AUGUST 2022: The Injectables Issue

One Treatment. Endless Options.

HydraFacial is for everyone. It’s suitable for all skin types and addresses all skincare needs.  The HydraFacial delivers immediate, noticeable results, with no downtime, that keep your customers returning regularly.

HydraFacial is your connection to millions of believers that know that beauty is more than a physical attribute – it’s a feeling. Our customers’ want to give their clients the best experience possible.

The HydraFacial Company helps them deliver it.

Consumers want to be pro-actively offered personalised solutions for skin health and provide them with education on their ideal, easy-to-follow skin health regimen1.

And your clients needs are as individual as they are, which is why HydraFacial has partnered with the best brands in aesthetics to bring you advanced booster options that meet the emerging consumer trends that are influencing our industry more than ever before.

HydraFacial is scored as a ‘99% Worth It’ rating by www.realself.com and on average, somewhere in the world, a HydraFacial treatment is now carried out every 10 seconds!

1 EddieWouldGrow Facial Research 2018, n=2000; 2 Mintel Trends 2017

to

Tips Tailored FOR Skin Type

Only HydraFacial uses a unique, patented Vortex-Fusion delivery system to exfoliate, extract and hydrate skin. The spiral design of HydroPeel® Tips, used in conjunction with the HydraFacial proprietary vacuum technology and serums, creates a vortex effect to easily dislodge and remove impurities while simultaneously delivering hydrating skin solutions.

• Convenient, single use, saves time; eliminates the need for sterilisation equipment • Range of exfoliation levels allows for custom treatment results • Spiral design delivers painless extractions

INTRODUCING KERAVIVE SCALP HEALTH

Expand into a new category with HydraFacial Keravive scalp heath treatment that leads to fuller looking hair. HydraFacial Keravive is a first of its kind 3-step treatment that includes an in-clinic component, as well as a 30-day take-home spray.

“I use Celluma LED in my clinical practice on a daily basis. In addition to the skin benefits, Celluma has been incredibly beneficial to my clients for joint and muscular conditions. The Celluma rental part of my business has proved popular for both skin and musculoskeletal concerns.”

Alison Fulford Independent Nurse Prescriber Harbourside Aesthetic Clinic (Poole,

UK)

08 News

The latest product and industry news 16 Expand Your Knowledge at CCR

Discover the unmissable clinical agenda driving innovation in the aesthetics field 18 News Special: Controlling Dermal Filler Regulation

Aesthetics investigates the updated MHRA guidelines for patient safety

CLINICAL PRACTICE

Harmonising With Hybrid Injectables

Dr Tapan Patel provides his tips for successful treatment using the new hybrid HArmonyCa injectable 23 Special Feature: Introducing Thread Lifting

Practitioners outline key considerations for adding threads to your portfolio 31 CPD: Menopause and Botulinum Toxin

Practitioners examine the link between neurotoxins and mood during the menopause 36 Exploring HA Filler

Longevity

Dr Ciara Abbott provides an introduction to HA filler longevity and gives advice on product selection 39 Using Cannulas

Dr Marcus Mehta explores the use of cannulas for dermal filler placement and provides his tips for success 45 Full-face Rejuvenation

Nurse prescriber Rachel Goddard discusses tips for facial restoration using the Teosyal range 46 Case Study: Managing NSR Complications

Mr Dominic Yue demonstrates effective management of an non-surgical rhinoplasty complication 48 Exploring Dermal Fillers and HSV

Dr Natalie Geary discusses how to diagnose herpes simplex virus in your patients 52 Understanding the Revanesse Portfolio

Practitioners detail their thoughts on the Revanesse range of dermal fillers 53 Abstracts

A round-up and summary of useful clinical papers IN PRACTICE 54 Awards Entries Now Open

What does it mean to be award-winning? 56

Dealing with Difficult Patients

Nurse prescriber Julie Scott provides her tips for managing challenging patients 59 Storing Before and After Images

Business director Jo Hayward advises on how to store patient photography appropriately 62 Understanding

Clinical Contributors

Elaine Williams is a registered nurse with more than 30 years’ experience, and has recently joined the Cosmetic Medicine faculty at University South Wales as honorary lecturer. She owns EOS Aesthetics, based in Sunningdale, Ascot.

Dr Ana Silva concluded her medical degree in 2000 in Brazil before earning both a PG Diploma in Dermatology and an MSc in Dermatology. Dr Silva works as a dermatologist in her private clinic and as a medical expert for the Brazilian Justice court.

Dr Ciara Abbott is the medical director and co-owner of Barstable Medical Clinic, Essex and has worked in the industry for the last 11 years. She is a trainer for Merz Aesthetics, and an associate member of the British College of Aesthetic Medicine (BCAM).

Marketing Automation

Digital marketing consultant Rick O’Neill explains how automation can make marketing more effective 65 In Profile:

Dr Mauricio De Maio

Dr Mauricio De Maio exclusively discusses the creation of the MD Codes and where he sees the industry going 66 The Last Word: Aspiration

Dr Joanna Niciejewska debates the use of aspiration before performing dermal fillers

Dr Natalie Geary is medical director of the Light Touch Clinic in Surrey and founder of the Consentz patient record app. She previously trained at the American Academy of Anti-Ageing Medicine, completing courses in brain health and microbiome. NEXT MONTH IN FOCUS: SKIN HEALTH • Understanding Psoriasis • Treating Skin Lesions

Mr Dominic Yue is a London consultant plastic surgeon working in both private practice and the NHS. He is passionate about non-surgical and surgical aesthetic procedures, and is a member of the BAPRAS, BAAPS and ISAPS.

Dr Marcus Mehta is an aesthetic practitioner with a background in medicine and post-graduate training in dermatology. He is the director of Harley Academy and the co-founder of Comma and STORY Clinics in Southwell, Nottinghamshire and Marylebone, London.

The new gold standard in pigment correction

As I write this, we are in the midst of a melting heatwave, but it didn’t stop our very first Aesthetics & CCR Summer soirée! For the first time, we hosted a summer get together at the beautiful Hurlingham Club in London, supported by Prollenium, to say a huge thank you to many of our biggest supporters and avid journal readers. It was a great morning of learning, followed by a whole afternoon of networking! You can read the highlights on p.15 and we hope to do another one next year, so stay tuned! Our next event will be CCR on October 13-14 – as well as the usual excellent clinical and business content alongside a huge exhibition with the latest and greatest brands and companies, we will be hosting The PHI-lanthropy Diwali Party, supported by Prollenium and Dr Tapan Patel, on the evening of day one of CCR. It will be another fantastic networking event, with all proceeds going to The Childhood Trust – get your tickets online www.ccrlondon.com.

Shannon Kilgariff Editor & Content Manager @shannonkilgariff

So onto this month in the Aesthetics journal… we have lots of injectable-focused content for you. Be sure to read the CPD on toxin and its impact on treating mood in menopausal patients (p.31), top tips for using cannulas (p.39), and we also have an article on considering herpes simplex virus when injecting (p.48). Dermal filler longevity is an interesting one, as anecdotally, practitioners are noticing that they are lasting longer than we think! We have a nice summary on p.36. Our special feature this month also fits our theme – we interview three practitioners who discuss threads for skin rejuvenating and lifting effects – an interesting read on p.23

This month also sees the opening of entry for The Aesthetics Awards! Be sure to get your patient case studies together, your team involved and begin writing those brilliant entries! Remember, writing an award-winning entry takes a lot of time and effort so don’t leave it to the last minute. Entry closes on September 30! As always, do let us know what you enjoy reading this month by tagging us on Instagram @aestheticsjournaluk or send the team an email – editorial@aestheticsjournal.com

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

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

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

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.

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.

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

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

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

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MARKETING

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DESIGN

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WE WANT TO HEAR FROM YOU!

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

Email: editorial@aestheticsjournal.com

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

ARTICLE PDFs AND REPRO

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Sharon Bennett, Clinical Lead

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Have you picked up last month’s copy of the Aesthetics journal? You’ll find an article I wrote that will help you develop a USP in aesthetics.

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Dr Tahera Bhojani-Lynch

@officialdrtahera We are at the Teoxane conference and the fabulous Cherry Healy is speaking. What a great start to the day.

#Education Sam Leon

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A busy day training all things Profhilo with Julie Scott #skinrevitalisation #training

ASA upholds toxin advertising complaint against clinic

The Advertising Standards Authority (ASA) has upheld two Joint Council for Cosmetic Practitioners (JCCP) complaints against Secret Surgery Ltd. The practice in Bicester, England, was investigated for two social media advertisements for botulinum toxin posted in January 2022. The adverts said shortages meant toxin stocks were low and encouraged customers to book consultations quickly before they ran out or prices increased.

The ASA ruled that prescription-only medication (POMs) like botulinum toxin cannot be advertised to the public, hence the first issue was upheld, as was the second because time pressure should not be applied to medical decision-making.

Sally Taber, a JCCP trustee, told Aesthetics, “This is a landmark ruling welcomed by the JCCP, and is to be noted by every provider in the sector. Treating a POM as a consumer commodity diminishes safety of not just botulinum toxin, but also other injectables.”

As a result of the ruling, Secret Surgery Ltd must not post adverts in the form complained of. Secret Surgery Ltd did not respond to our request for comment.

New topical hyaluronidase product available

#Networking

Dr Greg Williams

@drgregwilliamsuk I met some really interesting people at the first #TheDoctorsClub summer party held in Chelsea.

#Training

Dr Elle Reid

@dr.elleclairereid

Always a pleasure to be training with Dr Aran Maxwell-Cox #fillers

#injectables

Medical device manufacturer Prollenium has acquired topical hyaluronidase Topilase. The company explains that Topilase enables treatment adjustment without injecting product or introducing excessive product, as well as minimising over-correction and natural hyaluronic acid degradation. The product is made of a combination of enzymes concentrated within a dispersing agent, helping it to permeate the skin successfully, with the benefit of five additional natural ingredients: cistus, myrrh, lavender, aloe vera and helichrysum essential oils to restore, soothe, purify, revitalise and regenerate, explains Prollenium.

The enzyme complex within Topilase contains protease, lipase and hyaluronidase which helps to break down HA chains. According to the company, on average, patients require three treatments one week apart. The product is applied to the treated area and should be spread using a brush or gloved hands. The area should be massaged well for one to two minutes, explains the company.

Ario Khoshbin, founder and CEO of Prollenium, said, “Today we further demonstrate our commitment to providing best-in-class products to support safety, efficacy and expertise in the cosmetic aesthetics global market. We have made yet another exciting acquisition and it is no exaggeration to say that Topilase will likely revolutionise the practice of injectable enhancement ensuring both patient safety and treatment outcome.”

Industry

Regulation Scottish government to consider tighter regulation on procedures

The Scottish government will consider new regulations on non-surgical cosmetic procedures after overwhelming backing from public consultation. Of 437 responses comprising 382 individuals and 55 organisations, 98% felt further regulation of non-surgical cosmetic procedures (predominantly dermal fillers) was required, and those administering them should be trained healthcare professionals. Further, 61% agreed individuals who are not healthcare professionals should be licensed before performing such procedures, and 90% felt pharmacists should also be regulated in the same manner as healthcare professionals.

The Scottish government has stated it is now a ‘priority’ to consider regulation of dermal fillers and they will scope if any other procedures may warrant similar consideration.

Scottish Health Secretary Humza Yousaf said, “Our aim is to ensure that all non-surgical cosmetic procedures carried out in Scotland are delivered from hygienic premises by appropriately trained practitioners, applying recognised standards and using legitimate products.”

Aesthetic nurse prescriber Jackie Partridge said, “I feel the response that has been published is one more step in hopefully making Scotland a safer place for those seeking non-surgical treatments.”

Cutera unveils new training facilities

Aesthetic manufacturer Cutera has launched its new UK training facilities in Reading. According to the company, the Cutera University Training Academy aims to support its UK customers with an environment for in-depth theory and hands-on clinical training, across all of the companies’ devices. The company will be holding regular Core of Knowledge laser and IPL safety courses as well as Level 4 and 5 qualifications in partnership with Wynyard Aesthetics Academy.

Cutera customers can also attend the regular refresher product training and business support courses, explains Cutera.

UK country manager of Cutera, Leighannah Tickner, said, “Our new state-of-the-art training academy is just another example of our continued investment into delivering unrivalled post-purchase support for our customers. Our growth in the UK market over the past two years has been exponential, and therefore we recognise the requirement to have a central training facility to support our regional Centre of Excellence sites.”

Vital Statistics

(Cosmetic Surgery Solicitors, 2022)

In a survey of 2,000 adults, 29% are insecure about stretch marks (Mederma, 2022) 34% of 2,012 UK adults have suffered from acne at some point in their life (Censuswide, 2022)

New research reveals that 1 in 4 UK adults who don’t wear SPF believe that the sun in the UK ‘isn’t strong enough’ (Medino, 2022)

In a survey of 1,000 UK women, top skin

were dryness (60%), dullness (42%), dark eye circles (35%) and fine lines (27%) (Hada Labo Tokyo, 2022)

72.3% of 2,000 aesthetic clinics are more likely to post photos and videos online that are connected with treatments they have carried out (Whatclinic.com, 2022)

In a survey of 991 people, 56% of women have considered a non-surgical cosmetic treatment, compared to 22% of men

issues

Events Diary

9th September

IAPCAM iapcam.co.uk

10th September

BCAM conference bcam.ac.uk

15th-16th September

The BACN Autumn Aesthetic Conference bacn.org.uk

13th-14th October

CCR ccrlondon.com

12th November

Aesthetics United Charity Conference www.aucc.co.uk

IN THE MEDIA

What’s trending in the consumer press

SANCTIONS LEAD TO TOXIN SHORTAGES IN RUSSIA

Due to economic sanctions following the Russian invasion of Ukraine, it’s been reported by The Guardian that aesthetic clinics in Russia are running low on botulinum toxin. Imports of toxin fell to 74,500 units between January and March 2022. Sanctions such as these have led Russia into a deep recession, according to reports.

LUNCH BREAK TWEAKMENT TREND APPEARS ON THIS MORNING

Aesthetic practitioner Dr Aimee Vyas has appeared on ITV show This Morning to chat about the rise of quick-fix tweakments following John Lewis’ announcement that it is to offer botulinum toxin and other aesthetic treatments in some stores. Dr Vyas said tweakments have become a form of self-care that is seen by some in the same way as regular visits to the dentist.

