain areas of the body is called primary focal hyperhidrosis. Primary focal hyperhidrosis (PFH) often affects the axillae, palms, and soles, but may also impact other sites, such as the face and scalp. It can also be multi-focal, affecting several sites of the body at the same, or alternating times. A consensus panel comprised of international practitioners suggested a diagnostic criteria for PFH.8,11 They proposed that the patient must display focal, visible, excessive sweating of at least six months duration without apparent cause, plus at least two of the following characteristics: • Bilateral and relatively symmetrical sweating • Interferes with daily activities • At least one episode per week • Onset before 25 years of age • Positive family history • Localised sweating stops during sleep

Examples Psychological

Anxiety

Physiological

Pregnancy, menopause

Cardiovascular

Heart failure

Infections

Chronic infection e.g. TB, HIV, and malaria

Malignancy

Lymphoma, myeloproliferative disorders

Endocrine or metabolic

Hyperthyroidism, diabetes mellitus

Neurological

Parkinson’s disease, hypothalamic lesions, stroke, peripheral nerve damage

Drugs

Cholinesterase inhibitors, antidepressants, pilocarpine; propranolol, ciprofloxacin, aciclovir, esomeprazole, opioids

Other

Drug/alcohol misuse or withdrawal

Table 1: Causes of secondary hyperhidrosis to consider4

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Axillary First-line therapies

• Topical antiperspirants • Topical glycopyrronium

Second-line therapies

• • • •

Botulinum toxin Microwave thermolysis Systemic agents Iontophoresis

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Palmar/plantar

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Craniofacial

• Topical antiperspirants • Iontophoresis

• Topical antiperspirants

• Botulinum toxin • Systemic agents

• Topical glycopyrronium • Botulinum toxin • Systemic agents

Table 2: Suggested first and second line therapies for primary focal hyperhidrosis13

Axillary hyperhidrosis Therapeutic options for axillary hyperhidrosis include topical agents, oral medications, botulinum toxin and microwave thermolysis. Topical antiperspirants Topical antiperspirants are often the first-line treatment for hyperhidrosis. They are inexpensive, well-tolerated, readily available and easy to use. Antiperspirants work by blocking sweat glands to reduce the amount of sweat, and deodorants control the odour associated with sweating.14 The concentration of metal salts (usually aluminium chloride) in commercially available antiperspirants is low and are only really effective in managing mild to moderate symptoms.14 Prescription antiperspirants such as 20% aluminium chloride hexahydrate may be effective at managing hyperhidrosis in those who fail to respond to commercially available preparations.14,15 When the topical metal salt is applied to the skin there is precipitation of metal ions with mucopolysaccharides. This leads to damage of epithelial cells within the sweat ducts, which in turn, leads to a formation of plugs which blocks these ducts.14 A common concern about aluminium in antiperspirants is that it’s linked to cancers, specifically breast cancer. However, no studies to date have produced evidence linking the use of aluminium-containing antiperspirants with an increased risk of breast cancer.16 Topical glycopyrronium Glycopyrronium is an anticholinergic drug that aims to prevent sweating through inhibiting the action of acetylcholine on the sweat glands. It is applied once daily with an impregnated disposable wipe.17 Glycopyrronium is an anticholinergic, and as it is not systemically absorbed, side effects are unlikely. However, patients have reported adverse anticholinergic effects.17 Trial data supports the use benefit of glycopyrronium when looking at both patient reported and objective measurement of sweat production. As with topical antiperspirants, local irritation can occur, and some people may also experience systemic anticholinergic effects such as dry mouth. However, as glycopyrronium is poorly absorbed by the gastrointestinal tract and systemic effects are unlikely with topical use. Topical glycopyrronium wipes can also be difficult to source and expensive.17 Botulinum toxin Botulinum toxin is licensed for the treatment of axillary hyperhidrosis and research suggests it is safe and effective.18 It is delivered by multiple intradermal injections into the dermis using a fine gauge needle; approximately 10-20 injections spaced 1-2cm apart are delivered in each axilla.18 Botulinum toxin works by inhibiting acetylcholine release from the sympathetic cholinergic nerve terminals that innervate sweat glands. By blocking the release of acetylcholine, botulinum toxin

can temporarily reduce sweat production.18 Most of the literature either describes Botox or Dysport (Azzalure), although other formulations are likely to have the same benefit. The average doses per axilla is Botox: 50-100 units and Dysport/Azzalure: 100-300 units.18 In one randomised control trial involving 320 patients injected with 50 units of Botox into each axilla, 94% had an effective response at four weeks and 82% of patients at 16 weeks.19 The response to treatment is usually evident within the first few days and the effects usually persist for over three months. The duration of response is also likely to increase with subsequent injections.18 It should be noted that treatment can be painful, but topical anaesthetic can be applied to the axilla to reduce the pain from the procedure. It may also be expensive for some patients, which may be a limiting factor for its choice as a treatment.18 Microwave thermolysis The use of microwave energy has been supported by a randomised trial of 120 adults. Microwave energy is utilised to destroy eccrine glands and relieve hyperhidrosis in the axilla.20,21 Those who received active treatment reported a subjective reduction in axillary hyperhidrosis at 30 days, and this difference remained statistically significant at six months.22 An objective reduction in sweat was also seen, which was most significant for those that had a better response at 30 days.22 As the microwaves destroy the eccrine glands, the manufacturer reports that the benefits are permanent. Common side effects include altered skin sensation and localised discomfort. Transient ulnar and median nerve neuropathies have also been reported in some patients.23 The treatment is typically administered in two 20-30-minute treatment sessions separated by three months. The procedure is performed under local anaesthetic to minimise pain and discomfort however, the cost can limit the treatment choice. Palmer hyperhidrosis Many of the therapies used for axillary hyperhidrosis are effective for palmar or plantar hyperhidrosis; however, the approach to treatment may be somewhat different, and iontophoresis often plays a greater role in treatment. Antiperspirants As with axillary hyperhidrosis, prescription-strength antiperspirants can help with the symptoms of hyperhidrosis. However, research suggests there is a lower likelihood of success.14 Iontophoresis Sites of hyperhidrosis are immersed in water (or a wet contact applied) through which a weak electric current is passed. The exact mechanism of action is unclear, but treatment may temporarily inhibit the sweat glands.24 Iontophoresis is safe and simple to perform; it

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In one case series of 34 patients, where patients were prescribed glycopyrrolate alone or in combination with topical therapies, 67% reported an improvement in symptoms

should initially be performed by a healthcare professional, but once an improvement has been seen the machine can be purchased/ rented for home use.14 In one study with 18 patients it appeared to alleviate symptoms in approximately 85% of users with palmar or plantar hyperhidrosis. Reductions in sweating were noted within approximately two to four weeks with a 20-30-minute, three times weekly regimen. Side effects included dry cracked skin, erythema, discomfort and vesiculation.25 Time is generally reported as the biggest limitation for this therapy. Occasionally, the frequency and duration of treatments can be reduced, whilst maintaining adequate control of sweating. Special electrodes are available for use in other sites such as the axilla. The problem is that they do not always provide uniform contact with the skin and therefore can be less effective.26 Botulinum toxin Multiple studies support the use of botulinum toxin for palmar hyperhidrosis,27,28 but there are fewer studies in the use of plantar hyperhidrosis.29,30 The pain during the procedure is reportedly significant, but can be limited by a number of techniques including topical anaesthesia, cryo-analgesia and nerve block.31 The benefits of the procedure are noted within seven to 10 days and the effects persist for up to six months (ranging from 2-22 months).32,33 As with axillary hyperhidrosis, duration of benefit may increase with repeated procedures. Common complications include bruising and temporary muscle weakness.27 Average dose per palm or sole are: Botox: 50-100 units or Dysport/Azzalure: 100-240 units.32 Craniofacial hyperhidrosis The location on the face and scalp is a limiting factor for some hyperhidrosis therapies. The major treatment options include topical agents, oral medications or botulinum toxin. • Antiperspirants: Topical antiperspirants on the face are easy to apply and safe to use. Irritation can be significant and a limiting factor to their use.14

• Topical glycopyrronium: A small number of studies have shown some benefit of topical glycopyrronium for facial hyperhidrosis.34 The effects appear to last between one to two days; however, more studies are needed to explore the benefit as well as safety of treatment.35 • Botulinum toxin: A number of uncontrolled studies and case studies have documented the benefit of botulinum toxin for hyperhidrosis.36,37 Treatments needs to be carefully administered by those who have a good understanding of facial anatomy to avoid both cosmetic and functional compromise. Precautions and doses of botulinum toxin are dependent areas of the face requiring treatment.

Systemic treatments for primary focal and generalised hyperhidrosis Systemic therapies can be effective for generalised, focal, or multifocal hyperhidrosis. It is often considered when hyperhidrosis is not satisfactorily managed with other methods, as the potential adverse effects inhibit their regular and routine use.38 The most used agents are anticholinergics, which include propantheline, glycopyrronium bromide, oxybutynin, and benztropine.38 Oral anticholinergics, such as oxybutynin39 and glycopyrrolate40 (glycopyrronium bromide) decrease sweat secretion by competitive inhibition of acetylcholine at the muscarinic receptors near eccrine sweat glands. The use of oral glycopyrrolate is supported by retrospective case series. In one case series of 34 patients, where patients were prescribed glycopyrrolate alone or in combination with topical therapies, 67% reported an improvement in symptoms.41 Additionally, another study of 31 patients found that 71% achieved an improvement in symptoms during treatment with glycopyrrolate (with or without concomitant topical aluminium chloride).42 The use of oral oxybutynin is supported by randomised controlled trials.43,44 In one study of 60 patients over six weeks, 48% noted a great improvement and 26% a moderate improvement.45 Responses to oral anticholinergics usually take around one week for the maximal effect. Doses need to be carefully titrated to achieve acceptable reduction in sweating, whilst minimising any adverse effects. Potential adverse effects of anticholinergics include dry mouth, blurred vision, constipation, or urinary retention.40,42 Up to one third of patients cannot tolerate these symptoms and have to stop treatment.40 Anticholinergics are not recommended for those with glaucoma or urinary retention and caution should be practiced in older patients as there is an increased risk of adverse effects.46 Typical doses range for glycopyrronium bromide are from 1-2mg per day, but doses up to 8mg per day may be required.39 Typical adult doses of oxybutynin are a total dose of 5-10mg per day.45 This can be given as two divided doses for immediate release oxybutynin or once daily for modified-release oxybutynin.39 Higher doses of up to 20mg daily have been used, but this is very much dependent on the adverse effects the patient experiences.45

Surgery Although beyond the remit of this review, it is important to consider surgical options for hyperhidrosis. These should be considered as last-line therapies when a patient has not responded well to topical or systemic treatments. Local surgical treatments, such as surgical excision, liposuction, and curettage have been tried.47 Endoscopic thoracic sympathectomy (ETS) can successfully reduce sweating in the problem area, but is often reserved for the most severe cases

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Aesthetics Clinical Advisory Board Member and independent nurse prescriber Jackie Partridge says... Hyperhidrosis is a fact of life for many of our patients. It has a profound impact on their daily lives, as is well documented in this article. Gaining a full medical history is of paramount importance in order to give best advice for our patients and ensure that we aren’t treating something that could be masking a possible serious underlying health concern. Hyperhidrosis treatment should only be undertaken by a CQC regulated clinic in England and a HIS registered clinic in Scotland as it’s a medical condition. In my experience, patients suffering

owing to its potentially severe and irreversible side effects, such as compensatory sweating, extreme hypotension, arrhythmia, and heat intolerance.48 In ETS, surgeons interrupt the sympathetic chain by clipping the sympathetic nerves, in turn preventing activation of the sweat glands. It has been used for palmar, axillary, craniofacial, and sometimes plantar hyperhidrosis.47,48

Emerging therapies Alternative therapies that deliver energy to destroy or disrupt the eccrine glands are under investigation and have a limited number of studies supporting their use. These include ultrasound,44,49 laser,50,51,52 and radiofrequency microneedling.53 Radiofrequency microneedling is an emerging therapy in which energy is delivered into the deep dermis via insulated microneedles. In the short term, these therapies are likely to be expensive and scarce. Methods of combating the side effects of anticholinergic medications to make them more tolerable have also had positive results.54

Conclusion Hyperhidrosis can be primary or secondary, focal, multifocal or generalised. Secondary causes need to be excluded before treatment can be considered. Treatment should consider the location of involvement and the impact it is having on the patient. The psychological and social implications of the condition are not to be underestimated and this is why when selecting a treatment for hyperhidrosis a holistic approach is best employed. Treatment ladders are helpful as they recommend the use of the safest and most convenient options first and then progressing to those with broader side effect profiles if there are treatment failures or unacceptable control of symptoms.

with this condition tend to become patients of your clinic for a long period of time, and it’s important as a practitioner to build up a trusting relationship with your patients. In some cases, you might be sharing their treatment sessions with the NHS, and it would be wise to discuss sharing your clinical notes with the patient’s GP to ensure a continuation of medical care is adapted. Obviously, this should only be done with explicit permission of the patient. By sharing the treatment regime, you are making the NHS team aware of the ongoing condition and its impact on the patient. This could potentially encourage more frequent NHS appointments, which will save the patient money and demonstrate your ethical stance as a medical practitioner.

Test your knowledge!

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

Possible answers

a. b. c. d.

Anticholinergic medication Hyperthyroidism Pregnancy Infection

2. Hyperhidrosis is associated with…

a. b. c. d.

Warts Impetigo Scabies Pitted keratolysis

3. Iontophoresis cannot be considered

a. b. c. d.

Face Hands Axilla Feet

4. What is not a potential adverse effect

a. b. c. d.

Constipation Urinary retention Excessive salivation Blurred vision

5. What concentration of aluminium

a. b. c. d.

5 20 60 10

Which of the following is not a cause of hyperhidrosis?

for primary focal hyperhidrosis affecting the…

of an anticholinergic?

chloride containing antiperspirants should be considered if commercially available preparations fail?

Answers: 1. A, 2. D, 3. A. 4. C, 5. B

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

Dr Rakesh Anand is a London-based consultant dermatologist and fellow in Mohs micrographic surgery at the St John’s Institute of Dermatology. He has an interest in the procedural aspects of dermatology. Dr Anand believes in a holistic approach in achieving and maintaining healthy skin. This is informed by his training in psychology and behavioural neuroscience. QUAL: BSc (Hons), MSc, MB BS, MRCP (Derm) Dr Emma Craythorne is a consultant dermatologist, dermatological and laser surgeon and Mohs micrographic surgeon at the St John’s Institute of Dermatology at Guy’s and St Thomas’s Hospital NHS Trust. Dr Craythorne has expertise in all areas of skin scarring, skin cancer, general dermatology, and cosmetic dermatology. QUAL: MBChB, FRCP

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Treating the Abdomen with Cryolipolysis Dr Claire Oliver presents two female case studies on her approach to body contouring The desire for patients to improve their silhouette has led to an ever-increasing demand for non-invasive treatments that improve the body’s contours. This can be one of the most rewarding treatments to provide, both for patients and practitioners. Having personally undertaken more than 9,000 cryolipolysis treatments, I have found that men are almost exclusively concerned about their lower abdomen and flanks, whilst women are keen to look at treatment over a much wider range of areas including the lower and upper abdomen, the flanks, the inner and outer thighs, the arms, and the back. The development behind cryolipolysis stems from the clinical observation of cold-induced panniculitis.1 These observations led to the concept that lipid-rich tissues are more susceptible to cold injury than the surrounding water-rich tissue. With these historical observations in mind, Manstein et al. introduced a novel non-invasive method for fat reduction by freezing in 2007, termed cryolipolysis.2 This technique is performed by applying an applicator to the targeted area set at a specific cooling temperature for a pre-set period of time. This targets adipocytes while sparing the skin, nerves, vessels, and muscles. On average, fat cells in treated areas can be reduced by up to 27% and the results are permanent if a stable weight is maintained.3 A retrospective multicentre study by Dierickx et al. found that out of 518 participants, 73% reported being satisfied with the outcomes of cryolipolysis and 82% would recommend to a friend.3 In my experience, patient satisfaction is very high and there are minimal non-responders. This article outlines the successful treatment of two patients using the newest cryolipolysis device on the market and explains my approach to consultation and treatment protocols for optimum outcomes.

Patient consultation The first step when I begin working with a new patient is to schedule a 60-minute complimentary initial consultation. The key to this process is really understanding the patient’s primary concerns and identifying which treatment results will impact their lives in a positive way. After talking to the patient, I then take a full medical history. A detailed process of cryolipolysis is shared alongside examples of patient results. During a physical examination, I then discuss and establish realistic expectations for fat reduction, the sites for applicator placements and the number of cycles planned, based on a whole-body assessment. The majority of patients I find who enquire about cryolipolysis present to clinic after conducting research across a wide range of treatment options including liposuction. In my experience, these patients typically fall into three groups: 1. Those with busy lifestyles who have had children and are unable through diet and exercise to reduce pockets of fat and are keen to improve their silhouette and fit into their clothing again 2. Those who have been on a weight loss journey and require assistance in the final stage 3. Those who are planning for a special occasion or a holiday The best candidates are those within their ideal weight range and those who engage in regular exercise, eat a healthy diet, have noticeable subcutaneous fat bulges on the treatment area, have realistic expectations, and are willing to maintain the results of cryolipolysis with a healthy, active lifestyle. The treatment areas are then further prioritised to establish a plan to satisfy the patient’s needs, in keeping with their budgetary restrictions and lifestyle. Once the consultation is completed, information is provided together with a suggested treatment plan. The patient will have a minimum cooling-off period of 14 days, after which the

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clinic will contact them again to answer any further questions or to arrange treatment.

Treatment approach In my experience, the majority of female patients opt to treat their main area of concern in the first instance and gauge the results before seeking additional treatments in the main area or before moving to a new area, whereas male patients tend to prefer to undergo multiple treatments at once. In my clinic we use the CoolSculpting Elite, which is my preference because the treatment is comfortable for patients and can be managed without constant supervision, as well as having no downtime and instant results. On the day of treatment, the patient’s medical history is reviewed and updated, and baseline photographs and weight measurements are taken. We use a floor template to ensure consistency with before and after images is achieved and the treatment area is marked onto the skin using templates replicating the size of the applicators. The new CoolSculpting Elite system has a redesigned range of dual applicators. The applicator areas are thoroughly cleaned, and a gel pad is placed over the area to protect the skin’s surface, followed by the placement of the applicators. These are positioned centrally to the peak of the bulge to ensure maximum results. A small amount of vacuumpressure draws skin and adipose tissue into the cup (an increase of 18% with the new Elite applicators) securing placement and cryolipolysis begins. Each treatment cycle lasts for 35 minutes. Once the patient is comfortable, they can be left alone to rest, read, or watch a film while other patients are seen. If the patient needs assistance or the treatment cycle is nearing completion, we have an easily accessible call bell and a pager so the patient can alert the practitioner. As each cycle completes, the area should be vigorously massaged for two minutes to help accelerate the elimination process of fat cells. Massage has been shown to improve the clinical outcome, with one study indicating that it can improve results by up to 70%.4 Following the treatment, dead fat cells are permanently eliminated from the body through lymphatic drainage.

Case study 1 A 24-year-old woman (Patient A) presented to my clinic with concerns of a rounded tummy since adolescence and a dissatisfaction with how she looked and felt. She indicated in the consultation that she maintained a

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Before

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After

to check progress and week 12 to discuss full results. Photographs are taken at each review to plot the journey and to maintain engagement with the patient.

Potential complications

Figure 1: Patient A before and 12 weeks after one treatment session

healthy balanced diet and exercised four times per week. Despite undertaking a calorie-controlled diet for an extended period she had been unable to significantly reduce her abdomen. During examination, I found the abdomen to be soft, pinchable, subcutaneous fat with no visible skin laxity. I recommended a treatment plan of CoolSculpting Elite consisting of two cycles using C-240 (large) applicators to debulk the abdomen in the first instance. She was reviewed physically, and photos were taken at both week six and 12 where a noticeable reduction was seen. At her review, Patient A said she was delighted with her results, reporting her silhouette was more streamlined, her clothes fit better, and her general and body confidence had increased.

Case study 2 Patient B presented to clinic concerned with her ‘mummy tummy’. Aged 51, her medical records and consultation indicated she maintained a healthy balanced diet, exercised three times per week and is peri-menopausal. She had been unable to reduce the size of her abdomen area and was considering a range of treatments including liposuction. At examination, I found the abdomen to be soft, pinchable, subcutaneous, stubborn fat with skin showing minimal signs of laxity. A treatment plan was recommended of four cycles of Elite C-150 (medium) applicators to be placed – two in the lower and two in the upper abdomen area. A review at week six indicated a small visible reduction. The follow-up review at 12 weeks indicated a noticeable result and a recommendation to enhance the result with two further cycles of treatment using C-80 (small) applicators in the lower abdomen area. Patient B was very pleased with the results and is confident a follow-on dual sculpting treatment in lower abdomen area will provide the desired silhouette. Before

After

Figure 2: Patient B before and 10 weeks after one treatment session

Aftercare

Cryolipolysis has a high safety profile for body contouring and is accomplished with only minimal discomfort. However, as with any aesthetic procedure, there is always a risk of side effects. The common side effects are temporary and minimal, including erythema, bruising, and transient neuralgia. With a prevalence of 0.1%, late-onset pain is also a reported adverse effect.5 Cryolipolysis is safe for all skin types, with no reported pigmentary changes, and patients can benefit from repeated application.6 Cryolipolysis is contraindicated for patients with cold-induced medical conditions such as cryoglobulinemia and paroxysmal cold haemoglobinuria with sensitivities to inflammatory response as a result of exposure to cold temperatures (-1 to -7°C).6 Patient A and Patient B both reported erythema and swelling, most likely because of the strength of the vacuum and the temperature at which the tissue is kept for extended durations. This poses no threat to the patient. Both resolved between seven to 10 days post-treatment. Patient B reported reduction in sensation, which recovered in less than four weeks. Patient A reported late-onset pain, occurring two weeks post-procedure, and resolving without intervention at week four post-treatment.

Conclusion Cryolipolysis, when used for localised adiposities, continues to be a popular procedure for non-invasive fat reduction and body contouring and presents a compelling alternative to liposuction and other, more invasive methods. There is flexibility in terms of treatment areas and from my experience, results can be significant. The evolution to the new CoolSculpting Elite device has quickly improved the management of a popular treatment in clinic. Dr Claire Oliver is the medical director and founder of Air Aesthetics Clinics in Warwickshire and Birmingham, which was recently awarded The Cynsoure Award for Best Clinic Midlands & Wales at the Aesthetics Awards. She has more than 18 years’ experience in aesthetics and eight years of experience treating patients with cryolipolysis. Qual: GDC REFERENCES 1. Duncan WC, Freeman RG, Heaton CL. Cold panniculitis. Arch Dermatol 1966; 94:722-724 Epstein EH, Jr, Oren ME. Popsicle panniculitis. N Engl J Med 1970 2. Rotman H. Cold panniculitis in children: Adiponecrosis E frigore of Haxthausen. Arch Dermatol. 1966; 94:720-721 3. Manstein D, Laubach H, Watanabe k, Farinelli W, Zurakowski D, Anderson RR. Selective cryolysis: A novel method of non-invasive fat removal. Laser Surg med 2008 4. Dierickx CC, Mazer JM, Sand M, Koenig S, Arigon V. Safety, tolerance, and patient satisfaction with noninvasive cryolipolysis. Dermatol Surg 2013;39:1209-1216 5. Boey GE, Wasilenchuk JL. Enhanced clinical outcome with manual massage following cryolipolysis treatment: A 4-month study of safety and efficacy. Lasers Surg Med. 2014;46:20-26 6. Coleman SR, Sachdeva K, Egbert BM, Preciado J, Allison J. Clinical efficacy of noninvasive cryolipolysis and its effect on peripheral nerves. Aesthetic Plast Surg. 2009;33:482-488 7. Sasaki GH et al. Aesthetic Surgery Journal. 2014. 34(3) 420–431

After the treatment, patients are able to typically resume normal activities immediately post-treatment, however we recommend avoiding strenuous activity for 24 hours. Post-treatment care instructions are provided, which recommend a short massage of the area for a few days and guide as to possible physical after effects as the body continues to process fat cells. A telephone call is made 48 hours post-treatment to check-in and monitor these where relevant. Reviews are scheduled in week six post-treatment

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Thinning Temples in Women Mr Greg Williams explores the common causes for hair thinning in the temple area in women When a woman’s hair thins or recedes in the temples there is a self-perception, often negatively re-enforced by society, that her hairline is less feminine. This is because men have ‘M’ shaped hairlines, while rounded hairlines are considered normal for females.1 This can cause embarrassment, loss of self-confidence and even depression.2,3 Making an accurate diagnosis early is critical as some conditions are progressive and treating the cause can stop further hair loss. Most women, as they enter menopause, will experience a deterioration in their hair quality. This is part of a constellation of distressing symptoms that women are prepared by society to deal with. However, hair loss in women under 40 is less expected and is a cause of great concern.4 Not being able to pull back their hair in ponytails because of hair thinning in the temple area, and having to choose hairstyles that cover the area can

Figure 1: Congenital masculine hairline in a woman

be very upsetting. The degree of temple hair recession can be described in different ways, therefore, it is important to understand what is of concern to the patient so that expectations can be set against what is achievable.

Consulting women with thinning temples Hairs grow naturally on the scalp in groupings called follicular units that have one, two, three, four (and occasionally more) hairs emerging from a single orifice. The number of hairs per square centimetre is therefore determined by the number of follicular units per square centimetre, and the number of hairs per follicular unit.5 However, there are other factors that impact the appearance of hair density. These include hair diameter, hair curl, hair colour (as well as the contrast between hair colour and scalp skin colour), hair length, and exit angle of the hair from the

Figure 2: Temporal triangular alopecia. Image courtesy of Dr William Rassman

Figure 3: Frontal fibrosing alopecia

scalp surface. Consider, when a woman says that the hair around her temples is thinning, what does she mean? Does she mean that the diameter of the hairs is decreasing or that the number of hairs is less? Or both? Or does she mean that the area of deterioration is getting bigger? Like any medical condition, a thorough history is required including onset and rate of progression of the problem, any medical conditions, any medications being taken (prescription or recreational), and any vitamin/herbal/homeopathic supplements being used. An enquiry into eating habits and dietary composition, including protein intake, will also provide insight into the patient’s lifestyle.6,7 Telogen effluvium is the name for hair shedding that typically occurs three to four months after a stressful event.8 This can be physical stress like an illness, trauma or surgery, emotional distress or a negative psychological event. Asking specifically if any of these sorts of things happened in the previous months can reveal a possible contributing factor. It is likely that the hair loss associated with COVID-19 is due to telogen effluvium.9 Whilst we know that hair growth in women is affected by hormonal changes, the exact nature of which hormones are most important is not known. Noting the menarche, menstrual frequency, duration and severity, use of contraception and type, as well as any pregnancies and associated periods of breastfeeding is important.10 Taking a history in a woman with female pattern hair loss (FPHL) is far more time consuming than taking a history in a man with male pattern hair loss (MPHL). This is because there are so many more factors that can affect hair growth and hair loss in women. Whilst the epigenetic factors that affect the onset and severity of MPHL are poorly understood, they are even less well understood in women. However, there are specific conditions that should be ruled out when examining a woman who complains of hair loss in the temples and further specific questions that should be asked. Often the patient will have done some research on the internet and will present with a good idea of what is causing their hair loss. Many things that cause hair loss such as telogen effluvium, including medications, and dietary deficiencies (protein, iron, zinc, vitamin D) will present with global hair loss or hair deterioration rather than patterned hair loss affecting the temples symmetrically.