CONCERN OVER NEEDLE-FREE FILLER PEN TIKTOK TREND

Needle-free HA injector pens are all the rage on social media platform TikTok for users in China according to South China Morning Post, but experts in the country worry the trend is leading to irresponsible at-home use. The handheld device uses pressurised air to insert HA, but the US FDA has warned against their use.

Crown Aesthetics to host SkinPen Precision Autumn Symposium

Aesthetic manufacturer Crown Aesthetics will be holding its Autumn Symposium in October. During the event, the SkinPen Precision clinical data and evidence on the CE mark cleared indications for the UK and EU countries will be discussed. Live demonstrations on models using the SkinPen Precision device will take place to highlight the correct depths and details about the indications. Other talks will include marketing and education support available to customers, best practice for clinic growth and the science behind the clinical data, studies and efficacy of results, outlines Crown Aesthetics. Speakers confirmed for the event include aesthetic practitioner Miss Sherina Balaratnam, who will be discussing clinical education about skin remodelling, and digital strategist Rick O’Neill, who will speak on the importance of business development using correct digital practices. The symposium will be taking place on October 1 at 9am-5:30pm GMT at the Cavendish Conference Centre, London.

Recruitment

HA-Derma expands sales team

Distributor and training provider of IBSA Derma in the UK and Ireland, HA-Derma, has expanded its sales team. The company explains that the new account managers include Sam Leon for the south east of England, Sonia Tierney for the north west of England and Elaine O’Reilly to cover the Republic of Ireland and Northern Ireland. Leon has more than 20 years of sales and training experience in the beauty and aesthetic industry, Tierney has more than 23 years of sales experience within the pharmaceutical and aesthetic industry and O’Reilly worked more than 11 years in the beauty and aesthetic industry. Iveta Vinkler, director of HA-Derma, said, “Our focus is to deliver excellent customer service to complement our award-winning portfolio of products like Profhilo, and we are excited to grow our team.”

Charity

New psychological initiative IPAW launches

Psychologist Kimberley Cairns has launched a new wellness initiative for the aesthetics community. The Integrated Practitioners of Aesthetic Wellness (IPAW) responds to psychological trauma in clinics across the UK, aiming to provide an emotional prevention and response service. Members of IPAW are provided with online tools and digital support to overcome psychological threats in the clinic, including eliminating psychological shock when working in real-time with an adverse event. Members can benefit from bespoke policy and mentorship as part of its packages and have unlimited access to complication management, explains Cairns. Cairns commented, “When undergoing treatment, a patient experiencing an adverse reaction is everyone’s worst nightmare. In the event of such a disaster, many practitioners cannot currently support patients suffering any form of psychological symptoms associated with this. As a result, the focus is on the patient’s physical injury only, and the practitioners can often be left with untreated invisible wounds themselves.”

Entry for The Aesthetics Awards opens

Entry for The Aesthetics Awards 2023 has officially opened. The Aesthetics Awards aims to bring together the very best in medical aesthetics, and is open to those both new and established to celebrate the achievements over the past year. The Awards are presented to clinics, individual practitioners, manufacturers, suppliers and other aesthetic companies who have worked hard to represent the highest standards in clinical excellence and product innovation.

Shannon Kilgariff, editor and content manager of the Aesthetics journal, commented, “It’s time to start preparing your Awards entry once again, as submissions are officially open! The Aesthetics Awards is the perfect opportunity to highlight your achievements and progression in medical aesthetics over the past year. There are plenty of categories to choose from and something for everyone in the industry to enter, so don’t leave submitting your entry until the last minute.”

Entry will close on September 30 and Finalists will be announced on January 3, 2023. Turn to p.54 to enter. The Aesthetics Awards ceremony will take place at Grosvenor House after the second day of ACE 2023 on March 11.

Evolus recruits two new team members

Medical aesthetic company Evolus has appointed two new staff members to its team. Dan Stewart has been recruited as vice president and general manager of the company’s international business. Stewart has more than 20 years of experience in medical aesthetics and started his career with Ipsen where he supported the international assessment of Dysport for medical aesthetics. He has held various sales leadership roles for Allergan’s aesthetics division and ascended to the role of UK business unit director. Suse Alexander has also been appointed as general manager of the UK. Alexander has worked in a variety of sales and leadership roles at Allergan. She has recently overseen global professional education and the commercial excellence programme for Ethicon.

Alexander said, “This is an exciting time to be coming back into aesthetics as we get set to launch a different sort of company. Through the lens of performance meets beauty, Evolus is solely dedicated to aesthetic practitioners. My focus is on creating a superstar Evolus UK team and getting a training programme in place.”

BACN UPDATES

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

AUTUMN AESTHETIC CONFERENCE

Wanting to attend our annual BACN Autumn Aesthetic Conference on September 15-16 but can’t make both dates? No problem! Our one-day passes have been released and are now available to purchase on the BACN website. Don’t miss out on the biggest event of the year dedicated to nurses working within the specialism of medical aesthetics…

One-day passes are available for members to purchase at £65 per day, or the full two-day pass for £110. Guest tickets are also available for those who would like to come along to the event but aren’t a BACN member!

As well as gaining access to expert lectures and demonstrations, sold-out exhibition space and fantastic networking opportunities with medical professionals, the cost of your ticket includes unlimited refreshments, a warm lunch, goodie bags and an opportunity to attend the infamous BACN evening drinks reception.

This year’s first LIVE DEMO has also just been announced! Taking to the stage, BACN nurses Mel Recchia and Rachel Goddard will be discussing botulinum toxin type A off-licence use and advanced techniques.

Learn more about using botulinum toxin type A to treat palmar hyperhidrosis (including a demonstration of the treatment), axillary hyperhidrosis, perioral area, nasolabial folds, marionettes, jawline, nose and chin.

The conference agenda is in the late stages of being finalised – which means more announcements are to follow soon! You can stay up-to-date with all the latest news and updates on the BACN social channels, @BACNurses on Facebook and Instagram.

All conference tickets and information are online and available to visit now on our website, or you can access by scanning the QR code.

This column is written and supported by the BACN

AestheticSource launches Cyspera Intensive System

Skincare distributor AestheticSource has launched its new Cyspera Intensive System of three skincare products designed to target hyperpigmentation and discolouration within 16 weeks.

The skincare system is a three-stage line comprised of Cyspera Intensive, Cyspera Neutralize and Cyspera Boost. Intensive uses its trademarked Cysteamine Isobionic-Amid complex to target persistent brown patches and dark spots, then Neutralize rebalances the epidermis and neutralises the cysteamine odour before Boost uses the Isobionic-Amid complex to even the skin tone and improve complexion.

A clinical trial of 28 volunteers conducted by Dr Mukta Sachdev suggested that the products provide 10% better evening of skin tone within four weeks, and four times better toleration after the 16 weeks, with the company claiming this indicates they are effective for long-term use. Dr Jinah Yoo, consultant dermatologist and honorary senior clinical lecturer, said, “The Cyspera Intensive System is an exciting and innovative launch as it offers a long-awaited, clinically proven alternative to hydroquinone. The three-step system delivers impressive results on persistent epidermal pigmentation to even out the skin tone. Its suitability for long-term use makes it a game-changer in pigmentation treatments.”

Lumenis raises large funds for charity

On July 2 the Lumenis Cares Summer Dinner was held in aid of Children’s Burns Trust, with Dr Tapan Patel matching funds raised to bring the grand total to £28,000. Held in the Tapestry Room at The Ned in London, 70 guests enjoyed a three-course meal and music from Molly Hocking during the evening, which was sponsored by Dermaroller and XCELLARISPRO. After an introduction from Dr Dev Patel, the evening’s auction was hosted by Dr Tapan Patel. Children’s Burns Trust has been working in the UK for more than 20 years to provide rehabilitation and support for children affected by burn and scald injuries, as well as their families.

The charity’s chairman of trustees, Princess Marina Lobanov Rostovsky, said, “We are so grateful to everyone who came along and supported in some way. The incredible amount of money raised on the night will allow us to continue providing rehabilitation support for burned and scalded children, as well as supporting our prevention and awareness campaign for which there is little or no national funding.”

Laure Boisseux, founder of the Lumenis Cares Foundation, added, “We’re thrilled that our first fundraising event has been such a resounding success! It was a wonderful evening had by all for this very worthy cause.”

Recruitment Galderma introduces new sales team members

Pharmaceutical company Galderma has expanded its UK sales team with four new positions. According to the company, the new team members aim to provide increased strategic support and servicing across the country as a result of increased demand for the Restylane dermal filler and expanding toxin portfolios. The new members include Urvi Yadev who will focus on the East Midlands; Hannah Miller for the West Midlands; Hannah Finan to cover north London and Leanne Woods to be regional business manager for the north of England and Scotland. Head of sales for Galderma UK, Chris Dimmack, said, “2022 is a very exciting year for Galderma with the launch of Restylane Eyelight and our expanding toxin portfolio, so we are delighted to bring in top level talent to continue servicing our clients to the highest possible standards. We at Galderma are passionate about delivering the best products, training and support for our customers.”

Survey

AAD survey shows young Americans lack sun protection knowledge

An American Academy of Dermatology (AAD) survey has revealed that Generation Z adults lack accurate and adequate knowledge of the cruciality of sun protection. More than 1,000 US adults aged 18 or older were surveyed to ascertain the level of their understanding regarding sun safety, and many misconceptions emerged among the Gen Z 18-25 age group, which comprised 8% of the sample.

According to the survey, many Gen Z respondents were not aware of the potentially harmful side effects of tanning, with 60% getting a tan in 2021, and 38% believing that tanning is safe as long as burning is prevented.

Furthermore, the survey revealed that 49% of Gen Z participants did not know you can get sunburned on a cloudy day, 37% did not know the sun’s UV rays can penetrate clothing and 23% were unaware that sunscreen should be reapplied every two hours when outside. The AAD states that spending long amounts of time in the sun can accelerate skin ageing and increase the risk of skin cancer. The Academy recommends seeking shade, wearing sun-protective clothing and applying and reapplying sunscreen of SPF 30 or higher. Associate professor of dermatology at Yale University School of Medicine Dr Brittany Craiglow said, “If you are in Generation Z and are not protecting yourself from the sun, it’s essential that you start now if you want to reduce premature skin aging and your risk of skin cancer.”

Be Recognised As Leading in Your Industry

Enter The Aesthetics Awards 2023 now.

The Aesthetics Awards are the most widely respected and coveted awards ceremony within the medical aesthetics specialty. Running for more than 10 years alongside the Aesthetics journal and the Aesthetics Conference & Exhibition (ACE), the Awards represent a pillar of excellence within the community, and a chance to acknowledge the incredible achievements of clinics, practitioners and companies. From incredible results and stories of resilience to truly innovative products that have transformed lives, the achievements are astonishing. The hard work, dedication and passion of individuals is what drives this industry to greatness, and the commitment to their craft shines through in their entries. Winning an Award brings recognition from peers, gratitude to hard-working teams, shines a light on ground-breaking work and allows the Winner to describe themselves as ‘award-winning’, a phrase which holds great significance wherever it’s positioned. After a record-breaking year in 2022 in terms of entries and attendance, the Awards have now moved to a larger and more glamorous venue in London, Grosvenor House, with a capacity of more than 1,200 people. Perfectly located in central London’s Mayfair neighbourhood, Grosvenor House offers a luxury venue in an upscale setting and will be the perfect celebration of our industry in a breathtaking chandelier-lit ballroom.

Though it feels like we are still on a high from The Aesthetics Awards 2022, the aesthetics industry does not rest. Entries are now open until September 30 and we urge you to start yours early. There are plenty of supporting materials to be found on the website and some brand-new categories to enter – so carefully research the categories and read through the criteria to select the perfect one for you. Good luck, we cannot wait to see what our amazing industry has achieved in the last year!

Entries are open until September 30. Entry is FREE to Aesthetics journal subscribers.

The Awards ceremony will take place on March 11 after the second day of the ACE 2023.

iS Clinical releases new skin polish

Distributor Harpar Grace has launched the new iS Clinical Cleansing Complex Polish to its portfolio.

The company states that the foaming gel product, which contains eco-friendly micro-particles of cellulose and jojoba combined with salicylic acid, aims to cleanse the pores through both physical and biochemical exfoliation without drying the skin. Key ingredients, including microcrystalline cellulose, jojoba esters (15%), sugarcane extract (1%), willow bark extract (source of salicylic acid, 1%) and glycerin (5%) are designed to deep-cleanse the pores, as well as give them a smaller appearance.

Kimberley Saunders, head of customer experience at Harpar Grace, said, “We are delighted to announce the launch of the latest product from iS Clinical. The Cleansing Complex Polish offers our patients the opportunity to have a deeper and more effective physical exfoliating product as part of their routine. The formulation contains a combination of gentle yet active ingredients, and effectively provides a smooth glow to the skin.”

Treatment

Dermalogica unveils new professional services

Skincare brand Dermalogica has launched its new professional services overhaul.

According to the company, the new services have been introduced to build upon insights from changing consumer searches and drive the recovery of the industry post-COVID, by supporting accounts in new service business and client acquisition.

The announcement has seen the arrival of new additions to the treatment offering due to a rise in consumer searching for specific skincare solutions for needs such as sensitivity. The new approach allows professionals to optimise the business search engine optimisation.

The structure also sees the company enter the advanced services space with the introduction of nanoneedling and microneedling treatments, both set to launch later this year. Melissa French, education executive at Dermalogica, said, “Consumer demand is changing, and we are seeing an increase in patients wanting to tackle a multitude of concerns, using a single device with combined technologies. Offering a multifaceted approach to procedures, elevates your clinic to competitors and offers patients faster and improved skin rejuvenation.”

Education

HA-Derma expands training faculty

HA-Derma, the training provider for IBSA Derma products, is expanding its training faculty to fulfil demand for practitioner training. The new trainers joining the faculty are Dr Kerri-Lee Clark (Scotland), Dr Altona Myers (Dublin, nationwide), Dr Dallas Walker (Dublin, nationwide) and nurse prescribers Julie Scott (London, Essex, nationwide) and Adrian Baker (Oxford, nationwide). Dr Clark commented, “I am excited to join the HA-Derma training faculty as the Profhilo trainer in Scotland. It is an honour to be part of such a renowned company. The ethos and passion that HA-Derma demonstrate towards its product range, staff and customers are second to none.”

Scott added, “I wouldn’t educate on a product I don’t believe in 100%, but I’ve been successfully offering Profhilo in my clinic since the product first launched in the UK and it’s become such an important part of my offering to patients.”