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Typical FPHL described by the Ludwig Classification involves the central scalp, rather than the temples, and often the hairline is preserved. Examination of the scalp and hairs under magnification with a folliscope will frequently make the diagnosis obvious, but sometimes a biopsy is required so that a histological diagnosis can be made. The below are some common reasons why women might present with hair loss and thinning hair around the temples. Congenital hereditary temple recessions Some women will have been born with an ‘M’ shape to their hairline or will always have had a lower hair density in their temples. In these women a small degree of localised or global hair loss might accentuate the problem so a question to ask is what their hairline looked like when they were a teenager (Figure 1).11 Temporal triangular alopecia (TTA) This will have been present form birth and, as the name implies, is a triangular area of hair loss which is usually unilateral but can occasionally be bilateral (Figure 2). The degree of thinning is variable, but the area involved can be completely bald.12 Polycystic ovarian syndrome (PCOS) This is the most common cause of hair loss in young women and other signs of hyperandrogenism such as acne, hirsutism and irregular periods, so this should be asked about.13 In young women with hair loss, the presence of these other symptoms/signs should alert the clinician to the possibility of PCOS, which would require further investigation to make the diagnosis. Male hormone producing tumours Whilst rare, a woman who has rapid onset of a male-shaped hairline should be appropriately investigated. This would be similar to what happens in female transgender patients who start on male hormones – their male phenotype is unmasked. Similar to the

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It is important to understand what is of concern to the patient so that expectations can be set against what is achievable differing distribution of facial and body hair that occurs in trans men, the degree and extent of MPHL in women exposed to high levels of male hormones is unpredictable.14 Alopecia areata This autoimmune non-scarring alopecia can involve isolated patches of hair loss which, rarely, might involve the temples. This condition should be easily diagnosed as the hair loss usually presents in a round shape, is very likely to be unilateral, and often has a rapid onset.15 Frontal fibrosing alopecia (FFA) This is an autoimmune scarring alopecia where the hair follicles are destroyed. Often the entire hairline recedes and there may be associated eyebrow loss, as well as affecting the hair on the temples (Figure 3). It is thought to be a separate entity from lichen planopilaris (LPP), which affects the scalp more globally but might be first noticed by the patient as thinning hair on the temples.16 Trichotillomania Compulsive hair pulling is sometimes subconscious and a patient might not be aware of the habit, but broken hairs are almost always visible on examination with a folliscope.17 Traction alopecia This is common in women with Afro-textured hair who have worn their hair in tight braids for long periods of time. It can also occur in any racial background where the hair is pulled tight, or weaves and extensions are

used habitually (Figure 4). If diagnosed early, it can be reversible.18 Genetically-predetermined temple hair loss This is the most common cause of thinning hair around the temples in women approaching middle age. A typical history is that the hair in the temples which once was thick and dense has become fine and sparse, resembling baby hairs that neither grow long nor quickly. It may be part of generalised female pattern hair loss, but the extent of the temple hair loss does not correlate with the severity of hair loss in the central scalp.19

Treatment Treatment of hair thinning around the temples is obviously tailored to the diagnosis. Dermatological conditions need specific treatments which often involve topical, injected or systemic steroids or other anti-inflammatory drugs. Hyperandrogenism is treated with antiandrogens and hair-friendly forms of contraception.20,21 Trichotillomania and traction alopecia are addressed by stopping the hairpulling habits. For genetically-predetermined thinning temples, it is worth trying topical minoxidil 2% liquid twice a day or 5% foam once a day, but it has to be used consistently for at least six months before the benefit can be judged.22 The additional benefit might just be preventing further loss. Minoxidil can also be used in oral form off-licence, as can other medications that have antiandrogen properties such as spironolactone and finasteride.23,24,25

Before

Figure 4: Traction alopecia in Caucasian and Afro-textured hair

After

Figure 5: Before and after scalp micropigmentation. Images courtesy of Finishing Touches Group.

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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After

Figure 6: 62-year-old patient with thinning hair on the temple before and after hair transplant surgery.

There is a whole industry in hair makeup from coloured hairsprays and microfibres, to hair coloured scalp creams. Scalp micropigmentation can reduce the contrast of pale skin and darker-coloured hair (Figure 5) but needs to be done with caution in women with lighter hair colours because of the risks of blended pigment colours changing over time. Microneedling intended to cause microtrauma to the skin and stimulate repair might be beneficial, as might be low level light therapy (laser combs, bands and caps) and platelet-rich plasma injections.26,27 As long as there is no contraindication, hair transplant surgery is the most reliable way of restoring good quality hair coverage in women with thinning temples (Figure 6).

Mr Greg Williams is a hair transplant surgeon and member of the British Association of Aesthetic Plastic Surgeons (BAAPS) who currently works at the Farjo Hair Institute. He has more than 15 years of experience in hair restoration for hereditary male/female pattern hair loss, as well as alopecia from burns, trauma and other aetiologies. Qual: FRCS (Plast)

Understanding hair loss A better understanding of the causes and treatment options that are available can be very reassuring for women presenting with hair loss concerns. There are a wide range of options from cosmetic camouflage to topical and systemic medications, including non-invasive, minimally-invasive non-surgical treatments and hair transplant surgery. The first step to supporting your patients, if you are not experienced in treating hair loss, is to seek a well-qualified trichologist or a hair specialist dermatologist to make the diagnosis and suggest appropriate treatment. Then, if surgical hair restoration is desired, a consultation with a reputable hair transplant surgeon can start the journey to resolving the problem.

VIEW THE REFERENCES ONLINE! WWW.AESTHETICSJOURNAL.COM

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Assessing and Augmenting Lips Dr Ayad Harb and Dr Yalda Jamali present five principles to lip assessment and treatment for successful results The lips are a universal symbol of beauty and youth and throughout history have evolved as one of the key sensual landmarks in the face. Lip adornments, colours and cosmetics that draw attention to the lips, date back to fourth century BC, when lipstick was first used by Sumerians.1 Furthermore, lips are the focus for facial symmetry and the triangle of beauty.2 Added to this, lips play an important role in phonation, communication, feeding and intimacy. With the rise in demand for lip treatments, lips have become one of the most popular areas that aesthetic providers learn to treat. Enhancement of the lips usually involves enlarging, defining, and reshaping. Undoubtedly, there are significant individual differences in lip appearances, however, through an in-depth knowledge of anatomy, comprehensive structural assessment and using an appropriate technique, a practitioner can achieve natural, safe, and repeatable results. Within Dr Ayad’s clinic, we have devised a methodical technique for lip assessment and treatment, based on five key principles, which helps us restore and maintain a natural appearance.

Lip development and ageing The development of the lips in the foetus is an intricate process that occurs between four to six weeks’ gestation.3 The upper lip and palate are formed by the fusion of the maxillary processes bilaterally with the medial and lateral nasal prominences. These fusion lines remain visible as anatomical and aesthetic landmarks in the fully developed upper lip. The lower lip and mandible are formed by the meeting of two mandibular processes which fuse in the midline.4 The anatomical layers of the lips are composed of skin, muscle, and oral mucosa. The distribution of the superior and inferior labial arteries can vary, but they are predominantly submucosal (78.1%). Some variations exist whereby the vasculature is intramuscular (17.5%) or subcutaneous (2.1%).5 The lips follow a familiar pattern of decline and ageing, similar to the rest of the face, with the formation of wrinkles, loss of definition and decline in volume within the lip, as well as structural changes related to the underlying bone and muscle. The oral commissures drop,

giving a downward turning of the lips and the intercommissural width reduces. Maxillary retrusion results in a reduction in maxillary angle and height, which leads to a more posterior position of the lip. Tooth loss and tooth wear can lead to a decreased projection of the lips. Lips can appear inverted and thinner.6 The skin in and around the lip shows typical signs of ageing, resulting from the decline in collagen and elastin within the dermis. The results are visible static and dynamic rhytids, which typically appear as vertical barcode lines. Loss of vermillion border definition, as well as flattening of the cupid’s bow are particular to the lips. Furthermore, as the epidermis thins and the dermal-epidermal junction flattens, this creates a suboptimal skin barrier that leads to water loss and dry lips.6 A decline in the orbicularis oris muscle tone leads to a widening of the lip, as well as a reduction in lip height. A combination of muscle and skin laxity results in elongation of the cutaneous lip. An increased tone of the lip depressors, particularly the depressor anguli oris, contributes to the down-slanting appearance of the oral commissures, so is a characteristic of the ageing lips.6

Five principles of lip assessment For our lip assessment approach, it is considered in five components: lip volume, lip height, vermillion border and landmarks, oral commissures, and perioral skin condition. Each component is assessed separately, and a decision is made regarding the most appropriate treatment, if any.

Maxillary retrusion results in a reduction in maxillary angle and height, which leads to a more posterior position of the lip

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variations need to be considered. Vermillion height in Caucasian patients is lower when compared to lips of black or Asian patients. For example, Korean patients have a more diamond lip shape, and Chinese and black patients have an increased upper lip volume and increased vermillion height.10 There are also variations between male and female patients. It is important to note that narrower and wide lips are generally more favourable in men.11

After

Figure 1: 25-year-old patient before and after 1ml of Teosyal RHA 2 filler

1. Volume, symmetry, and proportion The assessment begins with the patient at rest, examining the top to bottom lip ratio from a frontal view. It is thought that the top to bottom ratio of 1:1.6, is ‘the golden’ and most ideal proportion in patients. However, ethnic differences need to be considered, for example black lips are found to have a 1:1 ratio.2 Anterior projection of the lips is assessed from the profile view. The projection of the lips in relation to other anatomical features, including the nose tip and chin, need to be examined. Analytic reference lines such as Ricketts, Steiner and Burstone may be used for assistance.7 It is common to assess the lips in a static position only; however, accounting for dynamic movement can help achieve more natural results as it will aid in lateral and medial volume assessment.8 Therefore, dynamic examination should include the patient fully smiling with a clear tooth show and the patient pursing the lips. It is generally accepted that lip volume is a personal and subjective decision that a patient can decide for themselves, based on personal preference and lifestyle. However, duty of care dictates that a medical professional must help the patient understand the natural limits of any desired volumetric enhancement. Furthermore, signs of unnaturally or disproportionally volumised lips should be pointed out to the patient and further volumisation should be avoided. 2. Vermillion border and landmarks The natural aesthetic landmarks of the lip border are assessed, paying special attention to the vermillion border, cupid’s bow, philtral columns and philtral dimple. The vermillion border should ideally be a sharp demarcation between the lips and the surrounding skin, giving definition to the lips. Initial consideration is given to the integrity of the vermillion border. Ageing and lifestyle choices, such as smoking, can weaken and thin the appearance of the vermillion border.9 3. Vermillion height The vermillion height is the distance between the superior and inferior vermillion border. Lip volume directly impacts this. Achieving an increased vermillion height is commonly sought after, but ethnic

4. Cutaneous upper lip The upper cutaneous lip has skin superior to the vermillion border. This area can be divided into philtral and lateral subunits. This region is assessed for the presence of dynamic and static rhytids, pigmentation, scars, and the overall condition of the skin. Perioral vertical lines become visible as we age due to continuous activity of the orbicularis oris muscle, as well as collagen and elastin degradation within the dermis. Assessing the patient as they purse their lips, accentuates these lines. The philtrum and philtrum height should also be assessed, as with age they flatten and lengthen. It is essential to visualise the upper red lip and the white lip proportions when treatment planning. The ideal height for the philtrum column is around 11-13mm in females and 13-15mm in men.2,12 5. Commissure The commissures are the corners of the mouth, where the top and bottom lip vermillion borders connect. The downward turning of the corners of the lips is a common aesthetic concern and worsens with age due to reduced structural support. Depressor anguli oris overactivity can also impact this drastically. This area should be assessed at rest and during dynamic movement.

Five principles of treatment After systematic assessment of the five components of the lip is complete, a suitable treatment plan can be formulated and followed in the same logical and methodical way. It is important to note that patients may require treatments to none, some, or all components. For example, young patients may well benefit from added volume and vermillion height, however, they will almost certainly not require commissural or perioral treatment. Before

After

Figure 2: 42-year-old patient before and after 1ml of Teosyal RHA 1 filler

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Before

5. Commissure Oral commissures can also be treated with neurotoxin and dermal fillers. Neurotoxin can be used to target the depressor anguli oris, whilst the oral commissures can be supported using dermal filler. Dermal filler is injected directly inferior to the fold and 5mm lateral to the mandibular ligament using a fanning/transverse threads technique.

Conclusion Methodical, anatomical assessment and appropriate, systematic correction should remain central in our practice. The external appearances that we recognise as signs of abnormality or ageing are dictated by the underlying anatomy and the predictable changes within the constant layers of the lip. Assessment of the lips should be anatomical and follow a systematic process. Aesthetic enhancements should stick within the natural boundaries and landmarks to restore and maintain a natural appearance. By following this five-step assessment and treatment system we can provide patients with accurate assessments and reliable, appropriate, and safe treatments. Additionally, we find that it eliminates unnecessary treatment and reduces risk of overtreatment, migration, or unnatural results.

After

Figure 3: 46-year-old patient before and after 1ml of Teosyal RHA 2 filler

1. Volume Volume should be injected within the tubercles (three in the upper and two in the lower lip) which are the natural volume centres of the lips. The filler is placed superficial, supramuscular and within the anterior dry mucosa. Broken linear threads or micro-blouses are preferred over large single bolus injections. 2. Vermillion border This should only be treated if indicated following assessment. It is an area that is commonly overtreated, especially in young patients with no vermillion border requirement. Injections should be extremely superficial, slightly inferior to the border and remaining within the pink lip. From our experience, this helps to reduce the risk of migration and expansion of filler into the cutaneous lip. 3. Vermillion height The most common approach to lengthen the vermillion height is ‘tenting’. This is where injections involve vertical retrograde linear threads, commonly starting at the vermillion border and aiming towards the wet-dry junction. However, our preference is to direct the vertical tenting injections from the wet-dry border towards the vermillion border. The aim is to reduce the risk of arterial injury or vascular occlusion, as well as reducing the risk of filler migration into or above the vermillion border. 4. Cutaneous lip This area can be treated by using a combination of neurotoxin, dermal filler with or without subcision and resurfacing with medical skincare, chemical peels, and lasers. A small dose of neurotoxin can be placed in the orbicularis oris muscle to reduce the strength of dynamic vertical perioral lines. These lines can be further reduced by intradermally blanching a low G’ filler. For deeper ‘barcode’ lines, subcision and superficial fat volumisation may be necessary. The philtrum columns can be redefined by injecting intradermally from the white vermillion at the Glogau-Klein points towards the columella.

Dr Ayad Harb is a world authority in non-surgical nose correction and has published seminal papers and book chapters on this subject. Dr Harb is also heavily involved in training, being a global key opinion leader in facial aesthetics and director of Aesthetic Intelligence, a training academy focused on advanced aesthetics. Dr Harb is the medical director and principal surgeon at Dr Ayad Clinics in the UK and Dubai. Qual: BM, FRCS(plast) Dr Yalda Jamali is a UK trained medical doctor, holds a Level 7 postgraduate qualification in aesthetic medicine and is currently completing a masters in clinical dermatology. She is an experienced aesthetics trainer and is the owner of Dr Yalda Clinics in the UK. Dr Jamali recently relocated to Sydney, Australia. Qual: MBChB, Level 7 REFERENCES 1. Gout, U. (2013). Anatomy & lip enhancement. E2c, pp.8–9. 2. Sito, G., Consolini, L. and Trévidic, P. Proposed Guide to Lip Treatment in Caucasian Women Using Objective and Measurable Parameters. Aesthetic Surgery Journal, [online] (2019). 39(12), pp.NP474– NP483. 3. Yoon, H., et al., Development of the lip and palate in staged human embryos and early fetuses. Yonsei Medical Journal, [online] (2000) 41(4), pp.477–484. 4. Wyszynski, D.F. and Sperber, G. (2002). Cleft lip and palate: from origin to treatment. 1st ed. New York: Oxford Univ. Press, pp.5–14. 5. Cotofana, S., et al., Distribution Pattern of the Superior and Inferior Labial Arteries: Impact for Safe Upper and Lower Lip Augmentation Procedures. Plastic and Reconstructive Surgery, [online] (2017) 139(5), pp.1075–1082. 6. Foutsizoglou, S. Anatomy of the ageing lip. [online] The PMFA Journal. (2017). 7. Hsu, B.S. (1993). Comparisons of the five analytic reference lines of the horizontal lip position: Their consistency and sensitivity. American Journal of Orthodontics and Dentofacial Orthopedics, 104(4), pp.355–360. 8. Johnson, M. (2016). Genioplasty. Facial Plastic and Reconstructive Surgery, pp.281–293. 9. Lopez-Jornet, P., Camacho-Alonso, F. and Rodriguez-Espin, A. Study of lip hydration with application of photoprotective lipstick: influence of skin phototype, size of lips, age, sex and smoking habits. Medicina Oral Patología Oral y Cirugia Bucal, (2010). pp.e445–e450. 10. Wong, W.W., Davis, D.G., Camp, M.C. and Gupta, S.C. Contribution of lip proportions to facial aesthetics in different ethnicities: A three-dimensional analysis. Journal of Plastic, Reconstructive & Aesthetic Surgery, (2010), 63(12), pp.2032–2039. 11. Patel, J.R., et al., (2011). A comparative evaluation of effect of upper lip length, age and sex on amount of exposure of maxillary anterior teeth. The Journal of Contemporary Dental Practice, [online] 12(1), pp.24–29. 12. Kar, M., et al., Is it possible to define the ideal lips? Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale, [online] (2018) 38(1), pp.67–72.

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Using RF in the Periorbital Area Dr Sheila Nguyen discusses using radiofrequency to enhance and rejuvenate the eye area and presents a successful case study of a male patient The demand for surgical intervention from male patients is rapidly increasing, and interest in non-invasive approaches has also grown. In fact, according to the American Society of Plastic Surgeons, there has been a 101% increase in men getting soft tissue fillers since 2000.1 What’s more, patient demand for non-surgical skin tightening with little downtime and preservation of the epidermis has increased 600% in the past 15 years.2 We’re also in a digital age now wherein patients of all genders are much more image focused, and the patients I see in my clinic are much more knowledgeable too. So, we are working with a much more informed population who are now able to research potential treatments thoroughly themselves. For many of my male patients, I am particularly seeing an increased interest when it comes to non-surgical procedures for the eye area, which has been increasingly popular because of the requirement to wear masks.

Ageing of the periorbital area The eyelids are the most delicate areas of the face due to their structural complexity and function, and the eyes are often an area that can first show obvious signs of ageing because the skin is typically thinner, more delicate and susceptible to structural changes around it.3 This includes things such as flattening of the mid-face fat pad, which can have a direct impact on its appearance, causing concerns like fine lines, dark circles, excess skin and prominent eye bags. Wrinkles are the most common complaint I am presented with, mainly due to the fact that the glabella and lateral canthal lines have been shown to be some of the most visible lines of expression that contribute to the aged appearance of the face.3

it with botulinum toxin or dermal filler injections. While, traditionally, ablative and nonablative lasers were the primary mechanisms to improve skin laxity non-surgically, these treatments came with associated risks such as burns and pigmentation changes.4 Alternatively, radiofrequency can be an incredibly effective, non-invasive treatment option. Resistance encountered by the RF energy flow causes a build-up of heat in the skin, which induces an immediate contraction of the collagen (an ‘instant lift’) and stimulates a natural wound-healing response, causing the production of new skin cells and collagen.5 When focused in the dermis and hypodermis, radiofrequency treatment can lead to improvements in the skin structure and tightening of lax and sagging skin.5 Typically, the most frequently reported side effects for this treatment are swelling and redness. These side effects usually dissipate within a few hours, but may last for a few weeks in extreme cases. Some patients have reported bruising as a result of their radiofrequency treatment, but again this is extremely uncommon.7

I am increasingly finding that radiofrequency devices offer an effective standalone treatment for treating lines in the glabella and lateral canthal area

Rejuvenation with radiofrequency There are, of course, a number of modalities which we can use to improve various aspects of skin ageing. However, I am increasingly finding that radiofrequency devices offer an effective standalone treatment for treating lines in the glabella and lateral canthal area. It can also be used as a combination therapy for maximum results. For example, combining

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Before

After

Before

After

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that the hotter it is, the more effective the treatment becomes. In this particular case, we were able to use the treatment at a high heat. The one-off treatment took approximately 60 minutes, but the time may vary from 30-90 minutes in other areas depending on the size. Immediately after the treatment finished the patient’s skin was slightly pink and a bit sensitive, which is to be expected. The patient was advised not to do vigorous exercise or come into contact with extreme heat for 48 hours to allow for the skin to recover. As well as the expected sensitivity, the patient commented that the skin felt noticeably tighter and smoother. The patient also noticed an immediate improvement in skin condition in this area, which continued to improve for the next six months. Following treatment, the patient was advised to use a hydrating eye cream and the ZO Skin Health daily sheer broad spectrum SPF, due to its protection against both UVA and UVB rays and hydrating properties. I also schedule a follow-up consultation in nine months to see when another treatment would be needed. The results of the treatment are expected to last up to two years, but a followup consultation at nine months enables us to understand patient requirements and whether top up treatments are required.7

Conclusion

Figure 1: 60-year-old patient before and immediatley after one treatment using Thermage FLX. Images taken by Aesthetics Lab

Case study A 60-year-old male patient presented to my clinic with concerns surrounding the eye area. In particular, signs of ageing with a focus on fine lines around the eyes and crow’s feet. The patient hadn’t undergone any previous treatments and wanted a procedure that would have little downtime and give an incredibly natural and yet refreshed result. The consultation began with a discussion about the possibility of using botulinum toxin to soften the lines as well as topical skincare. However, the patient ideally wanted a less-invasive no-needle treatment, and also requested something that would be fast acting without the need of multiple sessions. I therefore suggested radiofrequency as an alternative. Although many radiofrequency treatments require multiple sessions, the technology I use called the Thermage FLX only requires one session, which appealed to the patient. Treatment Firstly, the return pad was placed onto the patient’s skin around the eye. This is attached to the device to create a return path for the radiofrequency energy, which helps to prevent electrical burns.7 The treatment area was then mapped by applying a grid around the eye. A coupling fluid was then put onto the skin; I have found that applying a generous amount of gel tends to reduce the patient’s discomfort level as it helps the handpiece to glide easily over the skin and distribute the energy evenly. Using the device I targeted the specific eye areas of concern, and as this happened the patient described a succession of warm bursts onto the skin. This feeling is caused by the radiofrequency technology which heats the deeper, collagen-rich layers of the skin to offer a deep rejuvenation of tissues. The heat can be turned up or down according to the patient’s pain threshold, but I've found

Radiofrequency treatments are an extremely effective non-invasive way to tighten skin around the eye area, with very little downtime. They’re becoming an increasingly popular alternative to traditional surgery as they can demonstrate visible results, which can last for up to two years. They also have a relatively short recovery period, which is especially appealing for male patients. Dr Sheila Nguyen is a cosmetic dentist based at Aesthetics Lab. She qualified as a dental surgeon from King’s College London, and also holds a first-class honour’s degree in Biomedical Science. Dr Nguyen is one of the lead trainers at The London Academy of Aesthetic Medicine and over the last six years has delivered non-surgical injectables training to more than 900 doctors, surgeons, dentists and nurses. Qual: BDS, BSc REFERENCES 1. American Society of Plastic Surgeons, Plastic Surgery Report, 2018, <https://www.plasticsurgery.org/ documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf> 2. Dayan E, The Use of Radiofrequency in Aesthetic Surgery, Plastic Reconstructive Surgery, 2020 3. Mendelson B.C, O’Brien J.X., The Aging Face. In: Scuderi N., Toth B. (eds) International Textbook of Aesthetic Surgery. Springer, Berlin, Heidelberg, 2016 4. Atiyeh BS, Dibo SA. Nonsurgical nonablative treatment of aging skin: radiofrequency technologies between aggressive marketing and evidence-based efficacy. Aesthetic Plast Surg. 2009 5. E. Finzi, A. Spangler. Multipass vector (mpave) technique with nonablative radiofrequency to treat facial and neck laxity. Dermatol Surg. 2005 6. Castelo-Branco C, Duran M, González-Merlo J. Skin collagen changes related to age and hormone replacement therapy. Maturitas. 1992 7. Thermage FLX, Thermage Skin Tightening Treatment, <https://www.thermage.com/>

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

Hyaluronic acid filler

0123

Croma offers a complete range of HA fillers. The products are based on hyaluronic acid of non-animal origin and are manufactured in accordance with the highest quality standards. Safety and efficacy are clinically proven. Learn more about saypha® at croma.at. The medical practitioner confirms having informed the patient of a likely risk associated with the use of the medical device in line with its intended use.

SADB2B1220

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durations after the procedure, with some side effects such as erythema lasting for many weeks, remain unappealing. These days, fully ablative CO2 treatments have now largely been replaced by fractional treatments; nevertheless, fully ablative lasers may still be used for treating wrinkles, acne and atrophic scars alongside surgical procedures.