Advertising Influencer beauty ads restricted by new Australian regulations

The Australian government’s Therapeutic Goods Administration (TGA) has introduced new regulations preventing social media influencers from receiving payment for endorsement of health, cosmetic and skincare goods (therapeutic goods).

The amendment to the Therapeutic Goods (Therapeutic Goods Advertising Code) Instrument 2021 entered commencement on January 1, 2022, and was fully introduced on July 1 after a six-month transition period. The TGA states that the new rules are designed to ‘ensure consumers are not influenced excessively or inappropriately by endorsements and testimonials’, as consumers of therapeutic goods are ‘a more vulnerable consumer cohort’.

The changes have received some backlash, especially due to the fact that it also extends to SPF products. Samantha Brett, founder of SPF sunscreen brand Naked Sundays, has written to the TGA, saying, “I do believe sunscreens should be exempt from the TGA advertising laws when it comes to testimonials. Summer is just around the corner which means Australians are at greater risk of skin cancer and melanomas. I think influencers should be allowed to give their opinions about the sunscreens they’re using, whether paid, gifted or unpaid by a brand.” TGA representative Nicole McLay responded by agreeing that promotion of sunscreen on social media can have a positive impact, and that the regulation only blocks paid promotion. “The measure is designed to ensure, as much as possible, that testimonials are genuine and not influenced by commercial interests,” she said.

Aesthetics and CCR hosts first Summer Soirée with Prollenium

On July 18, the Hurlingham Club in Fulham played host to the first ever Aesthetics and CCR Summer Soirée event, supported by Prollenium, for a day of practitioner education and networking.

Guests braved the heatwave to gather for a morning of fascinating educational talks from aesthetic nurse prescriber Julie Scott, Mr Dean Rhobaye, Dr Emily Mehta, Dr Jo Ward and Dr Tapan Patel, covering topics including combination treatments, facial harmonisation and the Phi golden ratio. Attendees were also introduced to Prollenium’s new product Topilase – a topical hyaluronidase serum to reduce unwanted hyaluronic acid after filler treatment – which officially launched at the event and was sold on-site by Healthxchange. Following the talks, guests enjoyed a barbeque and networking drinks in the grounds, accompanied by live music from Cassa Jackson. Katie Bennett, head of marketing at Prollenium, commented, “Some events are talked about for years to come and I think this will certainly be one of them; the atmosphere, guests, speakers, food, Pimm’s, the band, the weather… it was memorable as well as being a great networking and training opportunity, attended by the greatest and the best in aesthetics.” Bennett added, “It was great to be surrounded by so much talent and with such a perfect backdrop as the Hurlingham. Thank you to all our speakers and guests, and I look forward to the next collaboration with Aesthetics and CCR – the PHI-lanthropy Diwali Party on the evening of October 13, after day one of CCR.” Tickets are on sale now via www.ccrlondon.com.

GetHarley and AlumierMD skincare trends event

The top trends of skinamilism, techceptance and mastering skin wellness were discussed at an event hosted by AlumierMD and GetHarley on June 29 in London. A total of 150 practitioners attended AlumierMD’s training clinic or tuned in live online. The event featured a panel discussion about the latest industry trends, featuring aesthetic practitioner Dr Nina Bal, Aesthetics journal editor Shannon Kilgariff, medical communications manager at AlumierMD, Victoria Hiscock and head of education/training at AlumierMD, Gemma Rabbetts. Among the topics covered was how relevant skincare is to optimise treatment outcomes and how practitioners can use trends to boost revenue and reputation as skincare experts.

Nadia Oakes, regional manager for AlumierMD, said, “The GetHarley and AlumierMD event was a brilliant way to launch our partnership to both introduce AlumierMD to GetHarley accounts and share with other practitioners how they can also partner with AlumierMD via GetHarley. Both of which are dedicated to making skincare pros accessible whilst protecting the sector.”

She added, “Discuss the Hot Skincare Trends of 2022/23 was a brilliant vehicle to help bring skincare to the front of minds for practitioners. With a focus on skinamilism, skintech and skin wellness, we had a great time discussing these hot trends!”

News in Brief

mesoestetic to hold its first distributor convention

Pharmaceutical company mesoestetic held its first worldwide distributors convention in July. The company were joined by 100 people from 55 countries at the Palau de la Música in Barcelona to present the mesoestetic awards, which recognises the alignment of vision and good practice, explains the company. Mesoestetic UK were nominated in five categories and were awarded for its work in digital marketing. Adam Birtwistle, managing director, said, “Our whole team in the UK are part of every success we achieve and only together will we continue our growth and values.”

New DANAI open day date revealed The Dermatology Aesthetic Nurses Association Ireland (DANAI) has revealed its next open day date. The event will take place on September 26 at 9am-4pm GMT in Kilmainham, Dublin. The association was founded in 2008 and members must be NMBI registered nurses with a minimum of three years’ experience. On the day, members will network with industry professionals, watch demonstrations and presentations, receive goodie bags, and lunch and drinks are included. DANAI chair Patricia Molloy, commented, “This is an opportunity for nurses interested in aesthetic medicine to join DANAI and meet like-minded nurses.”

Kimberley Cairns becomes board member at JCCP Psychologist Kimberley Cairns has joined the board at the Joint Council for Cosmetic Practitioners (JCCP). Cairns commented, “I express my gratitude with sincere honour to be joining the esteemed board of the JCCP. Like many colleagues, industry peers and stakeholders, I find the work of the JCCP inspiring. In my new appointment, I endeavour to strengthen parity to the physical and psychological experience of the patient journey. I will continue to promote patient safety for members of the public considering or seeking an aesthetic treatment.”

IAPCAM to take place in September

The International Association for Prevention of Complications in Aesthetic Medicine will be taking place on September 9. The event will be live and include an anatomy masterclass with injection techniques as well as complication case studies, with opportunities for the audience to be involved. It will be supported by IMCAS, the BACN, BCAM, CCR and ACE and will take place at Church House Conference Centre in Westminister, London.

Expand Your Knowledge at CCR

Discover the unmissable clinical agenda driving innovation in the aesthetics field

Plans are well underway for what is set to be an incredible CCR 2022 as we once again come together to learn, discover, network and celebrate with peers, friends and world-leading practitioners. With the new Elizabeth line providing direct trains from major stations including Paddington and Liverpool Street, your journey couldn’t be easier.

Combining a high-level academic programme with world-leading products is unique to CCR, and gives attendees the complete learning experience, from experts sharing knowledge in their craft, to how to implement this practically into clinics. CCR delivers world-class aesthetic education and learning with two days of in-depth sessions at the ExCeL, London on October 13 and 14. This year’s scientific agenda leads in pioneering techniques, introducing more clinical symposiums and business sessions with expert speakers presenting the latest medical advances. Headline Sponsor Galderma will host two symposiums in the Arena featuring live demos showcasing their aesthetics portfolio. Dr Priyanka Chadha is the first confirmed speaker joining the line-up. With a focus on a holistic approach to aesthetic medicine that provides a well-rounded platform for education, attendees have access to an agenda of FREE non-surgical education at CCR that will unveil the latest medical innovations and rediscover how extraordinary the aesthetics specialty is.

Innovative facial rejuvenation procedures

The Aesthetics Arena will host the latest and greatest non-biased advice on facial rejuvenation procedures. With sessions dedicated to each area of the face, topics will cover how to sculpt jawlines, transform tear troughs, master mid-face lifts, harmonise the lower face and tighten necks. Discover innovations in botulinum toxin, and how ultrasound could improve injection technique and aid complication management. Also included are sessions to enhance skincare knowledge, with the latest on chemical peels, how to treat pregnant patients safely, manage acne and build confidence in treating skin of colour.

Aesthetic wellness

In an industry first, CCR dedicates a brand-new agenda looking at the close relationship between aesthetic medicine and wellness. Curated by Dr Mayoni Gooneratne, the founder of Human Health, attendees will discover a new way to benefit patients and enhance

results, while also expanding their business. With the global wellness industry estimated to be worth US $7 trillion by 2025, now is the time to think about integrating holistic services into your practice. This agenda will teach you about the wellness market and why it might have a place in your aesthetic clinic, covering the positive physical and psychological impact these treatments have on your patients.

A dentist’s guide to aesthetics

For the first time, CCR dedicates a new stream of content to dentists looking to expand their offering in the medical aesthetic specialty. Curated by renowned dentist and trainer Professor Bob Khanna, this is an unmissable agenda for those wanting to enhance their knowledge from experts in the field. Starting with perfecting your consultation skills, the agenda will end with the opportunity to ask questions to our expert panel to help drive your medical aesthetic business forward

Confirmed speakers include:

Professor Bob Khanna, Dr Nina Bal, Dr Arti Singh and Dr Anjuli Patel.

Management of non-surgical aesthetic complications

Patient safety, regulations and training are at the heart of CCR. To ensure this essential education is offered, we are delighted to welcome back the Aesthetic Complications Expert (ACE) Group World to host their Group Conference at the event.

ACE Group World provides medical practitioners of all specialities with leading education to improve patient safety and discuss the latest industry developments with the prevention and management of complications occurring in practices. The agenda of well-renowned speakers is open to new and existing members of the ACE Group World, providing an opportunity for all to learn more about the latest evidence and guidelines on the management of non-surgical aesthetic complications.

Uniting surgical and non-surgical

The esteemed ISAPS Symposium UK returns for 2022, reinforcing CCR’s position as the home of the entire surgical and non-surgical medical aesthetics community. This agenda unites the world’s leading aesthetic plastic surgeons under one roof, integrating surgical education and networking to enable true cross-fertilisation of knowledge between surgical and non-surgical practitioners. ISAPS Symposium UK will feature an internationally renowned faculty from across the globe, putting CCR and the ISAPS Symposium UK on the world stage. Speakers include: Mr Naveen Cavale, Mr Tunc Tiryaki, Mr Francisco Bravo and Mr Daniel Saleh.

Paid for items with limited tickets available:

• ISAPS UK Symposium

• ACE Group World Conference

• Dr Tapan Patel LIVE Anatomy Masterclass

•

Develop your skills

As always, CCR will incorporate an unparalleled and comprehensive educational programme across its other conference agendas covering clinical and business training, all of which is CPD-accredited. The education highlights include an anatomy training course with industry guru Dr Tapan Patel and practice management advice to help aesthetic businesses develop their growth strategies. Attend the sessions that suit your learning needs and contribute to your career and clinic development, whether that involves laser treatments, bodycontouring methods, skincare approaches, injectables or business strategy. Further details on the agenda will be revealed soon.

Register now to be the first to find out more.

Headline sponsor

CCR Afterparty: PHI-lanthropy Diwali Party supported by Prollenium

professionals, which instead falls into the remit of the Department of Health and Social Care (DHSC). Instead, the MHRA has shared the feedback with the relevant DHSC team for consideration in its new licensing regime.1

In the document, the MHRA aims to prepare regulations reclassifying products such as certain implantable devices. This will extend the scope of regulations to include certain non-medical products with similar risk profiles to medical devices, such as dermal fillers, which will consequently be subject to more stringent regulation.2

Controlling Dermal Filler Regulation

Within the aesthetics specialty, regulation and patient safety has remained a continuous debate. However, with the recent Health and Care Bill 2022 being implemented by the Government to introduce a licensing scheme for practitioners operating in England, it seems that regulation within the industry is slowly starting to progress.1

In a recently published document, the Medicines and Healthcare products Regulatory Agency (MHRA) outlined the Government’s response to a consultation on the future regulation of medical devices in the UK.2 The consultation took place between September and November 2021 with 891 responses involving 263 healthcare professionals and 200 manufacturers of medical devices, as well as involvement from healthcare institutions, enterprises, members of the public and trade associations.

According to the document, the biggest support was on improving patient safety from the Government and the MHRA aims to prepare regulations to ensure this remains a priority. These include reclassifying products such as certain implantable devices, expanding the scope to include certain products within the definition of ‘medical device’ and ensuring a smooth transition and implementation

for the industry when the new regulations come into place.2

Furthermore, the consultation invited views on whether the UK medical devices regulation should be broadened to include devices without a medical purpose but have similar risk profiles to medical devices. Devices which respondents believed should be regulated included: buttock implants (93%), microneedling products (88%), dermal fillers (88%), liposuction devices (88%) and hair or tattoo removal lasers (81%).2 The respondents believed that this would deliver safety benefits to patients and would align with the EU Medical Devices Regulation.3

To find out more about the new regulations and how this might affect the aesthetics industry, we contacted the MHRA as well as nurse prescriber and co-chair of the Joint Council for Cosmetic Practitioners’ (JCCP) Clinical Advisory Group, Andrew Rankin.

Stricter requirements for dermal fillers

Within the consultation, the regulation of dermal fillers was outlined with respondents believing that they should be administered/ used by healthcare practitioners and should be available on a prescription-only basis. However, the MHRA outlines that it does not have a role in regulating healthcare

The MHRA states that there are no plans for dermal fillers to become prescription-only. They explain, “Dermal fillers currently placed on the UK market with a medical purpose are called medical devices and are required to carry a UK Conformity Assessed (UKCA) or CE marking. There are, however, dermal fillers that are marketed for aesthetic use only that are not currently regulated as medical devices, as the manufacturer is not making a medical claim. There are also dermal fillers without a medical purpose but contain a medicinal substance, such as an anaesthetic. These would both then fall under the medicine’s regulation.” Therefore, the MHRA aims to change the classification of all dermal fillers which will result in them becoming subject to increased regulation.

Once all dermal fillers are in the scope of the UK medical devices regulation, it is expected that they would become Class III medical devices under existing classification rules for implantable devices, and therefore a ‘summary of safety and clinical performance’ (SSCP) will be required for these products.2

The SSCP will detail information on the medical device’s safety, clinical data, and clinical performance.

The MHRA intends to require manufacturers of high-risk devices, including Class III medical devices such as dermal fillers, to publish data on device safety and performance following UKCA marking, for intended users of the medical device in the form of a SSCP. As part of the SSCP, manufacturers will need to define and set out the suggested profile and training for users, which would be checked by their approved body.2

The MHRA commented, “Most dermal fillers, where the manufacturer makes a medical claim, already fall under the highest risk classification (Class III) under the current medical devices’ legislation. However, under the new regulations, we intend for dermal fillers without a medical purpose, for example cosmetic,

Aesthetics

to also come under the scope of the medical device’s regulations. Therefore, the changes will afford greater protection to users of certain cosmetic products by broadening and strengthening the regulation of these devices.”