Fractional CO2 lasers The notion of fractional photothermolysis was introduced almost a decade ago to address the main shortcomings of non-fractionated ablative lasers. Fractionating the ablative laser energy into smaller individual spot sizes allows practitioners to maintain resurfacing power while covering only a fraction of the treated area (usually 5-30%) allowing for rapid re-epithelialisation from the intact, adjoining epidermis.6 The improved safety profile further reduces the usual recovery time required for ablative treatments, whilst also minimising post-treatment side effects such as oedema, burning, crusting, and erythema, which can last months.7,8 Clinical side effects Mr Ali Ghanem explores the considerations for are much rarer, with most side effects being adding CO2 lasers to your treatment offering minor and transient following fractional CO2 therapy.9 Tierney et al. recently published Since its inception in the mid-1990s, CO2 laser skin resurfacing a review specifically comparing non-ablative fractional lasers with has long been the gold standard for reducing wrinkles, smoothing ablative fractional lasers and determined that fractional CO2 lasers uneven skin texture, and improving skin tone due to the produced results which were on par with the earlier, fully ablative consistently high clinical efficacy in treating photodamaged skin.1,2,3 devices for improvement of skin texture, skin laxity, laxity of lower CO2 laser technology has also seen many advancements to keep eyelid skin, periocular and perioral rhytids.10 4 up with growing patient demand for laser skin resurfacing. By 2027 the global skin resurfacing market size is expected to reach a value Considerations for fractional CO2 devices of US $378.4 million, expanding at a compound annual growth rate With fractional CO2 laser devices being founded on the same of 7.2%.5 In this article, I will look at the types of CO2 devices available principle of photothermolysis, CO2 devices do present similarities. for purchase in the UK, the benefits of adding this modality to your Nevertheless, despite their resemblances these available devices business, and the considerations you should be aware of. present differences in terms of advancements in output power, dwelltime, distance between dots, varying scanner shapes and the laser Ablative CO2 lasers beam profile. I find these differences within each device can produce With its wavelength of 10,600nm in the mid-infrared, CO2 laser significantly differing clinical results and less flexibility with regards the energy is well absorbed by the high-water percentage in the gentleness and aggressiveness of treatment. skin, making it the perfect tool for precise ablation with excellent When choosing the best option for a laser device, power is clearly haemostasis and a high safety profile.6 CO2 lasers have many a major specification to consider. In my experience, 30W systems dermatological applications, from ablating skin lesions to revising are great for typical aesthetic concerns, but heavy-duty surgical acne and surgical scars, as well as advanced capabilities for procedures will require 50W or 60W options. The second most surgical procedures involving incision, excision, vaporisation, and important feature is pulse shape options or ‘emission modes’. This coagulation. Even with the broad range of dermatological and determines how much ablation and thermal spread is created.11 surgical capabilities for most aesthetic clinics, the major advantage of Practitioners should be cautious of devices with low power and long CO2 lasers lies in its value for rejuvenation of photoaged skin on the pulses as they won’t be able to ablate deep enough to treat scars.9 face and body. Equally, they should be wary of devices that only provide high power Ablative lasers were the first therapy to effectively improve options with short pulses as these will struggle to create significant photodamaged skin and acne scarring. They work by vaporising thermal spread for advanced laxity.12 the entire epidermis and papillary dermis. The first devices created There are many CO2 laser brands available, and I will always choose were hindered by bulk heating, unacceptable healing times, and one that is supported by numerous of clinical trials for several their severe side effects, such as hypopigmentation, scarring and indications. Due to the broad range of evidence outlined in existing slow wound healing. Although ablative lasers were created to better journals, I personally tend to choose fractional laser treatments over control the phenomenon of bulk heating, the lengthy recovery ablative due to the ability to replicate results. I will also choose a

Offering CO2 Lasers in Your Clinic

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

Beauty true to every side of you. Help your patients stay true to themselves with BELOTERO® Volume. Its 3D-Volume-Effect volumises at different angles to create the round and natural facial shapes that respect your patients‘ features and expressions.1 • Combines volumising effect with optimal modelling capacity 2 • Ensures a smooth transition between treated and untreated areas2 • May last up to 18 months 2, 3 Enabling your patients to look their best from every angle. 1 2 3

Prager W et al. J Drugs Dermatol. 2017; 16(4): 351-357 Micheels P et al. J Clin Aesth Derm. 2015; 8(3): 28-34 Kerscher M et al. Clin Cosm Inv Dermatol. 2017;10:239-247

www.merz-aesthetics.co.uk M-BEL-UKI-0663 Date of Preparation November 2019

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/reportan-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

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device that offers many different pulse shapes and a rolling or spray mode scanning, such as the DEKA SmartXide. Technical features With today’s devices, practitioners have increased flexibility through being able to control the pulse pattern, size, shape, precise control of depth, and heat produced by the laser. Their treatments are also assisted by computerised pattern generators/automatic scanning tools that allow practitioners to select from a range of shapes, densities, and scanning modes. These patterns can be varied in size to accommodate for small areas, such as those around the mouth, vermilion border, and nasal base. It’s my view that the best tissue effect is achieved by having a device which the practitioner can modify the laser pulse configuration according to the individual’s tissue characteristics. Newer CO2 lasers have complex pulsing and offer varied pulse mode options for optimum tissue effect. Overall, the ability to control these features can allow the practitioner to create customisable operational parameters for all treatable areas and skin types. I have found that having this uncompromised versatility can revolutionise your practise and treatment outcomes, as you have the capability to now tailor the treatment to the individual’s needs. The results In the hands of a skilled practitioner, the CO2 laser offers a very large range of dermatological indications and treatment capabilities. Due to the increased flexibility in specifications now available for fractional CO2 laser therapy, results can vary depending on the device used and the application. CO2 laser skin resurfacing also has a proven high patient satisfaction rating.13 As with all treatments, a lengthy consultation is needed to understand patient expectations and advise if these can be met. Surgical advances in laser technology have led to the invention of lasers that can accurately employ the transconjunctival approach to remove fat and thin layers of skin with minimal thermal damage to the surrounding tissue, which is particularly useful for treatments such as blepharoplasty. Wound contraction and scarring during the remodelling phase of healing following CO2 laser surgery are reduced compared to scalpel surgery.14 By sealing blood and lymphatic vessels and nerve endings, laser surgery significantly reduces the local inflammatory response and the pain level.15 My personal experience utilising CO2 lasers for blepharoplasty has resulted in reduced erythema, bruising, and skin trauma alongside reduced postoperative pain and downtime following CO2 laser surgery with a conventional scalpel, leading to exceptional results for my patients.

Considerations As with all technologies it is possible for things to go wrong. Fractional CO2 can result in infections, scarring, or long-term pigment changes, however complications are rare when the correct protocols are followed.17,18 The recent advancements, already discussed, in device flexibility offer an increased safety profile verses traditional CO2.4 With a range of CO2 devices on the market, I advise practitioners choose a well-established device with tried and tested protocols, experienced users for the full range of indications and, of course, plenty of hands-on training and support. CO2 is a protected revenue stream for medical professionals and is not available to the wider market. Given the efficacy and performance, these treatments remain in high demand and

the price point also remains high. Given the versatility of new CO2 devices, clinics will be able to offer the gold-standard of rejuvenating and skin quality improvements with high margins and little competition.

Considering CO2 for your practice There is an ever-growing market for safe, effective, reliable, and well-tolerated technologies capable of reversing cutaneous photodamage, fine lines, wrinkles, and hyperpigmentation. Despite the downtime, the CO2 laser remains a pillar across many specialties in the aesthetic field. Practitioners can achieve predictable and obvious benefits across a wide range of indications, for a wide patient demographic. Gold-standard treatment outcomes result in high patient satisfaction and loyalty. Disclosure: Mr Ali Ghanem is a key opinion leader for Lynton. Mr Ali Ghanem is a consultant aesthetic and plastic surgeon. He is the director of the Ghanem Clinic London – Bahrain, Rae Clinic London, and the Cranley Clinic London. He is also a senior clinical lecturer in plastic reconstructive aesthetic surgery at Barts and the London School of Medicine and Dentistry, and programme lead for the MSc in aesthetic medicine and reconstructive microsurgery with an active research, teaching and supervisory role. Qual: MD, PhD, FRCS (Plast) REFERENCES 1. Pozner, N. J., DiBernardo, E. B., Cook, C. Laser resurfacing of the aging face. Plastic and Aesthetic Research, 2021 2. Gotkin, R. H., & Sarnoff, D. S., A preliminary study on the safety and efficacy of a novel fractional CO₂ laser with synchronous radiofrequency delivery. Journal of drugs in dermatology: JDD, 2004 3. Christopher M. Hunzeker, MD, Elliot T. Weiss, MD, Roy G. Geronemus, MD, Fractionated CO2 Laser Resurfacing: Our Experience with More Than 2000 Treatments, Aesthetic Surgery Journal, Volume 29, Issue 4, July 2009 4. Rossi E, Farnetani, F, Trakatelli M, Ciardo S, Pellacani. G, Clinical and confocal microscopy study of plasma exeresis for non-surgical blepharoplasty of the upper eyelid: a pilot study. Dermatol Surg., 2017 5. Grand View Research, Inc., 2020. Skin Resurfacing Market Size, Share | Industry Report, 20202027.: <https://www.grandviewresearch.com/industry-analysis/skin-resurfacing-market?utm_ source=prnewswire&utm_medium=referral&utm_campaign=hc_08-jun-20&utm_term=skinresurfacing-market&utm_content=rd> 6. Omi T, Numano K. The Role of the CO2 Laser and Fractional CO2 Laser in Dermatology. Laser Ther. 2014 7. Lederhandler MH, Bloom BS, Pomerantz H, Geronemus RG. Case Series of Fractional Ablative Laser Resurfacing of Pediatric Facial Traumatic and Surgical Scars. Lasers Surg Med. 2021 8. Chwalek J, Goldberg DJ: Ablative skin resurfacing. Curr Probl Dermatol, 2011 9. Preissig J, Hamilton K, Markus R. Current Laser Resurfacing Technologies: A Review that Delves Beneath the Surface. Semin Plast Surg. 2012 10. Uebelhoer, N. S., Ross, E. V., & Shumaker, P. R., Ablative fractional resurfacing for the treatment of traumatic scars and contractures. In Seminars in cutaneous medicine and surgery, 2012 11. Alexiades-Armenakas MR, Dover JS, Arndt KA. The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing. J Am Acad Dermatol., 2008 12. Omi T, Numano K. The Role of the CO2 Laser and Fractional CO2 Laser in Dermatology. Laser Ther., 2014 13. Hantash BM, Bedi VP, Chan KF, et al. Ex vivo histological characterization of a novel ablative fractional resurfacing device. Lasers Surg Med., 2007 14. Sullivan, S, A., Dailey, R, A. Complications of laser resurfacing and their management. Ophthal Plast Reconstr Surg. 2000 15. Berwald, C, Levy, J, L, Maalon, G. Complications of the resurfacing laser: Retrospective study of 749 patients. Ann Chir Plat Esthet. 2004 16. Fife D J, Fitzpatrick R E, Zachary C B. Complications of fractional CO2 laser resurfacing: four cases. Lasers Surg Med. 2009 17. Tierney EP, Kouba DJ, Hanke CW. Review of fractional photothermolysis: treatment indications and efficacy, Dermatol Surg. 2009

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

Advertorial Cynosure

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The New Standard in Microneedling Introducing the latest development in radiofrequency microneedling

Radiofrequency microneedling is increasingly gaining momentum in aesthetic medicine. A recent 2020 review paper by two board-certified dermatologists concluded that they believe practitioners should consider adding this technology into their treatment offering for a variety of indications such as acne scars, hyperhidrosis, cellulite, rosacea, skin laxity, striae and skin rejuvenation.1

Introducing Potenza Representing the continued popularity and advancements, the Potenza device is the world’s first radiofrequency microneedling (RFM) system that combines monopolar and bipolar RF at 1 or 2MHz frequencies in a single device, taking the technology to a new level. With four RF modes, nine different needle configurations and customisable energy settings you can fine tune treatments based on your patients’ specific needs – all skin types, almost anywhere on the body, any time of year. The device’s four modes offer more customised treatments for patients and allows practitioners to deliver both shallow and deep treatments on a single system. The device’s monopolar RF mode delivers energy across a large area of tissue for deep heating and skin tightening through soft tissue coagulation. The bipolar RF mode offers more concentrated delivery of energy to treat superficial tissue and provide ideal skin revitalisation results. Mr Benji Dhillon, cosmetic surgeon and co-founder of Define Clinic, explains, “An example of the device’s versatility includes being able to change the intensity and distribution of energy we can use to tighten skin and modify the depth for different treatment areas. In my experience, the best area for treatment is the neck and jawline, where it can make substantial 52

improvements to loose skin in this area. However, it can also improve acne scarring and spots, dull facial skin or skin around the eyes, or on the body such as above the knees and stomach. With Potenza, we now have a device which can also target stubborn acne cystic spots to reduce the risk of them scarring the skin.” Mr Dhillon explains that like lasers, RFM is a minimally-invasive procedure, meaning there is no serious pain or downtime for your patients. He notes, “Minor bleeding is expected during the treatment and the patient will experience a sunburn sensation with some moderate swelling and tingling. However, this typically resolves in 24-48 hours.” Patients can then resume their everyday activities.

The Fusion Tip

Who can be treated? Mr Dhillon notes that Potenza treatments can be performed on all skin types, in the majority of places on the body and any time of year. Unlike a lot of other RF microneedling devices currently on the market, with Potenza you are able to adjust a number of settings to customise the treatments to different faces or different body parts. “The beauty of RF microneedling is that it is ‘colour blind’ meaning it is suitable for all skin colours and tones – it’s a true innovation,” he adds.

Patient before and after three radiofrequency microneedling

sessions. Results show an improvement in acne scarring. The Potenza device is now offering a brand-new Step 1 Step 2 tip designed to enhance topical penetration by 67%.2 The Fusion Tip operates in monopolar at 1MHz for deep and wide RF delivery and enhanced tissue engagement and Step 3 Step 4 topical penetration, with 21 insulated needle arrays and an adjustable depth of 0.5-2.5mm. When the Fusion Tip is used, air is trapped through enhanced Figure 1: The depth of the Fusion Tip opposed to typical RF needles tissue engagement and the needles create channels REFERENCES to deliver RF energy to the skin. Air is then 1. K Kesty & DJ Goldbery, Radiofrequency microneedling for acne, acne scars, and more, March 2020, Dermatological Reviews, released towards the skin, driving topicals Volume 1, Issue 1. <https://onlinelibrary.wiley.com/doi/10.1002/ deeper into the dermis. der2.9> 2. Cynosure Fusion Tip Brochure, Data on file While three to five treatments at roughly four to six weeks apart are recommended, This article was written and supplied by Cynosure patients may notice improvements in their skin after the first or second treatment and will continue to see improvements six to 12 months post-treatment.

Aesthetics | August 2021

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A summary of the latest clinical studies Title: A Laser Platform Incorporating a 524nm Laser Pumped by a Hair Removal Laser Treats Facial Redness and Lower-Extremity Spider Veins Authors: Bernstein E, et al. Published: Lasers in Surgery and Medicine, July 2021 Keywords: Laser, Rosacea, Vascular Abstract: Treatment of vascular lesions is one of the main applications of cutaneous laser technology, while the other is laser hair removal. A novel 524nm vascular laser was designed using a 755 nm hair removal laser as a pumping source. This 524nm vascular laser was used to treat facial redness and leg telangiectasias in 24 subjects. Four treatments were administered to the face at four-sixweek intervals and photographs were taken eight weeks following the final treatment, while two treatments were administered to lower-extremity spider veins at two-month intervals with follow-up photographs three months following the final treatment. Blinded analysis of digital images was performed by two physicians not involved in the study. Blinded evaluation of digital photographs revealed an average improvement score of 3.3 on a 0-10 scale for removing facial redness, a 33% improvement. Leg veins improved an average of 51% corresponding to a score of 5.1. Side effects were mild and limited to erythema, purpura, edema, and one instance of mild hyperpigmentation. This 524nm laser is safe and effective for treating vascularity on the face and legs and proves the ability to create a laser platform incorporating a hair removal laser which can be used as a pumping source. Title: Comparison of the Efficacy of Fractional Radiofrequency Microneedling Alone and in Combination with Platelet-Rich Plasma in Neck Rejuvenation Authors: Gawdat H, et al. Published: Journal of Cosmetic Dermatology, July 2021 Keywords: Radiofrequency Microneedling, Neck Rejuvenation, Abstract: Aesthetic improvements of the neck and cervicomental angle remains one of the most challenging aspects of rejuvenation. Fractional radiofrequency microneedling showed significant skin tightening and lifting of the lower third of the face. 20 patients with mild to moderate neck laxity were randomised to receive three sessions of either fractional radiofrequency microneedling + PRP (Group A) or fractional radiofrequency microneedling monotherapy (Group B). Evaluation was done using optical coherence tomography to detect dermis thickness, measurement of cervicomental angle, a score by two investigators blinded to used modality (GAIS) and patient satisfaction score. Both groups showed a statistically improvement in all parameters. Comparing the two groups, the mean dermal thickness after treatment was higher in group A compared with B but was found statistically insignificant. Favourable results were reported in group A according to GAIS. Other parameters showed comparable results. Fractional microneedling radiofrequency with insulated microneedles offers a safe and effective modality for mild to moderate neck laxity when used alone or in combination with PRP. It remains questionable whether combining fr-RF microneedling with PRP provides favourable results in efficacy and side effects.

Title: Tissue Fillers for the Nasolabial Fold Area: A Systematic Review and Meta-Analysis of Randomised Clinical Trials Authors: Stefura T, et al. Published: Aesthetic Plastic Surgery, July 2021 Keywords: Dermal Fillers, Nasolabial Fold, Tissue Fillers Abstract: Tissue filler injections remain to be one of the most performed cosmetic procedures. The aim of this metaanalysis was to systematise and present data on the aesthetic outcomes and safety of treating the nasolabial fold area with tissue fillers. We searched the MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, Scopus, Cochrane Controlled Register of Trials, CNKI and Web of Science databases. Primary outcomes included aesthetic improvement measured using the Wrinkle Severity Rating Scale score and Global Aesthetic Improvement Scale. Secondary outcomes were incidence rates of complications occurring after the procedure. At baseline, the pooled mean WSRS score was 3.23. One month after the procedure, the pooled WSRS score had reached 1.79. After six months it was 2.02 and after 12 months it was 2.46. One month after the procedure, the pooled GAIS score had reached 2.21. After six months, it was 2.32, and after 12 months, it was 1.27. Overall, the pooled incidence of all complications was 0.58. Most common included lumpiness (43%), tenderness (41%), swelling (34%) and bruising (29%). Title: Efficacy and Safety of Topical Spironolactone 5% Cream in the Treatment of Acne Authors: Ayatollahi A, et al. Published: Health Science Reports, July 2021 Keywords: Acne, Spironolactone, Topical Abstract: Spironolactone is an effective treatment for female patients with acne vulgaris. However, topical spironolactone could be a treatment option in both male and female acne patients due to the less possibility of side effects with its topical formulation. In this clinical trial, topical spironolactone 5% was evaluated to treat patients with mild to moderate acne twice a day for eight weeks. The rate of improvement by any alterations in the number of open and closed comedones, facial inflammatory papules, and acne global grading scores were assessed. Moreover, skin biometric characteristics including skin hydration, erythema, transepidermal water loss, pH, sebum, and propionibacterium acne bacteria activity were also assessed. 15 patients participated in our study with a mean age of 25. 66.6% were female and 33.4% were male. The number of acne papules, open and closed comedones, and acne global grading score decreased four and eight weeks after the beginning of treatment. No considerable side effects were reported. There was no difference between the skin hydration, melanin, erythema, TEWL, pH index, sebum, and P acne bacteria activity before, four, and eight weeks after the treatment. The topical 5% spironolactone cream seems to be an effective and safe treatment of acne vulgaris in both genders.

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

BELIEVE IN THE POWER OF SEEING. Ultherapy® is the only FDA cleared microfocused ultrasound technology that has real time visualisation (MFU-V).1,2

FDA-cleared and CE-marked so you can be confident of Ultherapy®’s good safety profile1 The Gold Standard for non-surgical lifting and skin tightening, as determined by an expert consensus panel3

For more information visit Ultherapy.co.uk @merzaesthetics.uki Merz Aesthetics UK & Ireland

REAL-TIME VISUALISATION

Real-time visualisation, enabling treatment customisation, precision targeting of tissues, and optimised patient outcomes 3

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

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-anissue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

Refer to the Instructions for Use (IFU) for complete instructions on operating the Ultherapy® System The non-invasive Ultherapy® procedure is U.S. FDA-cleared to lift skin on the neck, on the eyebrow and under the chin as well as to improve lines and wrinkles on the décolleté. The CE Mark indications for use for the Ulthera® System include non-invasive dermatological sculpting and lifting of the dermis on the upper face, lower face, neck and décolleté. Reported adverse events from postmarketing surveillance are available in the Instructions for Use (IFU ). Please see the available IFU in your country for product and safety information, including a full list of these events. © 2018 Ulthera, Inc. The Merz Aesthetics logo is a registered trademark of Merz Pharma GmbH & Co. Ulthera, Ultherapy, DeepSEE, SEE THE BEAUTY OF SOUND and the Ultherapy logo are trademarks or registered trademarks of Ulthera, Inc., in the U .S. and /or certain foreign countries. Merz Pharma UK Ltd. Ground Floor Suite B, Breakspear Park, Hemel Hempstead, Hertfordshire HP2 4TZ Tel: +44 (0) 333 200 4140 M-ULT-UKI-0988 Date of Preparation June 2021

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There are, of course, other advantages to ultrasound use which I will discuss later in this article, but my primary objective was to help minimise the risk of occlusion and hasten recovery in case of a complication by utilising vascular mapping on my patients. I would aim to scan patients prior to injection to identify and map the location of the large vessels and rescan patients after injection to check the blood flow, and in doing so try to minimise the risk of vascular occlusions by identifying and treating them as soon as possible. Having worked in A&E, ultrasound was not new to me. I had performed many nerve blocks, central line placements and cannulations under ultrasound guidance. I had also attended several emergency ultrasound courses to be able to perform extended focused assessment with sonography for trauma (eFAST) scans. Offering Ultherapy, an ultrasound-guided Dr Kim Booysen explains why you might want to lifting and tightening procedure, similarly introduce ultrasound into your aesthetic practice allowed me to become familiar with and shares her approach for implementation superficial facial anatomy ultrasound. So, taking the leap to scanning and Facial ultrasound seems to be the latest thing in facial aesthetics. vascularly mapping all my new patients did not seem as daunting, Every time I read new journal articles, it seems to be about ultrasoundand I was quite excited to get started. guided treatments or investigations. I had seen a few articles about For practitioners who have never used ultrasound, the journey will be ultrasound in the past but had not really considered its use in clinic.1,2 more difficult. You will need to learn the basics of how an ultrasound After dealing with a vascular complication, I became convinced that works, the types of images you will see, how to interpret the different ultrasound-guided treatments and vascular mapping would make a images, learn to identify different tissues using ultrasound and learn big difference to my patients’ downtime, and provide an added layer how to optimise the images you see on your screen to best interpret of safety when performing injectable treatments.1 Here, I share my the anatomy you are looking at. You will also need to become journey of discovery into the use of ultrasound in my clinic. acquainted with the doppler function on the ultrasound so that you can identify normal and abnormal blood vessel flow in a vessel. Why I decided to use ultrasound However, I believe ultrasound is a skill that can be learnt by most I initially became interested in facial ultrasound after dealing with a medical practitioners.4,6 tricky vascular occlusion. Anyone who has dealt with an occlusion is aware that resolution is not instant and often requires repeat injections How did I choose my ultrasound device? and daily reviews of the patient.3 I successfully reversed the occlusion There are several ultrasounds on the market and your choice will and the patient healed uneventfully, but I was convinced the treatment depend on your budget, ultrasound skills and how you plan to utilise could have been faster and less painful for the patient. If I had been ultrasound in your practice, so it’s important to do your research before able to doppler and identify the affected vessel by detecting the area investing. I wanted something lightweight and portable as I work in of abnormal blood flow using the ultrasound doppler mode,1,4,5 I could two locations and provide teaching around the UK and Ireland, so I then have injected hyaluronidase into the affected vessel under direct needed something easy to pack up and go. I also had to consider visualisation. This would have likely made the resolution and recovery the battery life as I needed there to be good amount of time before time much quicker. So, I began researching affordable ultrasounds that recharging. How the images are transferred and stored is also a factor; could be used in a facial aesthetic clinic setting. the ultrasound device I went with is visualised on an iPad or mobile device and images are stored to the cloud which integrated with my current devices in clinic and made saving images for the clinic records easier and faster. I also purchased a desktop charger, so the machine is always close by and ready to scan. Other machines need the battery to Epidermis and Dermis Subcutaneous Fat be unclipped and placed in a charger which can make scanning longer Frontalis Muscle Frontal Bone and take up more of the appointment time. In my experience, you don’t need the most expensive machine, but you do want a minimum 4-5cm visualisation depth and a scanning frequency of around 20MHz as this will allow you to visualise all the necessary facial structures. The higher the frequency the smaller the Figure 1: Visualising the depth of the forehead to improve injectable placement depth of penetration and the bigger spatial resolution. Facial structures

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Columellar branches Depressor labii inferioris and depressor anguli oris

How has ultrasound changed my aesthetic practice?

Being able to identify filler placement immediately after injection has made me Oral Maxillary Columellar mucosa Facial more aware of the need for small, linear central branches from artery incisor superficial labial thread placement in the deep fat of the artery mid-face, as this gives better integration in the tissue when viewed on ultrasound. I have also improved my accuracy of placement of periosteal boluses by being able to confirm Figure 2: Visualising vascular branches in the upper lip Figure 3: Identifying the facial artery along the jawline with visualisation what I had only perceived with tactile sensation when injecting.8 are rarely deep and therefore a higher frequency will get clearer Identifying blood vessels by vascularly mapping a patient has also images of these shallower facial structures.4 In time, you may want led to me adapting my injection depths to the individual patient’s to upgrade to a more expensive machine with higher resolution and vascular bed. This is particularly helpful with lip fillers, as identifying therefore better image quality, but as a starter machine I have found the position of the labial artery in, above or below the orbicularis oris my handheld scanner more than adequate. muscle in various areas of the lip, helps with safer placement of the Depending on the device you go with, there will likely be several filler (Figure 2).7,9 Other areas that are helpful to scan prior to injection add-ons you can choose from when purchasing your machine, are the chin, jawline, temple and glabellar area as you can identify such as needle visualisation assistance. Needle visualisation helps any large vessels in the area and aim to place the filler away from the you accurately see the needle when injecting under ultrasound vessels you have identified (Figure 3). Often the difference of a few guidance. Some companies offer a one-week trial of any add-ons millimetres can make your placement safer and improve results.6,7,9 such as needle visualisation assistance. I would advise that you first Patients are also very interested in the ultrasound, and I use it as an get accustomed to basic visualising of facial structures and using educational tool in clinic to talk about safety, correct filler placement, your machine well before you trial any of these other features, as anatomy knowledge and how these can benefit the patient during using advanced features will not be your top priority and this will be a their aesthetic treatments and any possible complications. As wasted opportunity if trialled too soon.3 vascular occlusions are rare, I have not had to use the ultrasound during a complication as yet; but I believe I will feel more confident in How do you improve your ultrasound skills? managing any occlusions.3,6 Being good at ultrasound takes a lot of practice. I started by scanning myself and my husband – a lot. Lockdown gave me a lot of time to just Ultrasound is progressing in aesthetics scan each of the major vessels, identify all the facial muscles, use the Ultrasound training and practice will take many, many hours of your different ultrasound functions, and basically play with the buttons on time and this can be disheartening in the beginning. You will also the scanner, until I could identify the major vessels and their tributaries need to invest in a machine and attend courses and scan patients using the colour doppler. Watching the flow of blood vessels is also until you are able to accurately visualise facial anatomy. Ultrasound important to get a sense of what is normal flow in the tissues in a will also make your consultations and treatment times longer and it particular area. I then started scanning patients before every dermal is not cheap. However, ultrasound visualisation is becoming the new filler treatment and identifying the large vessels that should be present standard for injectable treatments as it can improve accuracy, improve in the proposed injection area. I would also look at tissue depths anatomy knowledge, help select patients for treatment and assist in and identify the area I would ideally like to place my filler. Once the diagnosing complications when they arise.6,7 If you are an advanced treatment was complete, I would rescan the patients to assess my injector, then I would encourage you to explore introducing ultrasound placement and check blood flow to the vessels in the area. into your clinic. I also scanned patients who reported previous filler or threads to Dr Kim Booysen is an independent aesthetic clinic owner see if the treatments were evident and if the patient was suitable for in south-east London. She holds degrees in medicine, treatment. Interestingly, I’ve had a patient with a permanent implant law, international health management and business management. Her special interests are medico-legal request fillers, and after scanning the area I was able to better aesthetics and aesthetic education. advise which areas we could augment as fillers are not advised over Qual: MBChB, Dip Obs, LLB, MSc IHM, MBA, PG Cert Aesthetics (Level 7) permanent implants. It should be noted that visualising old fillers is very complex and requires years of practice and skill. Fillers and treatments are also constantly evolving, and this influences your ability to see these changes in the tissues.7 I would not expect practitioners to be able to accurately identify older filler in the first few months of using facial ultrasound, but with more practice and hours of visualisation, I believe TO VIEW THE REFERENCES GO ONLINE AT this is a skill that can be learnt over time. There are several ultrasound WWW.AESTHETICSJOURNAL.COM textbooks and online resources that can help you identify the 4 structures you see when performing ultrasound. In-person training is also available, although as this is such a developing field there are limited training providers available in the UK. Orbicularis oris muscle