Rankin welcomes this new regulation and believes it will help with public safety, clarity and transparency in the industry. He explains, “One of the biggest changes from the consultation is that UKCA, which will eventually replace CE marking in the UK, ensures that devices without a medical purpose are regulated the same way as medical devices. Currently, some dermal fillers are regulated as medical devices and have a robust regulatory system in place, but others are regulated as cosmetic products with a much lower level of regulation. I think this will make a huge difference in the industry and requires high standards to be met from initial manufacture through to post-market surveillance.”

A gradual transition

The MHRA plans for the new regulations to come into force in 2023.2 This enables

products which have conformity markings, either UKCA or CE, to remain on the market after the regulations come into force for a period of three to five years, depending on the device and the rules under which the existing conformity mark was given.2

The MHRA notes, “New regulations are still being finalised and laid in Parliament and are therefore subject to parliamentary approval, but they will reflect regulatory changes set out in the consultation response. We will gradually phase in the new requirements with transitional arrangements, prioritising patient safety while giving the industry enough time to adapt to the change.”

Rankin concludes that practitioners should be aware of new regulation processes coming into place in the future. He states, “From a practitioner point of view, there are no real challenges with these changes, although they should be mindful of the new information provided with the device to be given to patients and clients. For manufacturers and distributors, there probably are additional challenges. For example, manufacturers or distributors that are unable to comply with the new regulations will be unable to market their

products within the UK. Practitioners should be careful of where they are sourcing their products from and conduct thorough research before purchasing from an appropriate supplier. As well as this, practitioners should also be looking out for the new UKCA marking when buying products which will eventually replace the old CE mark. The objective of these changes is public safety and with new levels of clarity and transparency, it should be easier for patients to do their research into the products to seek the assurance they deserve. Despite this, one change which didn’t come out of the consultation was restricting the supply of dermal fillers. However, the new licensing regime probably offers the best forum to make those changes.”

VIEW THE REFERENCES ONLINE!

AESTHETICSJOURNAL.COM

Harmonising With Hybrid Injectables

2.

Tapan Patel is a consultant to Allergan and part of its AMI faculty.

I always felt there was a missing piece from the treatments we had to offer our patients. We had great innovations for building volume, treating pigmentation and improving skin texture, but there were a lot of patients who we couldn’t help – those with poor skin architecture. With dermal fillers, you might be able to improve patients to a certain extent, but they would still have some lines and creases and accordion lines, which are those that form from the corner of the mouth and go across to the lower part of the cheek. Of course, there was calcium hydroxyapatite (CaHA), which could create positive results, but the problem was that it didn’t last very long. That’s why we have a place for the new hybrid HArmonyCa™ collagen stimulating injectable, which combines CaHA and hyaluronic acid (HA) in a single syringe for both an immediate and sustained lifting effect.1-3 I was part of Allergan’s ‘experience phase’ so I’ve been using this product in my practice for about 15 months. I’ve treated many men and women with all different skin types using the product. It has become my go-to product for my established patient database – I’m currently treating around five people per day, with positive results and patient feedback. Here, I provide my top tips for using this new hybrid injectable so you too can implement it successfully into your practice.

1. Understand the science

The first step to getting excellent results with HArmonyCa™ is to understand its mechanism of action. Supporting the body’s own collagen production,4 CaHA works deep within the dermis to form a scaffold for internal growth of fibroblasts.5,6 Pre-clinical data has shown this can help produce new collagen fibres as early as one week after injection2 and induce related remodelling of the extracellular matrix.4,7 HA particles integrate with collagen fibres of the lower dermal layer, which may create volume for an immediate lifting effect.1,8

Select the right patient

Fundamentally, the best candidate for HArmonyCa™ is men and women who already have fairly good volume who could benefit from a potential improvement to their skin architecture.1 They should have lines and wrinkles at rest or on animation, who also may require a bit of skin tightening. My patient age tends to range from 30-80 and it’s strictly for use in patients over the age of 18.1

3.

Know your injection depth

We know that anatomical knowledge is key to successful results, but specifically with this product it’s about also being comfortable with the injection depth and the injection equipment.2,9,10 The depth is superficial – you should be injecting into the deep dermal and sub-dermal layers.1,2 I would stick to the lateral area of the face – so typically the best zones are the jawline and under the cheek bone..

4. Always under correct It’s more important than ever not to overtreat when using HArmonyCa™. Remember, the immediate effect will be enhanced over time and the results progress over three to six months;2,6 although, in my personal practice I’m seeing ongoing improvements for up to a year. Always under correct to avoid unnatural results. Common postoperative adverse events include erythema, oedema (swelling), pain, tenderness, and itching. Treatment site reactions typically resolve within 24-48 hours and swelling within a week.1

5. Ensure you seek training with HArmonyCa™

It’s vital that you are adequately trained in all new products that you are thinking of adding to your treatment portfolio, particularly if you don’t have any previous CaHA experience. Allergan Aesthetics runs regular training days for healthcare professionals, and it’s a great opportunity to come and get hands on with HArmonyCa™. To find out the next training days, contact Allergan Medical Institute® Training at amitraining@allerganeventsteam.com. Note that the Allergan Medical Institute® is promotional – Allergan products will be discussed.

©AbbVie 2022. All rights reserved. Material produced and funded by Allergan Aesthetics, an AbbVie company. www. allerganaesthetics.co.uk

Adverse events should be reported. Reporting forms and information can be found at: UK adverse events reporting https:// yellowcard.mhra. gov.uk/ Adverse events should also be reported to Allergan Ltd. UK_medinfo@allergan.com or 01628 494026 Irish adverse events reporting https://www.hpra.ie Adverse events should also be reported to Allergan Ltd. UK medinfo@allergan. com or 01628 494026.

Disclaimer: this article is based on Dr Patel’s personal experience and ultimate decisions regarding patient care lies with the treating HCP and the patient.

REFERENCES 1. Allergan Aesthetics. HArmonyCa™ Lidocaine IFU. M032 V01. 2021. 2. Allergan Aesthetics. Data on File.INT-HAR-2150040. HArmonyCa™ Lidocaine. Collagen stimulation. Jul 2021. 3. Allergan Aesthetics. Data on File. INT-HAR-2150036. HArmonyCa™ Lidocaine. Lift capacity. Jul 2021 4. Gonzaga da Cunha M et al. Surg Cosmet Dermatol. 2020;12(2):109–17. 5. Segal T et al. Post marketing study of safety and efficacy of Crystalys, a calcium hydroxyapatite based filler for facial soft tissue augmentation. Kosmetische Medizin online. https://www.kosmetischemedizin-online.de/uebersichtsarbeit/post-marketingstudie-zursicherheit-undwirksamkeit-von-crystalys-einem-auf-calcium-hydroxyapatit-basierenden-fillerfuer-die-weichteilaugmentation-im-gesicht/ Accessed July 2022 6. Berlin A et al., Dermatol Surg 20008 ;34(1 Suppl)S64-67 7. Gonzalez N and Goldberg DJ, Dermatol Surg. 2019;45(4):547-51. 8. Hee C et al. Dermatol Surg. 2015;41(Suppl 1):S373–81 9. Braz A and Cazerta de Paula Eduardo C. Indian J Plast Surg. 2020 Aug; 53(2): 230–243. 10. Fallacara A et al Facial Plast Surg. 2017 Feb;33(1):87-96

Dr Tapan Patel provides his tips for successful treatment using the new hybrid HArmonyCa™ collagen stimulating injectable

This article is produced and funded by Allergan Aesthetics and is intended for healthcare professionals. UK-HAR-220207 | Date of preparation July 2022

Introducing Thread Lifting

The power of dermal fillers can’t be argued with. Offering instant effects and long-lasting results makes them an essential tool for all medical aesthetic practitioners. In patients with excessive facial sagging, however, results don’t always quite go far enough. So what do you do? Referring patients for surgery is of course an option, but for many patients, it will be out of budget and the invasive nature with lengthy downtime isn’t often very appealing.

According to four seasoned professionals, this is where threads come in.

Aesthetic practitioners Dr Victoria Manning, Dr Charlotte Woodward, Dr Zunaid Alli and cosmetic dental surgeon Dr Rita Poddar all have significant experience in performing thread lifts and champion their effectiveness.

“Of course, if there’s volume loss then you need filler, but you may also need to address and lift the fat compartments that have descended over time, which can be achieved using threads,” says Dr Poddar. Dr Manning adds, “Fillers can go so far in patients with mild ptosis and sagging, but if you use them when you need a decent amount of superficial fat lifted, you will end up with a

cushioned face that look unnatural.”

Dr Alli agrees, “I will fill and volumise as best I can using dermal fillers, but sometimes I will need something to lift tissue and hold it in place.” He adds that as well as lifting and repositioning tissues, threads can stimulate collagen production, which offers enhanced, long-term results.

Patient selection

So, are thread lifts suitable for everyone? No. The practitioners agree that ensuring you select good candidates for treatment is essential for successful results. “Usually, we have patients aged 40+ come to us who feel their face is sagging. They have jowling, flat cheeks and their infraorbital fat pads have started to herniate. Some patients will have weak forehead muscles, so they have a drooping brow, which then makes the eyelids look heavy,” explains Dr Alli, noting that these people would be ideal candidates. He also treats patients who have lost a significant amount of weight and are now left with sagging skin.

Dr Poddar adds that patients with heavy-looking nasolabial folds and loose skin on the neck are also suitable, highlighting that age isn’t always a factor; she has treated

patients in their late 20s and early 30s who have been suitable candidates.

“My ideal patient is someone with mild to moderate sagging and good tissue integrity –there needs to be enough fat there to actually hold the thread,” advises Dr Woodward, pointing out that a thread lift won’t be suitable for those with advanced sagging; these patients will need to be referred for surgery.

Dr Manning continues, “Patient selection for a thread lift is absolutely key. Threads have had a lot of negative press, but it’s basically down to the wrong patients having treatment. For every 10 patients that come to see me, I will probably only put threads in three.”

It’s not one or the other when it comes to selecting an appropriate treatment, Dr Poddar says, suggesting that practitioners should always consider combining a thread lift with other procedures.

Dr Manning agrees, saying, “We always need to be thinking about combination therapies; whether it’s repositioning with threads, muscle modulation with toxin or volume enhancement with filler, as well as introducing energy-based devices to stimulate further collagen and elastin production – the more combinations you can do, the better the outcome, the better the longevity and the happier your patients are going to be.”

As always, Dr Poddar emphasises that it’s better to under-promise and over-deliver. “Make clear that a thread lift isn’t going to give a surgical result. Downplay the effects it could have and you should then have happy patients leaving your clinic,” she explains.

Preparing for treatment

Before a patient can be deemed suitable for a thread lift, a very detailed consultation needs to be undertaken, says Dr Alli, adding that a cooling-off period is essential. He will offer more than one consultation if he thinks it will benefit the patient, and encourages them to take their time before going ahead. “I talk them through the type of thread I’ll be using, the brand, show them before and after photographs and discuss the clinical evidence in layman’s terms. Of course, I also tell them about all the risks so they are completely informed.”

A full medical history is of course part of this, with Dr Woodward saying this should examine if the patient has any autoimmune diseases, which would usually be a contraindication for treatment.1 However, she notes that treatment can sometimes

Key considerations for practitioners interested in adding absorbable threads to their treatment portfolio

Letybo� Botulinum toxin type A

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new ways

Letybo® is indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows in adults <75 years old seen at maximum frown (glabellar lines), when the severity of the facial lines has an important psychological impact. Response rate was defined as a ≥ 1-point reduction in FWS at maximum frown based on the investigators assessment. References: 1. Mueller DS, Prinz V, Adelglass J, Cox SE, Gold M, Kaufman-Janette J et al. Efficacy and Safety of Letibotulinum Toxin A in the Treatment of Glabellar Lines: A Randomized, Double-blind, Multicenter, Placebo-controlled Phase 3 Study. Aesthet Surg J. 2022; Jan 29: sjac019. doi: 10.1093/asj/sjac019. Epub ahead of print. PMID: 35092418.; 2. Letybo® smPC, https://www.medicines.org.uk/emc/product/13707 2022

Letybo 50 units powder for solution for injection; Abbreviated Prescribing Information: Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: One vial contains 50 units botulinum toxin type A produced by Clostridium botulinum. After reconstitution each 0.1 mL of the solution contains 4 units. Indication: For the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows in adults <75 years old seen at maximum frown (glabellar lines), when the severity of the facial lines has an important psychological impact. Dosage and administration: Should only be administered by physicians with expertise in this treatment. Posology: The recommended dose is a total of 20 units divided into five injections of 4 units (0.1 mL) each: 2 injections in each corrugator supercilii muscle and 1 injection in the procerus muscle. Botulinum toxin units are not interchangeable from one product to another. Doses recommended are different from other botulinum toxin preparations. Treatment interval should not be more frequent than every three months. In the absence of any undesirable effects secondary to the previous treatment session, a further treatment session with at least a three-month interval between the treatment sessions is possible. The efficacy and safety of repeat injections beyond 12 months has not been evaluated. Special populations: No specific dose adjustment is required for use in the elderly older than 65 years of age. Letybo is contraindicated in patients 75 years or older. There is no relevant use in the paediatric population. Method of administration: Intramuscular use. Care should be taken to ensure that Letybo is not injected into a blood vessel. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome, amyotrophic lateral sclerosis). Presence of acute infection or inflammation at the proposed injection sites. Patients with bleeding disorders. Warnings and Precautions: Injection into vulnerable anatomic structures must be avoided. Avoid use when the muscle shows excessive weakness or atrophy. Risk of eyelid ptosis following treatment. Procedure-related events: Needle-related pain and/or anxiety have resulted in vasovagal responses, including transient symptomatic hypotension and syncope after treatment with other botulinum toxins. Pre-existing neuromuscular disorders: Patients with unrecognised neuromuscular disorders may be at increased risk of clinically significant systemic effects including severe dysphagia and respiratory compromise from typical doses of botulinum toxin type A. Hypersensitivity reactions: An anaphylactic reaction may occur after injection of botulinum toxin. Epinephrine (adrenaline) or any other anti-anaphylactic measures should therefore be available. Local or distant spread of toxin effects: Adverse reactions possibly related to the spread of toxin distant from the site of administration have been reported. Patients may experience exaggerated muscle weakness. Swallowing and breathing difficulties are serious and can result in death. Use not recommended in patients with a history of dysphagia and aspiration. Patients should be advised to seek immediate medical care if swallowing, speech or respiratory disorders arise. Pregnancy & Lactation: Not recommended during pregnancy or lactation and in women of childbearing potential not using contraception. Undesirable effects: Most common effects are headache and injection site reaction. Very rarely aspirational pneumonia. For full list of side effects, consult SmPC. Legal Category: POM; Pack size: Packs containing 1 5ml vial. Multipack containing 2 (2 packs of 1) vials; Price list: UK - 1x5ml: 65GBP, 2x5ml: 120GBP; MA Number: PL 29863/0002; PA Number: PA0846/001/001; MA Holder: Croma-Pharma GmbH, Industriezeile 6, 2100 Leobendorf, Austria; Date of preparation: 11/04/2022; Unique ID no CRP001/001;

go ahead if there’s no active disease. “I will often do blood tests to ensure there’s nothing untoward going on,” she says.