Mandible

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Working With Sales Representatives Sales consultant Vanessa Bird discusses how to have an effective partnership with a sales rep in order to grow your aesthetics business The working relationship with a company sales representative is often under-valued when planning the future success of an aesthetic practitioner or clinic. In my experience, sales representatives are often branded as pushy, order-takers, or viewed as someone you briefly need to deal with if you want to buy a product or device. However, practitioners who understand the true value of a sales representative when it comes to developing their business are really on the road to success. Sales representatives can help support you, identify often-overlooked areas of expertise you can tap into, and give advice on how to build a lasting, mutually beneficial path to success. This article will cover the key ways you can benefit from working with sales reps, identifying the areas you should focus on. It will outline the best approach to take and explain how working with the reps can help you manage and grow your business above and beyond making a purchase.

get off the ground despite their best efforts, and either stagnate or close their clinic and move on to pastures new. Others would do well, earning a good living and building their reputation successfully. A select few would excel, growing more quickly than other clinics, appearing in the press and becoming key opinion leaders (KOLs) for companies keen to partner up with these rising stars. However, I soon noticed a pattern. The vast majority of practitioners who worked with sales reps and trusted their expertise, achieved a more rapid return on their investment because they could integrate the new technology far more successfully than those who didn’t. I’ve found that mutual trust and respect between sales reps and practitioners can also spark more sales in clinic and help to develop a working partnership that brings about future opportunities for clients, which can enhance their professional profile. So, how do you get started?

The learning curve

What to look for

Having a background as a capital equipment sales representative in the aesthetic medicine specialty means I have banked years of experience working with industry experts, clinic owners and practitioners. In my time I’ve noticed that some clinics would never quite

Your initial contact with a sales rep begins with an enquiry about the product or service they offer. In some instances, you may have done business with them before and know how they work, but if you haven’t, what should you look out for?

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Experience is important, especially industry experience. Aesthetic medicine is quite a unique field and what works in another sector won’t necessarily work in aesthetics, so you should ask your sales rep about their background. Be cautious if they have moved around a lot over a short period of time. In my view, sales reps who stay for less than two years in a role are usually less committed to a technology/product and won’t share the same passion or knowledge as a rep who has stayed for two plus years, and those who move companies cannot provide the longterm support a successful partnership needs. You should also check to see if they have knowledge of other technology or products, not just their own. A good sales rep understands the features and benefits of competitors and can help you incorporate multiple technologies into your clinic. You should ask your peers for recommendations on who to work with. People buy from people and if your peers recommend a sales rep, it’s because they have delivered exceptional service. Red flags include not being able to reach your sales reps because they ignore calls or emails. If they don’t reply now, they certainly won’t after the sale is completed and this is a huge issue if you really need their support. Another red flag to look out for is a sales rep who slates the competition and pulls them down to promote their product, rather than talks about the benefits of the technology or product because it is a classic sign of unprofessionalism. Do you really want to work with someone who focuses more on their competition? Wouldn’t it be preferable to work with a sales rep who is confident in their own technology or product and can talk about the features and benefits, the strengths of what they are offering and how it can work for you?

Lay the foundations In order to lay the foundations of a successful partnership, be honest and open with your communication at all stages of the sales cycle with your sales representative. Sales reps have to create forecasts every month so their manager can predict what business is coming in, prepare stock levels accordingly and start booking in training. If you’re at the research-only stage and have no intention of buying anything for another six to 12 months, please tell them this. Give them a realistic timeline so they can forecast accurately. Sales representatives work on targets so this also helps them focus on more urgent sales for the quarter and means they won’t

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Be open to listening to any ideas, advice, or guidance your sales representative offers be emailing or calling you constantly to find out where you’re up to; something which may feel annoying when you’re busy in clinic. Communicate your timeline honestly and they will be able to book in your training and delivery for when you are ready to move forward, ensuring everything runs smoothly and without delays.

Access their expertise Be open to listening to any ideas, advice, or guidance your sales representative offers. They know their product or technology better than you do and have worked with similar clinics, so they will know what works and what doesn’t. They are not just limited to advice on techniques or combination therapies to try, although these alone will help you increase revenue. They will also be able to discuss marketing ideas, pricing, will train your staff on how to talk about and sell the treatments, and may even host an open event for you in clinic. By listening to their advice and acting on their guidance you can side-step mistakes others have made. Think of it as a fast-track path to success. Don’t forget to tell them when you have tried something and reaped the benefits and if you have the time, email their manager with positive feedback. Never underestimate the pride a sales representative will feel knowing you have benefited from their expertise. Everyone wants job satisfaction, and everyone enjoys working with someone who is grateful for their recommendations and respects their professional opinion.

Build the relationship Don’t block them from visiting you. Be open to their visits, ask them questions and offer your services back where applicable. Your sales representative is a business professional who can share valuable insights on the current economic climate, upcoming developments or trends in aesthetics. They have a more varied circle of contacts than you, regularly visiting other clinics, speaking with finance and insurance brokers and talking to sales reps from other companies.

They see the business from a different angle, and it can be insightful. Do you want to develop your speaker profile? Ask them if they are looking for a KOL. The sales representative is more likely to put someone forward if they’ve taken time to develop a partnership. Or perhaps you would like to be a reference clinic they can send others to for feedback? This helps the sales rep close more deals and it also give you an accolade to put on your clinic website. See the relationship as a two-way street. If you genuinely appreciate the work they put in, recommend them to others or introduce them to colleagues and they will look after you, reacting quickly if you have any issues, offering you discounts and fast-tracking new technology to you. You may even receive a referral fee, consumables bundle or get a lovely lunch out of it.

Provide feedback Sales representatives are busy people. They don’t have time to waste chasing people who have no intention of buying from them. Yet, a lack of honest feedback from you can result in that sales rep chasing you for a sale that you’ve no intention of placing. Yes, often it’s hard to say no, and you may feel you don’t want to disappoint anyone so avoid calls and emails hoping they’ll eventually ‘get the message’, however they will appreciate it when you do tell them the truth. Please let your sales representatives know if your timeline has changed, if you have decided not to proceed or if you have purchased something else. They will not think any less of you and will focus their time on active sales elsewhere.

When things go wrong We have all experienced a negative sales experience at some point in our lives and aesthetics is no different. Not all sales reps work to the same professional standards, and some may be economical with the truth about a contract or deal that leaves you out of pocket or feeling aggrieved. When this happens, it is important to discuss it with

the sales rep and, if necessary, with their line manager. We all react in anger, but it is important to remember to allow them the opportunity to listen to you and address the issue, as sometimes miscommunication may the root cause rather than deception or fraud. Always remain professional and polite and do not let anger cloud your judgement. Once resolved, look at either developing the existing sales rep partnership or consider requesting a new point of contact. As tempting as it may be to tell everyone about your negative experience or post on social media about the issues you have, you must remember that this is someone’s professional character or a company you are potentially damaging by doing so, regardless of whether it is justified. If you do feel strongly about warning others, then privately point out the issues you had with anyone who asks for your opinion or feedback rather than shouting it from the rooftops. Another common problem is having difficulty reaching your sales rep after the sale is completed. You may have questions about pricing or the treatment protocols or perhaps want support planning an open evening, but your sales rep isn’t picking up your calls or replying to emails. The frustration you feel is normal and it must be addressed as soon as possible to avoid it negatively impacting your business. In this instance, go directly to their manager and discuss ways they can provide the support you need. This partnership is what leads to more sales for the company and better results for you.

Start utilising your sales reps Never forget that sales representatives are professionals with a keen eye for business. They are very-well connected in their chosen field and have a wealth of clinical and business experience you can benefit from. Quite simply, people like to do business with people they enjoy working with and a sales rep who feels respected and valued by you will pass on opportunities and open doors for you. Success is born from long-term business partnerships, so reach out to your sales reps today and forge that connection!. Vanessa Bird is the founder of The Aesthetic Consultant. She has more than two decades of experience working in sales and selling capital equipment, teaching her to recognise key areas for partnership development between the sales rep and the customer.

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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Combination is Key Aesthetic nurse Anna Gunning explains how you can be one step ahead of the game and invest in devices for optimum results Now having more than 16 years of fulltime experience in aesthetic medicine, I can say my business has grown and been successful because I diversified into devices early on to provide for my patients’ needs. Results for my patients has been at the forefront of my business ethos and has its own unique importance and a place in each of my three clinics. My focus has been to retain my patients under one umbrella, rather than seeing them go elsewhere. I have always sought the very best technology available as my reputation is based on results and satisfied patients. The growth of non-surgical versus surgery is more popular than ever. It is also great that more people are breaking the ‘taboo’ and talking about non-invasive treatments, including high profile names like Tess Daly. Therefore, positioning yourself to provide what patients want is only going to enhance your business revenue and secure your future as an aesthetic practitioner. Skin tightening globally is the one of the most popular aesthetic requests and one of my patients’ main concerns either in preventing or treating, therefore I needed to provide this treatment. I have used radiofrequency devices for years but when I became aware of ultrasound energy and its ability to lift and tighten it was an easy decision to invest. Ultherapy® is the gold standard for lifting and tightening, partly because it is the only device of its kind with visualisation technology so you can plan a customised treatment and see exactly where you deliver the therapy. It is a vital part of my clinic’s menu alongside all of my other devices. I invested in a second Ultherapy® device last year because of the demand and the growth within this area.

Combination treatment for overall skin health is where you need to be for optimal clinical outcomes I personally have always believed in a combination approach from the very beginning, and I started with both injectables and devices 16 years ago. My advice for clinics that want to offer optimum results and the ability to customise treatment protocols tailored to each patient is combination. When deciding on a device to purchase, it is important to identify what type of patients and conditions are most common in your clinic. Then match the technology you invest in with your existing patient base. For instance: • You are mainly providing injectables, and these patients would benefit from skin tightening on areas where you may not be able to achieve this look with injectables alone. • Your injectable patients are happy with their treatment outcomes and would be delighted if there was a once-a-year treatment to even further enhance the aesthetic outcome of their regime. In both of these situations the Ultherapy® device may be a good option, which provides lifting and tightening on the face, neck and décolletage. Ultherapy® works by using micro-focused ultrasound to strengthen a deep foundation of collagen in the skin which, when used in a combination treatment plan, has proven to augment the outcome of injectable treatments. The introduction of aesthetic devices into your clinic practice will retain your current database but will also attract a new patient Aesthetics | August 2021

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base to your clinic. For example, it might be more appealing to those people who were initially more hesitant to try treatments with needles. Once you have successfully introduced a device to meet the needs of your current customers, you can grow and diversify your device and clinic to attract a range of patients. If you have patients already and the need is there, then next make sure to buy a trusted and efficacious device from a company that provides good training and aftercare service. Ensure you look out for FDA clearance and CE certification. My experience with buying Ultherapy® devices from Merz Aesthetics has been very positive and supportive right from the initial training, continued ongoing support, educational online webinars, on-demand training videos to provide a refresher at any time and local representatives to support any concerns. Yes, investing in a device can be daunting, but if you have a loyal patient base who trust you that’s the first step. Injectables, as amazing as they are, do have their limitations. Providing a varied choice of treatments has also helped my clinic become a ‘one-stop’ clinic that can offer solutions to an array of skin concerns and our retention continues long term. I only use advanced FDA-cleared technology from the highly renowned suppliers in the industry. I have never looked back with any decision to diversify using devices and continue to be at the forefront of aesthetics in Ireland. Anna Gunning is an aesthetic nurse and the clinical director of The Laser and Skin Clinic, which has three locations in Ireland. The clinic won the Enhance Insurance Award for Best Clinic Group, UK & Ireland (3 Clinics or More) in 2018.