Additionally, the practitioners advise checking the patient is not on anticoagulants, they’re not pregnant and aren’t predisposed to keloid scarring. The practitioners agree that optimising skin health is extremely valuable pre-thread lift. “If patients are very slim with thin skin, I will often pre-treat them with something like a radiofrequency microneedling device such as Morpheus8 to boost dermal thickening and provide a canvas to work with,” explains Dr Manning. At the other end of the scale, patients with excess fat can be treated with a cryolipolysis device such as CoolSculpting, she says. Dr Manning will also sometimes prep the skin with Alonzo three months ahead of treatment in order to stimulate tissue and build integrity. “If you haven’t got enough dermis to place the thread in, you’re going to get dimpling and puckering,” she warns. They all recommend their patients take Arnica tablets before treatment as, anecdotally, patients do tend to bruise less afterwards.2 “We also ask patients to stop taking supplements such as omega3 because they can increase the risk of bruising,” says Dr Woodward. Dr Poddar notes that patients are also advised to take paracetamol and have a good breakfast on the morning of treatment as the local anaesthetic injections can sting. As with all aesthetic treatments, the practitioners advocate taking photographs prior to the procedure at different angles, talking them through with the patient, pointing out any existing asymmetry and, to best manage their expectations, outlining what can realistically be achieved. Dr Manning uses a skin laxity scale to indicate to patients the severity of their concern and better suggest an appropriate treatment combination.3 “It’s a really helpful tool as patients can clearly align themselves to the different grades and appreciate your recommended advice,” she says.

The procedure

When a patient arrives for treatment, their hair is tied back and face cleaned.

The practitioners agree that the next step – mapping out the insertion and tracking points – is the longest part of the procedure. “It takes about 20 minutes to make sure you have everything right – I also always show my patient the markings to give them an idea of what I’m going to do,” says Dr Manning.

Dr Poddar adds that the whole procedure can take up to an hour and a half. “This shouldn’t be regarded as a lunch-time treatment,” she says, emphasising that patients should be made aware of the seriousness of it. Then, the practitioners say it’s time for the most painful part. Local anaesthetic injections are given at the entry and exit points, and can also be used in other areas. “The anaesthetic is the nasty bit,” says Dr Manning, explaining, “I tell my patients it’s eight out of 10 horrible, but short-lived. If they’re feeling a bit anxious, I play cheesy music to distract them!”

She highlights that people will ask why she doesn’t use tumescent anaesthetic all the way through the procedure. “The reason for this is that my patient is my GPS,” she says, explaining, “The patient will be pretty comfortable, but if I go too deep or too superficial, then it’s going to be uncomfortable – without anaesthetic, patients can alert me to this so I ensure I am in the correct plane and avoid hitting a vessel.”

There are various kinds of threads on the market (Table 1).4

Each practitioner uses

a different brand of thread, so techniques can vary; Dr Poddar uses Princess PDO, Dr Alli uses Mint PDO and Dr Woodward and Dr Manning uses Silhouette Soft, MINT PDO and Aptos. The practitioners advise that the number of threads used will depend on the type and severity of laxity the patient is experiencing, as well as the kind of threads being used. Dr Alli notes, “Of course, the more threads you put in, the better because you will be able to lift the tissue in many different directions. You may be lifting heavy tissue, so you need enough force to not only lift, but also to keep it there.”

Dr Woodward highlights, “I tend to work bottom up rather than top down in case the patient has any bleeding that could affect my threads below.”

Once the threads have been placed, the practitioners will review and make any necessary adjustments. They are then tightened and engaged into position.

Following treatment

Patients are advised to avoid exercise for up to two weeks post-procedure. Dr Manning says, “Research has suggested that Silhouette Soft threads take up to 10 days to fully integrate into the tissue.” Paracetamol is a suitable painkiller post-treatment, with Dr Alli advising that non-steroidal medication such as Ibuprofen is not recommended as the threads rely on the inflammation process to stimulate collagen and elastin.

Of course, SPF and sticking to an effective skincare routine is always recommended. Dr Alli adds that it’s important to make clear to patients to come to you directly if they have any questions or concerns, saying,

Before After

Figure 1: 50-year-old patient before and eight months after Princess Anchor and Anchor Plus PDO threads. Images courtesy of Dr Rita Poddar.

“I’d rather patients ask me a question than look at some of the horror stories on Google!” Usually, the practitioners will arrange to see the patient at a follow-up appointment two weeks later to check how the threads have settled. They will then be reviewed after three months and any additional recommended procedures will be administered.

The threads will remain in place until they dissolve, which depends on their material. While the threads may have dissolved, results can last much longer and some patients can see effects for up to two years, the practitioners say.

Dr Woodward says results generally depend on the patient’s lifestyle. “If someone’s a marathon runner, results aren’t going to last as long as someone sedentary, for example.” On average, she says they will last about 18 months, adding, “If you treat the brow, longevity is usually just shy of a year.”

Potential side effects and complications

The practitioners note that bruising and swelling are usual side effects associated with a thread lift. “It can be really uncomfortable for two to three days, and then it gets easier,” says Dr Manning.

They add that entry-point dimpling can also occur, which can be fixed by releasing the tethering slightly.

Things you don’t want to see include asymmetry, granuloma formation, nerve damage and infection. “It can be difficult to get hold of the infection, and sometimes a suture will need to be removed,” notes Dr Manning.

According to Dr Poddar, “You will mitigate risk by having a thorough consultation with your patient,” adding that using a cannula also helps maintain safety.

“Some patients who are quite thin with low body fat may feel the presence of the

thread,” says Dr Alli. He notes that as long as it’s not visible, then he is confident it is in the right place. “One of the greatest risks, though, is lack of result,” emphasises Dr Alli, explaining that this generally stems from poor patient selection. “If the degree of collagen and volume loss is so great that threads aren’t going to do much, you’re going to have unhappy patients,” he says.

Considerations

If you’re considering introducing thread lifting to your practice, Dr Woodward advises seeking training with a reputable company. “Don’t go somewhere that teaches you once and then you’re left to get on with it,” she says, noting that mentorship programmes are most beneficial, whereby you will be supervised and can ask for support whenever you need it.

The practitioners also emphasise the importance of sourcing your threads from a reputable company and avoiding discount websites. “I like being part of a company that has my back if I do have any concerns,” says Dr Woodward, while Dr Poddar adds that product traceability is extremely important and a credible company should provide this.

When choosing products, Dr Poddar says not to be swayed by a low price. “It’s a high-quality product that shouldn’t be underpriced,” she says. “When you use quality products, patient satisfaction will lead to referrals and future bookings, so they are worth the money spent.” Dr Alli adds, “It’s essential that you check the clinical efficacy of the product – it must do what it says on the box.”

Dr Alli’s advice is to have dermal filler/toxin injecting experience of at least two years, or a part-time equivalent, before attempting thread lifts. “From doing so, you will gain a good understanding of the topographical anatomy of the face, the functional anatomy and all of the fat compartments that the face and neck have. Your anatomy knowledge has to be at a very good level,” he notes. If anything happens that is beyond your knowledge level, always have referral pathways in place.

Figure 2: Silhouette Soft skin laxity scale. Image supplied courtesy of Sinclair.

Figure 3: 62-year-old patient before and seven weeks after treatment with Silhouette Soft. Patient treated at River Aesthetics.

Figure 4: 53-year-old patient before and three months after treatment with Silhouette Soft. Patient treated at River Aesthetics.

(Botulinum Toxin Type A)

Observational Masterclass.

FEEL GOOD LOOK GOOD

Bocouture® (botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials*. Prescribing information: M-BOC-UK-0432. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of botulinum toxin. BOCOUTURE should only be administered by an appropriately qualified healthcare practitioner with expertise in the treatment of the relevant indication and the use of the required equipment, in accordance with national guidelines . The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Total recommended standard dose is 20 units. 4 units into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 4 units injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 10 units to 20 units is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 2 units, 3 units or 4 units is applied per injection point, respectively. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photo damage). In this case, patients may not respond to botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with botulinum toxin hypersensitivity, amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with

caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare - exaggerated muscle weakness, dysphagia, aspiration pneumonia). Hypersensitivity reactions have been reported with botulinum toxin products. Glabellar Frown Lines: Common: headache, muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: eyelid oedema, dry eye, injection site haematoma. Upper Facial Lines: Very common: headache. Common: hypoaesthesia, injection site haematoma, application site pain, application site erythema, discomfort (heavy feeling of frontal area), eyelid ptosis, dry eye, facial asymmetry, nausea. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90, 100 U twin pack £459.80. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation:August 2021. Further information available from:. Ground Floor Suite B, Breakspear Park, Breakspear Way, Hemel Hempstead, Hertfordshire, HP2 4TZ Tel: +44 (0) 333 200 4143

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard for the UK. 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.

For information about dates and locations and to reserve your place, scan the QR code.

Free from complexing proteins

Adverse events should be reported. For the UK. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for Yellow Card in the Google Play or Apple App Store. For Ireland. Suspected adverse events can be reported via HPRA Pharmacovigilance, Website: www.hpra.ie; Adverse events should also be reported to Galderma (UK) Ltd, Email: medinfo.uk@galderma.com Tel: +44 (0) 300 3035674

Restylane

DOP July 2022.

Menopause and Botulinum Toxin

Nurse Elaine Williams and Dr Ana Silva look at the relationship between neurotoxin facial aesthetic treatment and mood in perimenopausal women

The menopause transition is a natural phase of women’s lives. Generally between the ages of 42 to 55, many women experience perimenopausal symptoms, which are described as a group of symptoms related to autonomic nervous dysfunction in women.1 These symptoms are a consequence of pituitary hyper-function and ovarian function decline, with consequent fluctuation and/or decline in oestrogen levels. There are understood to be 34 known symptoms related to PMS, which include hot flushes, night sweats, depression and anxiety.2 Literature presents evidence of women’s lived experience of shame relating to menopause symptoms, and pervasive, negative discourses regarding menopause and ageing.3 Loss of oestrogen activity may negatively impact mental wellbeing, including the experience of ageing.4,5

Depression is a common psychiatric disorder but regardless of its prevalence and potential severity, clinical definitions for depressive disorders continue to be debated.6 DSM-IV has identified nine diagnostic criteria of depression, of which there needs to be five present over a defined length of time for diagnosis.7 It is understood that during perimenopause women have an increased risk of developing depression with a higher severity rate than pre-menopause, further, it is indicated that vasomotor symptoms are related to depressive symptoms during the menopausal transition.8

There is some evidence that recipients of botulinum toxin A (BoNT-A) facial cosmetic injections report increased emotional wellbeing beyond the cosmetic benefit.9,10 Injecting the glabellar complex changes the facial expression from sadness or anger to happiness, which can lead to an improved emotional experience.11 As such, we undertook a literature review to explore the potential use of botulinum toxin as a treatment for depression in menopausal women.

Methods

A search strategy was developed using MeSH and free text terms in the following databases: PubMed, CINAHL, DiscoverIT, FindIT and Google Scholar. Additionally, the reference lists of the identified screened publications were scrutinised. A search of electronic databases using key author names rather than key terms, in order to potentially identify additional research or other evidence published, was also undertaken.12

Keywords in the search strategy included: (botox* OR botulinum toxin* OR botulinum toxin type A* OR OnabotulinumtoxinA* OR botox injections*) AND (mood* OR low mood* OR depression* OR anxiety*) AND (menopause* OR perimenopause*) AND (treatment*). Initial exploration of the databases was conducted in January 2021, with a final search undertaken in May 2022. Results were limited to freely available publications dating from 2010 onwards, published in English language and duplicates excluded.

Discussion

Depression is a common illness worldwide, with more than 264 million people affected, and is associated with approximately 850,000 deaths by suicide each year. Indeed, across all countries, women have a lifetime risk of major depression roughly twice that of men . The perimenopausal phase of a woman’s life is a critical period for the potential to develop depression, which is characterised by anxiety, lack of energy and feelings of guilt, as well as somatic complaints, e.g. headaches and muscle and joint pain.13 Depression during midlife is particularly worrisome, as the incidence of heart disease –a major killer of women – increases dramatically in the wake of the menopause, and is adversely affected by co-morbid depression, with increased mortality risk.14

Recently, there has been increasing interest in the glabellar use of BoNT-A as a novel intervention in the treatment of major depressive disorder (MDD). As discussed in Table 1, the first case series published in 2006 included a cohort of 10 female patients aged 18-65, diagnosed with MDD. Nine patients responded to treatment with onabotulinum to the glabellar complex, with eight going into remission for depression. One participant who displayed only a partial response had a diagnosis of bipolar disorder.15

It has been postulated that the mechanism of action of the glabellar injections of botulinum toxin (GBTx) targeting depression comprises: the attenuation of negative emotions through the relaxation of the frowning muscles, and the improvement of depressive symptoms following the reduction of negative emotional experiences.16

The first statement is about the facial feedback hypothesis, which proposes that a feedback mechanism from facial expressions has an impact on emotions, i.e. frowning can make a person feel angry, whereas smiling can make them feel happy.16 Indeed, in the 19th century, Charles Darwin and William James first predicted a link between our facial expression and emotions. According to them, facial expressions of sorrow or grief send signals to the emotional part of the brain, inducing or exacerbating feelings of distress.17

Facial expressions are thought to influence emotions through multiple pathways, categorised as the cognitive processing of emotional information, motivational behaviours and the autonomic nervous system activity.16 These pathways can be both complementary and/or overlapping16 depending on the stimulus, the circumstance and the involved feeling. In other words, according to the current facial feedback theory, the cognitive appraisal of a stimulus often initiates emotional reactions. At the same time, our facial expressions are highly influenced by cognitive appraisals. The second proposed mode of action of GBTx suggests that mood improvement is the result of decreased negative emotional

Ref no Published Study Design

Finzi, et al19 2006

Wollmer, et al20 2012

Sample Size Injection site Results

Conflict of Interest

RCT 10 Procerus and corrugator supercilii 9/10 reported resolution of their depressive symptoms None

RCT 30 Glabellar Positive change in HAM-D score at week 6 post injection None

Dodick, et al21 2013 RCT 50 Glabellar, procerus and corrugator Improvement in the symptoms of depression after injection of BTA None

Magid, et al22 2014

RCT 74 Procerus and corrugator supercilii

Significant improvement in depression, higher response and also higher remission rates after sole or adjunctive BTA injection compared to placebo

Wollmer, et al23 2014 RCT 30 Glabellar The identification of agitation as a positive predictor of response may be helpful in the development of stratified medicine approaches in the treatment of depression. The findings suggest that glabellar injection of BTA may also be effective as a treatment of other psychiatric disorders associated with negative emotions and increased psychomotor activity

Magid, et al24 2015 Review 7 studies Glabellar, procerus and corrugator H

Zamanian, et al25 2015 Pooled analysis of RCTs

At the point of the review, only onabotulinumtoxin-A has been investigated as a treatment of depression. It is probable, but formally remains to be established, that also other types of botulinum toxin are effective in this new indication

E. Finzi has been awarded a patent for the treatment of depression with botulinum toxin. The Chevy Chase Cosmetic Center, which provided funding for this study, is solely owned by E.Finzi

None

None

30 Glabellar 3 studies – BTA was superior to placebo in all psychopathological efficacy outcomes None

Brin, et al26 2017 RCT 28 Glabellar Change in BDI score at week 6 with a self-reported improvement None

Coles, et al27 2019 Meta analysis 7 Glabellar Statistically significant reduction in depression scores 6 weeks after intervention, for both primary and secondary outcomes. However, concerns were raised by authors regarding the validity of the results due to the substantial asymmetry in the effect sizes distributions in the primary and secondary outcomes

Qian, et al28 2020 Systematic review and meta analysis

417 Glabellar, procerus and corrugator

Brin, et al29 2020 RCT 255 Glabellar, procerus and corrugator

Schulze, et al30 2021 Meta analysis 417 Glabellar, procerus and corrugator

Primary outcomes of all included studies were the improvement in depressive rating scale at week six after BTX-A injections compared with placebo – concluding BTX-A to be an effective intervention for MDD

None

None

Consistent improvement in depression when 30 units were used, in contrast to lower doses None

The results for the investigation of the difference between BTX and placebo 6 weeks after treatment showed that subjects who received BTX were significantly less depressed than participants who received placebo

Table 1: Studies evidencing a link between botulinum toxin and mood improvement19-30

experiences. There is not enough evidence for such a prediction, though. In fact, reduction in negative emotional experiences represents only one aspect of a universe called depression. Depression, in a broader sense, can be secondary to exacerbated negative emotional reactions, attenuated positive emotional events, or, most likely, a combination of both.18 The age ranges for all the studies in the table below is 18-65; none of the studies identified if participants were perimenopausal. Table 1 presents the studies related to onobotulinum toxin and depression and omits those related to migraine and those addressing perimenopause and depression.

Summary of findings

It is well known that depression can be severe and burdensome during the menopause transition.31 Extrapolation of the available findings and current knowledge demonstrates there is scope for further investigation of the impact of BoNT-A on mood during the menopause. For instance, as shown above, GBTx could be an alternative treatment for depressive patients who fail to properly

respond to the standard antidepressant therapy, including perimenopausal women, who represent a large proportion of aesthetic patients. From a safety perspective, GBTx is very well tolerated with limited, short-lived adverse effects reported.32 However, until now, the effectiveness of GBTx for this purpose remains contestable, and it is not currently approved.

Current limitations

In Table 1, we can observe that the assessment of depression and its severity is highly heterogeneous across the revised trials, which reduces the overall comparability of results. Furthermore, the reviewed studies have used a variety of doses and sites of administration, making it even more difficult to compare or draw conclusions from the combined papers. Other limitations for the generalisability of the findings are related to gender due to females’ overrepresentation. Most of the RCTs also had small sample sizes –an average of 68 participants per study. Cole’s et al.27 meta-analysis assessed seven clinical trials containing quantitative information for obtaining effect sizes. Their primary

Allergan/Ipsen advisors, amongst other conflicts

outcome was the comparison of depression scores between placebo and GBTx groups after six weeks from the baseline. They also investigated secondary outcomes referred to within-subject which was the comparison of depression severity, before and after treatment. For both primary and secondary outcomes, a statistically significant reduction in depression scores was demonstrated six weeks after intervention. Nevertheless, a substantial asymmetry in the effect sizes distributions in both cases was noted, thus making the authors raise important concerns regarding the validity of the findings. The most relevant was the extraordinarily large effect size for the primary outcome, which was 2.65 times greater than the overall effect size of standardised antidepressant drugs. Additionally, almost 100% of the effect sizes came from researchers with conflicts of interest, i.e. sponsored by toxin manufacturers. Another limitation refers to the fact that in those clinical trials, it is somehow difficult to blind investigators and patients to what they are injected with, since only BoNT-A treatment will have a notable effect on appearance, in contrast to the placebo. Finally, some evidence of publication bias has been uncovered in the meta-analysis.27

The next steps

There are sufficient reasons for the pharmaceutical industry to invest large amounts of resources to test the impact of BoNT-A on mood in perimenopausal women. GBTx has a long safety record, requires treatment once every 12-16 weeks, is relatively inexpensive when compared with continuous medication and other therapeutic modalities, and has a high rate of cosmetic efficacy and patient satisfaction.17 However, the methodological limitations and statistical concerns described above suggest it is premature to conclude in favour of GBTx as a first choice treatment for depression.

Continuing research

Research has turned its attention to novel approaches that are beginning to provide promising results in treating refractory depression.32 The initial hypothesis suggests there may be a causal link between perimenopausal women looking for cosmetic interventions, the disseminated use of BoNT-A in the aesthetics practice and an unintended consequence of improved mood. Conclusions point to several potential advantages of this treatment modality for depression, including safety, cost, compliance and efficacy.33 However, for this specific indication, there is currently no approved treatment protocol for the use of BoNT-A. The reviewed studies have used a variety of doses and sites of administration, making it difficult to compare or draw conclusions from the combined papers. Additionally, there is disparity in the study’s run time, definition of pre-, peri- and post-menopausal age ranges and follow-up periods. Patient reported outcome, patient satisfaction and patient reported experience measures appear to have been omitted from all the studies. Understanding the interventions through the lens of the patient would add further quality and depth to research in this field.

Whilst BoNT-A can be considered an effective and safe treatment for patients with mild to moderate depressive symptoms, the findings are not valid for patients with severe symptoms or risk of suicide, nor for those with other psychiatric comorbidities. In such cases, a close follow-up with a psychiatrist is advised. Well-designed prospective clinical trials with larger samples and more objective assessment tools are necessary to confirm or refute the alluded benefits, and to establish recommendations and application protocols.

Elaine Williams is a registered nurse with more than 30 years’ nursing experience in both NHS and private practice. She has studied extensively in the fields of mental health and cosmetic medicine, recently joining the cosmetic medicine faculty at University South Wales as honorary lecturer. Williams is currently a PhD student at the University of Northampton and owns EOS Aesthetics, based in Sunningdale, Ascot UK.

Qual: MSc, PG Dip, Pg Cert, INP, BSc, RN

Dr Ana Silva concluded her medical degree in 2000 in Brazil and held a residency in paediatrics until 2006, then moved into pathology. She then earned a PG Diploma in Dermatology at Queen Mary University London and an MSc Dermatology at the University of Hertfordshire. Currently Dr Silva works as a dermatologist in her private clinic and as a medical expert for the Brazilian Justice court.

Qual: UMFG, MSc

Test your knowledge!

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

Possible answers

Questions

1. What age do women generally experience perimenopause? a. 42-55 b. 50-55 c. 40-50 d. 38-48

2. Some studies have suggested BoNT-A improves mood when injected into which group of muscles?

a. Frontallis b. Glabellar complex c. Corrugator muscle d. Orbicularis oculli

3. What is the facial feedback hypothesis? a. A feedback mechanism from facial expressions has an impact on mood e.g. frowning can make someone feel angry b. If you see someone smiling, you feel happy c. If you see someone frowning, you think they are angry d. Observing emotion on someone’s face makes you mirror that emotion

4. How many known symptoms are there in perimenopause? a. 44 b. 10 c. 34 d. 16

5. Which parts of the body does perimenopause impact on? a. Cardiovascular, skeletal and muscular systems b. Reproductive, endocrine, and nervous system c. Immune and excretory systems d. All

Answers: A, B, A, C, D

Key features for CCR 2022

NEW A Dentist’s Guide to Aesthetics with Professor Bob Khanna NEW Start-ups Trail showcasing innovation in medical aesthetics

NEW Aesthetics

Wellness stream curated by Dr Mayoni Gooneratne

ACE Group World host an agenda dedicated to managing complications*

NEW The Diwali PHI-lanthropy Ball supported by Prollenium* Anatomy & LIVE Injection Masterclass with Dr Tapan Patel*

ISAPS Symposium UK surgical conference curated by Dr Naveen Cavale*

LIVE Demos in the Galderma Symposium. Dr Priyanka Chadha confirmed

I really enjoyed CCR. I met with friends and colleagues and updated my knowledge and experience in aesthetics. I wish it was more than two days as I would have loved to attend more of the sessions.

@ccrlondon CCR London *Paid for sessions.

Mohammed Mohammed, Speciality Doctor and Medical Director

Exploring HA Filler Longevity

The question of how long dermal fillers last is one that patients and practitioners alike wish to know the answer to. Multiple filler treatment options are currently available to help create revolumisation and facial rejuvenation, including hyaluronic acid (HA), poly-L-Lactic acid (PLLA), calcium hydroxyapatite (CaHA), polymethylmethacrylate and autologous fat transfers.

HA is the most commonly used facial dermal filler in aesthetic medicine, due to its biocompatibility, safety, reliability and reversibility.1 With the ever-increasing number of new HA fillers now available on the market, and longevity of these products is an important area for discussion amongst injectors.2

In this article, we will be focussing on what the research says about the factors affecting filler longevity in patients, with an overview to provide a structured approach for practitioners in their choice of product and how they can inform patients regarding expectations relating to longevity.

What is longevity, and why does it matter?

It is generally considered that the ideal dermal filler:3

• Is safe and easy to administer

• Can produce reliable and reproducible results with few, if any, local adverse events

• Provides longevity (lasting between nine-18 months or more)

• Affordable to both the patient and the practitioner

When we speak about longevity, we are referring to the amount of time that one would expect the filler to be active and provide results for the patient.

For the patients, longevity matters for several reasons: post-procedure downtime, such as bruising, potential discomfort of undergoing filler procedures and of course the financial implications. In general, patients would prefer not to have to undergo a procedure repeatedly every few months if they can instead choose to have just an annual treatment. Fundamentally, patients wish to ensure their filler procedure produces a long-lasting aesthetic result.

What factors impact HA filler longevity?

After injection, HA filler will integrate with the tissue before being broken down over time and eliminated from the body. How long this process takes varies. This is usually anywhere between three and 12 months, however some retrospective imaging studies have highlighted some HA fillers lasting for more than two years and, as discussed below, practitioners in the industry are highlighting that HA fillers are lasting longer than we think.4,5

Many factors impact filler longevity, including the rheological characteristics of the product used (for example, particle size, the concentration of HA within the product and the level of cross-linking), the indication the product is being used for (such as how dynamic that area is) and patient-specific biological responses and lifestyle.6-9

Rheological properties

Cross-linking

In its pure state, the HA molecule is present in nearly all species, including bacteria and mammals, and is considered immunologically inert.4,10-11 Due to its physicochemical properties, HA is one of the most hygroscopic molecules in nature, and hydrated HA can contain up to 1,000-fold more water than its own weight.8,12 This makes it an appealing choice from a biocompatibility perspective. However, in this pure state, the half-life of the HA molecule is just 24-48 hours.9 Therefore, to create longevity, HA dermal fillers are cross-linked to form a viscous gel that delays degradation.4,9,13

Cross-linked fillers are classified as monophasic or biphasic. Monophasic fillers consist of a homogeneous mixture of high- and low-molecular-weight HA, making their application easier.15 Biphasic fillers have cross-linked particles of HA dispersed in a non-cross-linked HA vehicle.6,14-16 The most used cross-linking materials are divinyl sulfone, 1,4-butanediol diglycidyl ether (BDDE) and p-phenylene bisethyl carbodiimide, which are refined to reduce risk of sensitivity.3 Cross-linking is known to reduce a product’s degradation rate, and therefore the degree of cross-linking denotes the mechanical strength of the product and directly represents a measure of its longevity.17

Research has highlighted that biphasic cross-linked HA fillers show greater rheological stability than monophasic fillers. It is thought that due to their increased level of cross-linking, they exhibit greater durability, have a lower propensity to be homogeneously distributed throughout the injected area and are able to withstand compressive forces when passing through a needle.7,18,19 This therefore produces the clinically longer-lasting results of biphasic products, compared to monophasic.3

Viscosity, cohesivity and elasticity

The other major factors that impact filler longevity are the viscosity, cohesivity and elastic modulus of a product. In addition, a study by Park et al. showed that a significant factor determining the degradation of HA particles is the gel swelling ratio, which is related to the particle structure of the gel.7

There is a large spectrum of HA filler products available in the UK, with different gel properties designed for specific indications, and it is important for practitioners to understand the intrinsic differences in these properties so that they can choose the correct product for the correct tissue plane and treatment indication.

It is thought that the firmer the product, or the greater the G prime (G’), the more volumising potential and therefore the longer it may last.21 For example, if you’re using a lighter, less cross-linked HA for superficial tissue application, results are likely to remain for closer to six months than 12. Alternatively, with a firmer HA with a greater G’ for significant tissue projection, it is more likely results will last for between 12-18 months.17,20

Dr Ciara Abbott provides an introduction to HA filler longevity and gives advice to practitioners on product selection for longer-lasting results

Factors Definitions

Cohesivity The strength of the cross-linking adhesion forces that hold the individual HA units together

Elastic modulus (G’)

Anatomical placement

Areas of dynamic movement may also affect longevity. For example, perioral, nasolabial and the lips, where dynamic movement is continuous. Products with lower cohesivity would be preferable in these areas, and therefore may see lower timeframes for longevity (from six to nine months) due to shear and compression forces from surrounding mobile muscular structures.19 Unlike ‘static’ areas such as the temples or tear troughs, where there is very little movement, in these areas, HA is more likely to provide longer-lasting results (from nine-18 months). The area being treated therefore requires thoughtful product choice to ensure the right rheological properties are utilised to allow for ultimate longevity.21

Patient-specific factors

I have observed anecdotally in my own practice that external factors (including lifestyle) can impact the longevity of fillers and how quickly a patient metabolises them on an individual basis.14,21 For example, one of my patients is an ultra-marathon runner, with a low BMI, who has repeatedly displayed a shorter time frame in the aesthetic outcome of her filler procedures compared to other patients whom I have treated with the same product for the same clinical indication.