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the easy solutions you can implement to help boost the effectiveness of your advertisements.

Pressing the ‘boost’ button

Enhancing Your Facebook Advertising Digital marketing professional Richard Gibbons outlines the common problems and simple solutions of Facebook advertising to increase your patient enquiries Facebook advertising is a goldmine for clinics looking to generate high-quality patients. In the UK, 57% of small businesses use social media for marketing purposes.1 However, I have noticed that many are not using it to its full capacity. In this article, I aim to explain why many people fail when it comes to Facebook advertising and will provide the best tips to help them. The great news is that these tips work for both those experienced with Facebook advertising, and those who are complete beginners. Although we will be discussing Facebook, the same techniques and approaches are transferrable to Instagram. I have found, however, that Facebook commonly attracts patients who are more likely to have a disposable income and are therefore more likely to convert into paying patients.

The use of Facebook advertising Firstly, it’s vital to understand exactly what Facebook advertisements are. Facebook advertisements are shown on users’ news feeds as they’re scrolling through looking at their friend’s posts. Advertisers can choose to place adverts in between these posts, with the aim of capturing the attention of their potential customers. This advertising platform is completely different from traditional marketing such as leaflet drops, radio ads, and emails. When running Facebook adverts, you only have around 1.7 seconds to capture the user’s attention to make them stop scrolling!2 This means your ads need to be short, snappy, and intriguing straight away. So, let’s talk about the top mistakes I have witnessed clinics make on Facebook, and

The problem The most common mistake that I see clinics make online is pressing the ‘boost’ button. This is a shiny blue button that appears under many Facebook posts you will create on your business page. The idea behind it is to reach more people, which sounds like a good plan. However, I have found that it’s one of the quickest ways to waste your advertising budget. Why? Because your goal isn’t to just reach more people, it is about converting people into paying patients. The boost button can be useful if you want to have more viewers on your posts. You can pay as little as £1 a day and have your posts seen by more of your followers. This is helpful as only 5.2% of your page followers will see your organic posts!3 However, we want to discover ways to ensure a great return on investment from our advertising and generate new bookings. The solution The ideal way to solve this problem is to use Ads Manager inside of Facebook.4 This tool allows you to set up adverts that are tailored towards generating high-quality leads. The benefits of Ads Manager are that it allows you to: • Implement more detailed targeting/ customer demographics • Split test ads to find the ‘winner’, meaning you can compare two adverts to see which performs the best • Choose new ad ‘placements’ such as on messenger ads or Instagram stories. I’ve found that placing adverts on the ‘Facebook Timeline’ is the most effective way to generate enquiries With this tool, you will also be able to accurately track your adverts and ensure that the money you are spending is being utilised. I’ve personally seen clinics switch to Ads Manager and reduce their cost per lead by more than 50%.

Forgetting the call to action

You only have around 1.7 seconds to capture the user’s attention to make them stop scrolling

The problem As I mentioned, you only have 1.7 seconds to capture your potential customers attention on Facebook.2 A call to action refers to the next step you want your audience/reader to take, such as clicking on the ‘book an appointment’ button. I regularly see adverts online which

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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have no clear call to action and it’s hard to understand what the clinic is advertising or wanting individuals to do (without spending time reading the ad). With any Facebook adverts, you want to have the call to action extremely clear and easy to understand. The solution In my experience, it’s useful to focus on your results rather than the intricate ins and outs of the treatment process. Of course, we want to educate potential patients, but firstly, we want to hook them in, so they book an appointment with you. You can have this information later in the post, where the patient can choose to read more, or on your website, and of course you should reiterate this in the actual consultation. I recommend focusing on promoting one treatment per advert. If you try and advertise all the treatments in one, it will likely confuse the potential patient and they will scroll past. On the advert, you will want to include real images/videos of the treatment in action. In my experience, this works much better than stock images as people online will want to see your team, clinic and real-life patients being treated. Please ensure that you have consent for any images/videos you use and make sure you follow Facebook’s guidelines on what images/wording you can include on the adverts to ensure they are not banned.4,5

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very common for landing pages to look incredible on a computer screen, but when viewed on a phone, it can look messy. This makes potential patients leave the page straight away and you will have lost that booking! 81% of Facebook users access the platform through their mobile devices, which is why you need to ensure your pages are optimised correctly.8 The most important element on the landing page, when viewed on a mobile, is that the ‘opt-in’ button is ‘above the fold’, meaning the user doesn’t have to scroll down on their phone to find the button, and it is visible as soon as they arrive on the landing page. The best converting layout I have seen working for clinics is: 1. Business logo 2. Clear headline explaining what you have to offer 3. Short paragraph explaining details 4. Image of the treatment in action. You can’t show any before/afters or treatments with needles as this is against Facebook’s Advertising Policies9 5. A large button to opt-in (to collect name, email and contact number) If you include these five elements on your landing page, in my experience you will begin to see great results.

Lacking a follow-up strategy Excluding a landing page The problem When running Facebook advertising, the goal is to convert your adverts into paying patients. For most clinics, their first thought is to send people directly to their website homepage. Although this sounds like a good idea, the results it yields are low. The reason for this is your website has lots of buttons, services, menus, and it can be too overwhelming due to the amount of choice available. Removing navigation bars on a landing page can lift conversions by 28%.6 The solution This is where landing pages come in! Landing pages are websites (usually onepagers) which are specifically designed with one goal in mind: conversion. If you have a dedicated landing page for your Facebook advertising, it’s highly likely you will generate more enquiries. You must also ensure that the landing page is mobile optimised.7 The easiest way to do this is to duplicate the landing page and alter it to fit your phone’s dimensions correctly. It’s

The problem Generating enquiries is amazing but can be frustrating if they don’t convert into paying patients! Before you launch any paid advertising, you need to ensure that you have your follow-up strategy in place. If you don’t, you will be losing out on new patients every single day! The solution Delegate a member of your team to follow-up with all enquiries, provide them with a sales script and ensure they understand the end goal. When you use the same script, it’s easier to discover areas in the sales flow that is affecting the booking rate. You can then tweak certain parts and see if this increases your bookings. It is vital that the team understand the wording on the adverts, the offer available, and all emails that the patient will receive. By knowing the exact information patients have sent through, you will be able to discuss this on your phone calls to help build trust and authority. The best formula I have seen work for clinics is contacting all enquiries within five

minutes of them being sent through (between working hours) as it’s 21 times more effective than calling after 30 minutes.10 The longer it takes you to phone up the enquiries, the less chance there is to convert them! If you are a solo practitioner or don’t have the number of staff to power through all enquiries within five minutes, there are solutions to solve this. You can set up text responses within your customer relationship management (CRM) system, send out emails automatically or use a third party such as Aesthetic Response, Pabau and Clinic Minds who can sort this for you. However, I have discovered that calling enquiries and having a real conversation with patients is the best way to build trust and book them in for an appointment. If you have spoken to patients through this criterion, you will be aware that they are local, have a disposable income and are a good fit for the treatment you’re advertising. All you need to do is be persistent in following up with enquiries.

Don’t be disheartened! Facebook advertising can be confusing and frustrating for many clinics, however, as you have read in this article, a few tweaks have a huge impact on the results. Test out these tips on your next campaign and you will see an uplift in quality enquiries coming through. Richard Gibbons is the founder of Facebook advertising agency Boost My Customers and specialises in helping clinics generate bookings. He has been in the industry for four years and has learnt and gained experience through mentors. He is the author of the upcoming book The Clinic Marketing Blueprint. REFERENCES 1. Hebblethwaite C, ’Only 60% of UK businesses using social media’ (2018) <https://marketingtechnews.net/news/2018/jan/04/ only-60-uk-businesses-using-social-media/> 2. Facebook For Business, ‘Capturing Attention in Feed: The Science Behind Effective Video Creative’ (2016) < https://www. facebook.com/business/news/insights/capturing-attention-feedvideo-creative> 3. Sehl K, ‘Organic Reach is in Decline—Here’s What You Can Do About It’ (2020) <https://blog.hootsuite.com/organic-reachdeclining/> 4. Facebook Ads Manager - Tutorial <https://www.facebook.com/ business/help/200000840044554?id=802745156580214& helpref=search&sr=1&query=ads%20manager> 5. Facebook Terms and Policies <https://www.facebook.com/ policies_center/> 6. Muhammad F, ‘Should You Use Navigation on Landing Pages?’ (2020) <https://cxl.com/blog/use-navigation-landing-pages-datadriven-consideration/> 7. O’Neill R, ‘Optimising Website for Mobile’, Aesthetics journal (2020) < https://aestheticsjournal.com/feature/optimisingwebsite-for-mobile> 8. Tankovska H, ‘Device Usage Of Facebook users Worldwide As Of April 2021’ (2021) https://www.statista.com/statistics/377808/ distribution-of-facebook-users-by-device/ 9. Facebook Advertising Policies <https://www.facebook.com/ policies/ads/> 10. Elkington D, ‘How Much Time Do You Have Before Web-Generated Leads Go Cold?’ (2007) <https:// content.marketingsherpa.com/heap/DG07SFSlides/ LeadResponseManagementReport.pdf>

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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

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

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

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

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

My plans for the future… I’m launching my own wellness retreat, Anasa, in Scotland this month! The week-long retreat aims to press the reset button for your body and mind.

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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The Last Word Dr MJ Rowland-Warmann debates the pros and cons of live model sharing in aesthetic injectable training There is nothing more ‘real’ than working on live patients. Phantom heads are great for theory and a little bit of practical, but they are not the same as human tissue. The way needles go into a phantom head is very different from a living, breathing person. Experiences such as the depth of needle, whether touch is too firm or too light, or the way injection feels can be near impossible to gauge with phantom heads. Live models are ideal – they allow delegates to experience not only the tissue that is to be injected but also the range of human responses they are likely to experience during their aesthetic treatments. But are delegates getting appropriate training with live models on UK courses? And are models having a suitable treatment experience?

Model sharing It’s a common occurrence in beginner injectable training courses that one model is shared between several delegates, who may each treat half of a patient’s face. Often models are shared because the training provider does not attract enough models, or, in many cases because the trainers don’t have a practice attached to the training school to draw models from, and therefore lack access to them. Sometimes, models may pull out on the day of the training, and maybe the training provider does not have enough space in their training facility to allow for one model per delegate. Although sharing models is undoubtedly better than training on phantom heads, model sharing also comes with its own disadvantages; both for the model and the practitioner. Delegates pay an awful lot of money to come and learn on training days, and many feel like they are being short-changed when they are asked to share a model. Some training schools will argue that model sharing may improve peer learning – drawing on each other’s opinions and ideas to bring about the patient treatment. However, as discussed below, I would argue that using one model per practitioner is a much better approach. From the model’s perspective, although they are usually getting free or reduced treatments, and expect novices to work on them in a training session with oversight from an experienced trainer, it’s important to remember that they are still patients. As clinicians we

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have a duty to keep them safe and also deliver the very best care to them. I believe that sharing them around like a game of pass the parcel is not delivering excellent medical care. Practitioners have different degrees of experience and skills, apply product to different injection depths, with different levels of pressure and this manifests in the results they achieve. One practitioner might be over cautious, whereas the next may be heavy handed. This combination on one single face inevitably gives the patient a result which is less desirable than expected. The face has two halves, and if delegates don’t want their patient’s face to end up completely different from one side to the other, model sharing is not advisable. It is also important to consider aftercare in any treatment plan. Models, like any patient, should be afforded clear aftercare provision, with the opportunity for treatment reviews and treatment management in the unlikely event of a complication. For shared models, it can be very difficult to assign who is responsible for the post-treatment review process. What if something goes wrong? What if the patient wants to compliment the practitioner for the treatment? So many difficulties arise with multiple practitioners working on one patient.

Using one model per practitioner I’ve found that many training providers don’t bother teaching consultation skills, treatment planning, patient discussion or aftercare – they just assume delegates are going to pick this up. As a result, there are a vast number of poorly prepared, inadequate communicators in aesthetics who can stick the needle in the skin but can neither consult nor properly care for the patient, because the most basic training hasn’t been covered on their courses. With 1:1 model to delegate ratios, it is like private tuition in a group course. Delegates experience the whole consultation and treatment process, so they are more likely to integrate it seamlessly into their practice and start treating with their new skills competently and confidently from the beginning. By virtue of the fact that they have treated whole patient/more patients they will have gained more experience, which makes them more confident. I believe that simply doing more in the course will prepare them better for real-life patient treatment. I also believe that peer learning is very much still possible when delegates each have their own models; if anything, it is more beneficial seeing a peer conduct the entire treatment from end to end to learn from, rather than the patchwork learning that many practitioners end up getting with a shared model experience.

Future training Aesthetic medicine training is largely unregulated, but this does not mean delegates and patients don’t deserve a positive educational and treatment experience. Models are patients who deserve goldstandard care no matter what the treatment circumstance and even in training circumstances should be awarded personalised, dignified and appropriate care rather than conveyor-belt treatment. I believe that it is time educators and delegates hold themselves accountable to promote better training in aesthetics. Dr MJ Rowland-Warmann is the founder and clinical director of Smileworks Liverpool and the educational facility Aesthetics Training Hub. She has more than 10 years’ experience as a dentist and aesthetic injector and holds an MSc in Aesthetic Medicine (with distinction) from QMUL. She is a trainer and key opinion leader for Sinclair Pharma, and a regular contributor to industry publications and the national press. Qual: BDS, BSc, MSc, Aes.Med, MClinDent Orthod, PGDip Endod, MJDF

Reproduced from Aesthetics | Volume 8/Issue 9 - August 2021

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August 2021: The Devices Issue

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