Extrinsic factors such as smoking, alcohol intake, UV exposure and even excessive exercise are known to deplete HA reserves and accelerate ageing due to free radical formation, but there are also intrinsic factors that need to be accounted for such as individual skin elasticity.22-23

Product selection

As an aesthetic practitioner, longevity is an important factor in choosing which brand to use and which product to select from within that brand for a specific indication. To provide the best outcomes for our patients, we should have a pallet of products to choose from, and it is our job to select the

best product based on what that patient needs. Incorrect product choice in the wrong anatomical place will certainly have an effect on the longevity of results. In addition to this, managing patient expectations and having an open dialogue with patients regarding product choice is essential. For example, helping patients to understand that for significant jowl lifting or jawline augmentation, a product with a high G’ is usually required which will have longer-lasting results, versus soft and subtle lip augmentation with an HA with lower cohesivity and cross-linking, which the patient will need to understand is likely to last for less time.

In my practice, I primarily use the Belotero range. Belotero VOLUME is an extremely versatile product with an established tolerability and safety profile from the injection time and up to 18 months post-injection.24

For areas such as the tear troughs, I use the Teosyal Pursense Redensity 2, which lasts up to 18 months, and Juvéderm Volux for the jawline. This has been shown to last up to 24 months.17 Of course, there are many other suitable brands available.

Late-onset complications

Finding the optimal balance between longevity and safety is a priority. From a practitioner’s point of view, we should always think about what is safest for our patients; knowing that the product has a good safety profile and robust research behind it is important.

There are also long-term side effects to consider. The longer a filler lasts, the longer any potential side effects may impact your patient. With HA dermal fillers, long-term complications are minimal as the reversibility of HA makes complications more manageable and treatable. However, there is increasing evidence that HA fillers may be present in tissue for considerably longer than expected, and that late-onset complications associated with HA fillers can occur several years after their placement and well after

their cosmetic effect has worn off.4,25-31 The advent of ultrasound scanning in aesthetics now allows practitioners to visualise filler that has been previously injected into patients and determine how long it is lasting.8 This is particularly useful in the management of complications, and has become widely adopted now due to advances in technology which have made handheld devices a reality. I predict this type of imaging will be key to future studies surrounding filler longevity and its significance to the treatments we provide.

Further research

HA dermal fillers are the most widely used dermal fillers due to their reversibility, and advances in their manufacturing means that practitioners now have longer-lasting products available to them. Individual patient needs, product selection and product placement is key in matching the right product to the right indication to minimise risk and maximise longevity.

Our understanding of how dermal fillers behave in the tissues, and, in turn, their longevity, is being enhanced now with the use of ultrasound scanning. While dermal fillers are generally thought to degrade after a maximum of 18-24 months, we are now seeing evidence that HA fillers can last significantly longer, long after their cosmetic effects have dissipated. Further research is being done on this, and we should continue to update our approaches accordingly.

Dr Ciara Abbott is the medical director and co-owner of Barstable Medical Clinic, Essex and has worked in the aesthetic industry for the last 11 years. Her clinic was shortlisted for Best Clinic South England 2017 at The Aesthetics Awards and she is an associate member of the British College of Aesthetic Medicine (BCAM). Abbott works as a trainer for Merz Aesthetics as a Merz Innovative Associates.

Qual: MBBS, Bsc, MRCS(Eng), MRCGP

Table 1: Definitions of some of the rheological properties influencing filler longevity

Viscous modulus (G”)

inability to recover the original shape after shear deformation

Using Cannulas

The use of blunt-ended cannulas has increased in the last five years, with more evidence emerging showing that they allow for a safer dermal filler treatment of key areas of the face. Studies have indicated that blunt-ended cannulas are able to reduce trauma to tissues, decrease the risk of vascular injury and also lessen bruising, meaning lower downtime for patients.

In my practice, I now use cannulas for more than 80% of my patient cases, and as the industry advances, I have seen more and more practitioners switch to cannula use for most areas of the face.

One of the fears practitioners have when switching from needle to cannula is the technicality involved, which requires extra training and practice to become competent at. Aesthetic medicine education has traditionally focused around needle use rather than cannula because it is easier to teach and learn when starting out. In this article, I will explore the pros and cons of cannula use, explain how I use cannulas in my practice and provide some of my top tips to get the most out of them.

Why use cannulas?

There are many benefits to using cannulas for your dermal filler treatments, which include: lowered risk, less downtime and accurate and different product placement.

Lowered risk

When injecting filler, one of the most severe risks is causing obstruction to a blood vessel. Vascular occlusion can occur as a result of compression or direct occlusion when filler blocks a blood vessel due to inadvertent puncture of the vessel wall.1,2 Injections with a cannula have been shown in the literature to be less likely to cause vascular occlusion due to them being blunt (Figure 1).3

Although cannulas have a lowered risk of causing a vascular occlusion, it is important to note that it is not impossible. When we are speaking about gauge of needles or

cannulas, the larger the number the smaller the diameter of the instrument. Cannulas that are 27 gauge and smaller have the same arterial penetration force as a needle, so offer no safer advantage.4 One clinical study examined 294 penetration procedures of the facial and superficial temporal arteries performed in four fresh frozen cephalic specimens using both needles (20, 22, 25, and 27 gauge) and cannulas (22, 25, and 27 gauge). The study showed that all measured sizes of cannulas except 27 gauge required greater forces for intra-arterial penetration compared with correspondingly sized needles. The authors stated that this confirmed the safety of 22 and 25 gauge cannulas for the use of facial soft-tissue fillers; however, they found that 27 gauge cannulas required similar forces as 27 gauge needles, indicating that an artery could be penetrated with a similar force independent of whether the injector used a 27 gauge needle or a 27 gauge cannula.4

Different product placement

Using a cannula for filler allows for longer threads of product to be injected, meaning the practitioner is able to treat larger areas and ensure a smoother result, especially when injecting in the subcutaneous fat. In my experience, this allows for a cosmetic result that is better for the patient as it reduces the risk of aggregation of the filler which can cause lumps.

When using a cannula, you get tactile feedback when moving through facial layers, especially when pushing through the superficial musculoaponeurotic system (SMAS). This allows you to accurately know that you are sub-SMAS and in deep fat when

injecting. This is not possible with a needle when the only real feedback you get is when you touch the periosteum, denoting you are supra-periosteal with the needle tip.

A 2017 study where 10 fresh-frozen cephalic foreheads (nine male, one female) were injected with radiopaque material using both needles and cannulas demonstrated the accuracy of cannula use.5 In this study, the needle injection relied on a perpendicular transcutaneous approach, whereas cannulas were moved in the supra-periosteal plane until reaching the same location as the needle – here, radio opaque material was injected. In this study, the authors noted that in 60% of injections using a needle, the implanted material changed its plane; this was not observed when using the cannula (0%; P=0.003). They went on to say that if precision in filler injection is defined as the filler material remaining in the plane of intended implantation, then using cannulas resulted in a more precise injection of material as compared to needles. Applications with needles resulted in the distribution of material into more superficial layers, which was not noted for cannulas.5

Another 2017 study involved the injection of cadaver heads with dye material and soft-tissue fillers at multiple aesthetic facial sites on the supraperiosteum.6 The authors concluded that although direct extrapolation from cadavers to the in vivo situation cannot be made, the use of a cannula resulted in more precision in product placement. This was because with the sharp needle, the material was injected on the periosteum, and then migrated in a retrograde direction along the trajectory of the needle path, ending up in multiple anatomic layers.6

The downsides of cannula use

Although there are many benefits to using cannulas, there are also considerations to be mindful of. As mentioned above, much like aspiration with a needle,

Dr Marcus Mehta explores the use of cannulas for dermal filler placement and provides his tips for success for those newer to aesthetic medicine

Injections with a cannula have been shown in the literature to be less likely to cause vascular occlusion due to them being blunt

Beauty flows through us

Blunt-tip reduces friction and glides through dermal tissue

Ultra-thin cannula wall increases lumen diameter and reduces injection forces

Premium quality single-use cannula used by clinical and industry leaders

Made in Britain for over 30 years

using a cannula is not a fail-safe option for preventing vascular occlusion. It is still possible to penetrate a vessel and cause damage with a cannula.4 In my practice I use 22 gauge and 25 gauge cannulas, but never a 27 gauge or anything smaller to reduce the risk of vessel penetration.

The other consideration is the patient fear surrounding cannulas, which can be difficult for practitioners to navigate. In my experience, patients are often more fearful of cannulas due to the fact that they appear to be longer/larger than needles. I find new patients who have seen cannula treatment on social media, for example, are quite scared as it can look more painful on video despite often being more comfortable than needles. I always try to educate my patients, and explain what a cannula is and the benefits before beginning treatment, and I try to avoid showing them the instrument itself.

As mentioned above, introductory dermal filler courses usually focus on using needles, so before you get started with cannulas you would require additional training (and a lot of practice) which takes time and is a cost to you and your business. However, this is integral to ensure you are skilled and knowledgeable in using this instrument. The other downsides which relate more to your business are that using cannulas might take slightly more treatment time than using a needle, and it’s an additional expense as dermal fillers often do not automatically come with a cannula.

Top tips for success

Choosing a cannula

The length of cannulas can range from short 13mm cannulas up to much longer 90mm cannulas. The area of the face you are treating will determine the cannula length best suited. For example, in the jawline I often use a 50mm cannula to help reach the chin

tip, and along the jawline itself and in the lips and mid-face a 25mm or 30mm. When I started injecting with a cannula around four years ago, I found longer cannulas harder to use. My advice would be to get familiar with a shorter length before progressing on to longer cannula sizes such as a 50mm.

When it comes to cannula brands, there are many brands available including TSK, Silkann and SoftFil. I personally use the SoftFil cannulas as I find the EasyGuide tool, which is a pre-hole needle guide, means I know where the insertion point is and I can get to the required depth easily. Other ways to help not lose the entry hole is to gently squeeze the skin so a small dot of blood forms on the skin, or better still, have an assistant pass you the cannula whilst you are still looking at where the insertion point has been made.

Practice makes perfect

It’s important to take your time and practise using a cannula in different areas of the face. Sometimes, when you first insert a cannula you will find it difficult to progress from the insertion point. My advice would be to not panic, but spend time slowly attempting to progress the cannula gently; sometimes spinning the cannula can help move past this initial point.

One of the key things I learnt when using a cannula was being able to feel the layers as you go through them. When treating the mid-face for example – deep medial cheek fat or pre-zygomatic space – you want to be below the SMAS to access the deep fat. To get there you must pass through the SMAS with the cannula, and you will consciously feel a pop when you do. Practising this sensation allows you to be sure you’re in the correct plane – going on a cadaver training course is a great way to do this.

Think about new treatment areas

You should start to consider different areas where you could use a cannula, for example, the lips. For many new and even experienced practitioners who have been in the industry for a while, they are used to treating the lips with a needle, and the transition to using

a cannula here is challenging as it takes some time to feel confident. My patient demographic is between 40 and 70 and I use a cannula to treat almost every lip I see in clinic. I find it volumises much more evenly, reduces pain and gives a result with much less downtime than a needle.

Consider cannulas in practice

Cannulas form an important part of modern aesthetic practice, and learning to use them competently is a key skill in developing as a practitioner. The main benefit is reduced risk to key structures beneath the skin and allowing for different product placement; however, it is important to be mindful that vascular injury can still occur with a cannula.

As with all things in aesthetic medicine, combining treatment techniques as well as modalities is one of the best ways to achieve good results for your patients. I often use a needle alongside cannulas, for example, when treating the lips I use a cannula in the lip body and a needle in the vermillion border, or when treating the mid-face I use supraperiosteal boluses with a needle combined with cannula in the deep medial cheek fat. Having a good understanding of treatment techniques which often combine needle and cannula use allows for us to offer treatments that are the most effective and ‘above all’ safe for our patients.

Dr Marcus Mehta is an aesthetic practitioner with a background in medicine and a post-graduate training in dermatology. He is the director of Harley Academy and the co-founder of STORY Clinics and Comma. Qual: BSc (hons), MBBS, PgDip (Derm)

REFERENCES

1. Martyn King, Lee Walker, Cormac Convery, and Emma Davies, Management of a Vascular Occlusion Associated with Cosmetic Injections, J Clin Aesthet Dermatol. 2020 Jan; 13(1): E53–E58. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7028373/>

2. Murray G, Convery C, Walker L, Davies E. Guideline for the Management of Hyaluronic Acid Filler-induced Vascular Occlusion. J Clin Aesthet Dermatol. 2021 May;14(5):E61-E69. Epub 2021 May 1.

3. Alam, M., Kakar, R., Dover, J.S., Harikumar, V., Kang, B.Y., Wan, H.T., Poon, E. and Jones, D.H. (2021). Rates of Vascular Occlusion Associated With Using Needles vs Cannulas for Filler Injection. JAMA Dermatology, 157(2), p.174.

4. Pavicic, T., Webb, K.L., Frank, K., Gotkin, R.H., Tamura, B. and Cotofana, S. (2019). Arterial Wall Penetration Forces in Needles versus Cannulas. Plastic and Reconstructive Surgery, 143(3), pp.504e512e.

5. Erlbacher, K. (2017). Precision in Dermal Filling: A Comparison Between Needle and Cannula When Using Soft Tissue Fillers [online] JDDonline - Journal of Drugs in Dermatology. <https:// jddonline.com/articles/precision-in-dermal-filling-a-comparisonbetween-needle-and-cannula-when-using-soft-tissue-fillersS1545961617P0866X/>

6. Van Loghem, J.A.J., Humzah, D. and Kerscher, M. (2017). Cannula Versus Sharp Needle for Placement of Soft Tissue Fillers: An Observational Cadaver Study. Aesthetic surgery journal, [online] 38(1), pp.73–88.

Figure 1: Needle vs cannula for reducing risk of vascular occlusion1,2

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Case Study: Full-face Rejuvenation

Assessment, ageing and anatomy

This 55-year-old female presented to my clinic as she wanted to improve her facial sagging, jowls and wrinkling around the chin. When carrying out an assessment for all of my patients, I use a 4D approach, which means looking at the patient when they’re being expressive and observing the dynamics of the face. This patient had loss of mid-face volume due to atrophy of the deep and superficial fat. There was a loss of jawline definition due to atrophy of the superficial jowl fat and jowls caused by the weakening of the pre-masseteric and mandibular ligaments, and there was dynamic dyschord and reduced anterior projection of the chin. I noted that her chin was wider than the female ideal, and this needed to be taken in to consideration when treating so as not to masculinise her.

Technique and product selection

Before performing a dermal filler treatment I always recommend using good skincare products to optimise the results. For this patient, I suggested she use the Teoxane AHA Cleansing Gel, RHA® Serum and Advanced Perfecting Shield SPF 30 in the morning, while using a combination of RHA® Micellar Solution and Advanced Filler Normal to Combination moisturiser in the evening. Skin quality can also be improved with a course of Teosyal® Redensity 1. When it came to injecting, I used the ATP approach from Teoxane – looking at the anatomy, assessment, technique and product. Having a robust knowledge and understanding of the anatomical changes we observe in our patients guides our choice of product so that we can achieve optimal results. For this patient, I used a combination of Teosyal® PureSense Ultra Deep (PS Ultra Deep) and Teosyal RHA® 4, using a multi-layering technique for some of the treatment. I started by using PS Ultra Deep to provide anterior projection and lift to the cheek by treating the deep cheek fat and lateral SOOF. I used three separate injection points on each side, injecting 0.1ml per point down to periosteum. I chose this product as it has a very high cohesivity with excellent lift and projection capabilities. I used a needle for this area because

Before After

I find it can help make the injections very precise, and I also find I use less product than I do with a cannula. I then injected 0.2ml on to periosteum in the anterior medial cheek to give support and help to shorten the tear trough. Then I moved onto RHA® 4 and used a cannula to inject 0.4ml each side along the lateral lower cheek to blend in the transitions of the superficial fat compartments, restoring natural volume and confluence. Then I moved on to the chin using RHA® 4 to treat the labiomental crease, again with a cannula. I used

subcision here with the cannula to create more space and then I injected 0.3ml. This helped with myomodulation and meant we didn’t need to use toxin to correct her overactive mentalis muscle. Next, I switched back to PS Ultra Deep to inject 0.2ml to the pogonion to create projection and more feminine proportions. Then I used RHA® 4, injecting 0.3ml into the soft tissue using a cannula to provide support and balance. Next I moved onto injecting PS Ultra Deep with needle onto periosteum to treat the pre-jowl sulcus, using 0.15ml per side.

Finally we moved onto the jawline. It was important to avoid increasing the patient’s bigonial width as this would masculinise her. I injected 0.2ml PS Ultra Deep onto periosteum, ensuring that the injection point was superior to the angle of the mandible. I then used this injection site as an entry point for a cannula to inject 0.2ml of RHA® 4 in to the pre-auricular area to lift the jawline further. Overall I used just under four syringes of dermal filler, and the treatment took around 45 minutes. We achieved natural looking results, and by improving areas of projection, light reflection was increased, giving the patient a youthful, rejuvenated appearance.

Top tips for success

Knowing your anatomy inside out and using the ATP approach is very important to ensure that you are choosing the right products. The rheology of the products is also very important to understand for creating the right treatment plan – make sure every plan you make is individualised and specific to that patient. That’s the beauty of the Teosyal® range – you’ve got deep static fat support, lift and projection with Teosyal® PureSense Ultra Deep, then the resilient hyaluronic acid in the RHA® range, which offers a product for all areas of concern from lips to superficial volumisation.

Rachel Goddard is an independent nurse prescriber who has specialised in medical aesthetics since 2004. She is a country expert for the Teoxane Medical Faculty. She is director of Totally Aesthetics and Rachel Goddard Aesthetics in Manchester.

Qual: RGN, INP, MSc, PgCert

Nurse prescriber Rachel Goddard discusses her tips for facial restoration using the Teosyal® range of dermal fillers

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Figure 1: 55-year-old patient before and after full face rejuvenation using PureSense® Ultra Deep and Teosyal RHA® 4

Case Study: Managing NSR Complication

Non-surgical rhinoplasty (NSR) using dermal filler is an increasingly common procedure.1

It is particularly effective in cases with a low radix, mild to moderate dorsal hump, insufficient tip projection and to improve the nasolabial angle.

The most common filler product used is hyaluronic acid. This is because it has good biocompatibility and is reversible. It also has reasonable longevity with typically 12-18 months of filler presence, depending on the specific product used.2

It has been observed in my own practice, as well as in the literature, that HA injected into the nose may last longer than other areas.2 It is considered a more advanced filler technique with a relatively steeper learning curve, requiring good knowledge of the anatomy and techniques to maximise safety and aesthetic outcomes. Like other filler procedures, common complications are minor and include bruising, erythema, pain, oedema and under- or over-correction. Patient satisfaction overall tends to be high.2 Incidents of serious complications, which include blindness, have been well described in the literature but are generally a low figure.3 A recent large meta-analysis reported a rate of 0.43% for skin ischemia and necrosis, and 0.09% for vision loss.3

This article discusses a patient who had filler injected into the nose in December 2020 at a different clinic before being referred to my clinic for review and continued management of an ischemia related complication.

The complication

A 32-year-old male patient had presented to another clinic requesting a straighter nasal dorsum and better tip projection. He previously had filler in the nose and in the lateral brow areas. The practitioner injected 1ml of a well-known dermal filler using a cannula with a single-point entry at the nasal tip. The clinic reported there were no obvious ischaemic changes to the nose or surrounding area immediately. In the early stages of vascular occlusion, visible changes

to the skin can be subtle and, as in this case, can look similar to initial erythema and skin colour change from moulding the filler. The following day, the patient reported some pain and change in skin colour along the nasal dorsum towards the tip and on the right lateral wall of the nose. He was asked to return to the clinic for review. By this time, there were obvious early signs of vessel occlusion, erythema and livedo reticularis along the dorsum of the nose, right nasal sidewall and glabellar areas.

The treatment

The practitioner injected two doses of hyaluronidase, each containing 1,500 units along these areas. It was then discussed virtually with me as the referring clinic wanted another opinion on the severe complication. As no other therapy had been started, I advised him to take 300mg of aspirin (continuing with 75mg for a week thereafter) and 30mg of prednisolone for three days to reduce swelling that had already started. No other therapies, such as antibiotics, glyceryl trinitrate patches, phosphodiesterase inhibitors nor hyperbaric oxygen, were commenced as there was no indication or a paucity of evidence for clinical effectiveness.4,5 By day two post-procedure, the distribution of skin colour changes increased. In addition to the above areas, the upper and lower eyelid rim became purplish. Erythema was present along the right brow and extended into the right malar area. The medial one third of upper and lower lid eyelashes had fallen out. He went to an emergency eye hospital for review

and, finding no intraocular abnormality, was discharged with no treatment. He attended my clinic for the first time for a face-to-face review, as the previous practitioner wanted to get a second opinion on the case.

As the discolouration extended, I reinjected more hyaluronidase (450 units, with 1% lidocaine for comfort) as microdoses to spread evenly across this extended area. It is worth noting that his previous brow filler, which lay within the distribution, also dissipated. Gentle warm compresses and massages were performed to help disperse the drug and encourage vasodilation. The nasal dorsum was not reinjected as this area had high doses injected the previous day. He was asked to commence on vitamin C and zinc supplementation to maximise healing. I advised on basic skincare to keep the area clean with gentle cleansing, light moisturisation and sun protection. There was the beginning of some pustule formation, which lasted the subsequent seven to eight days. The distribution of the discolouration stopped progressing by day three but deepened in colour until day four to five. The peak of inflammation was on day four to five, and thereafter, the discoloration started improving. The final pustule dried out by day 10.

At two weeks, there were no scabs, pustules or inflammation, and skin texture started to normalise. Discolouration had downgraded to mild erythema. I advised him to start a vitamin C serum, niacinamide serum and to continue with sun protection to minimise hyperpigmentation. At four weeks, there was only faint erythema at the nasal bridge with a slightly depressed scar. By six weeks, all discolouration had resolved, but the depressed scar was visible. By three months, the depressed scar was almost imperceptible. The photo timeline in Figure 1 illustrates the progression of the complication.

Retreatment

The patient was keen to have another NSR but was advised to wait at least six months before further injections. This allowed the soft tissue envelope of the nose to settle and

Mr Dominic Yue presents a case study demonstrating a non-surgical rhinoplasty complication and how it was effectively managed

Figure 1: The progression of skin changes at four intervals – day two, six, 14 and three months after. Images courtesy of Mr Dominic Yue

any subcutaneous scarring to mature. It was emphasised that any filler procedure in the area would be higher risk due to scarring or possible aberrant vessel anatomy. The patient understood the risks and elected to have another procedure six months after the skin change had settled, with a non-complicated outcome (Figure 2). This was performed with 1ml of Restylane Lyft using a 27G short needle and slow injection technique at the supraperiosteal and supraperichondrial planes. For this procedure, I applied a cool pack to the dorsum of the nose for 10 minutes prior to injecting, which vasoconstricts the blood vessels temporarily for safety and reduce bruising. Using the non-injecting hand, the sides of the nose are compressed to guide midline placement of filler and prevent spread of filler in case of inadvertent intravascular injection. Segreto et al describes a further modification to this – to blanch the area by pushing down with the same fingers before injecting, draw up the tissues ‘onto the needle’, then maintain some pressure on the nasal sidewall when injecting.6 Before injecting, I always aspirate, although it is debated whether this is a useful manoeuvre.7 Slow injection in small aliquots is important to prevent larger quantities of filler being injected into a vascular area. Gentle continuous pressure is applied as each injection point is completed to minimise bleeding. For 30 minutes post-procedure, a cool pack was intermittently applied to the area to reduce inflammation. He was advised to sleep with a slight head-up position for the first night. He was invited back for a two-week review.

Minimising vessel occlusion events

This was a typical case of vessel occlusion from filler material entering the vascular network. Early signs include blanching, pain, reticular pattern of erythema with pustules formation and skin ulceration. Late

consequences, if suboptimally managed, include depressed scarring, textural and pigmentation differences and asymmetry. If early (<2 days) treatment is commenced, less ischaemia is allowed to consolidate and therefore outcomes are maximised. Late presentation is associated with skin necrosis and scarring.8 Having knowledge of the anatomy around the nose is essential prior to performing injections in the area.9,10

Placement of filler is safest in the midline and at the supraperiosteum and supraperichondrium layer where there are fewer vessels.11 In my opinion, injecting directly into the sidewall should be avoided if possible, but if required, placing tiny aliquots with constant movement may minimise the risk. There is variability of vessel anatomy between individuals, especially in those who have had previous filler complications or surgical rhinoplasty.11,12 When I inject patients, the injection order is usually radix, rhinion, tip and supratip. This ensures that the maximal tip projection achievable for a patient’s skin envelope can be matched with the supratip. If the tip is performed last, there is a risk that not enough tip projection can be achieved to match the supratip injection.13 Recurrent tip droop can be due to under-treatment, restrictions of a tight skin envelope or presence of a tight face mask resting on an area of the nose. I tend to overcorrect the tip of the nose, if the skin allows, by 1-2mm. This allows for a reliable projection of the tip with a supratip break after the oedema settles. The use of needles and cannulas are valid techniques. Some argue that it is difficult to ensure the tip is in the correct plane when using a cannula, and that it can give a false sense of security when injecting larger volumes.14 Larger bore cannulas are less likely to cause vessel damage, and easier to maintain in a deep plane.15 As a practical point, cannulas are not ideal for those with a marked dorsal hump. From the entry point at the tip of the nose, the cannula would have to contour over the hump significantly to maintain a supraperiosteal plane superior to the hump.

When complications happen

The Aesthetic Complications Expert (ACE) Group World and Complications in Medical Aesthetics Collaborative (CMAC) both have guidelines for the management of filler-

associated vessel occlusion.4,5 Due to the time-sensitive nature of vessel occlusions, it is advisable to have a kit ready, which contains all the equipment and hyaluronidase vials along with a copy of the guidelines. If treated early, most cases will not progress to skin necrosis.2,6 Use of hyaluronidase in those without ischemic sequelae should not be taken lightly. There is a small risk of anaphylaxis and local skin allergic reactions occurring. Be wary of those with bee or wasp sting allergies as there is cross-reactivity. An intradermal test can be performed, but ensure the clinical space has anaphylaxis support available.15,16 Hyaluronidase will dissolve other filler material in the treated areas. In the case described, the patient’s previous right brow filler was dissolved. The effect of hyaluronidase in the tissues lasts up to six hours, and filler re-injection is possible but not recommended.16,17 The local tissue inflammation and presence of pustules render the whole area a zone of trauma. Until the soft tissue envelope settles fully (at least six months after the event), re-injection is high risk.16,17

Recognise complications early

NSR using dermal filler is an effective and generally safe procedure as long as certain risk-reducing techniques are implemented. Ischemic complications relating to vessel occlusion should be recognised early, treated expediently with the help of guidelines and monitored for best outcomes.

Mr Dominic Yue is a London consultant plastic surgeon working in both private practice and the NHS, where he specialises in burn, hand and skin cancer surgery. He is passionate about both non-surgical and surgical aesthetic procedures. He is a member of the BAPRAS, BAAPS and ISAPS.

Qual: MBBS, BSc, FEBHS, FRCS(Plast)

Figure 2: 32-year-old patient before and after nose filler redone, six months after the prior complication had settled. Images courtesy of Mr Dominic Yue.

Exploring Dermal Fillers and HSV

During injections of dermal fillers, HSV will mostly be triggered around the mouth perimeter of the face, known as oral herpes, but can also cause concerns of other areas of the body. No matter where herpes arises, the virus will remain contagious and so will require medical treatment. Oral herpes causes sores on the lips and around the mouth which we know as cold sores or fever blisters.6

Despite this, you still should not let that hold you back from performing dermal filler injections on sufferers completely. HSV is quite a common virus, and many practitioners have treated HSV positive patients with no problem. In fact, the risk of HSV reactivation after dermal filler is estimated to occur in less than 1.45% cases.7

Diagnosis

Diagnosis of HSV can be done through recognition of visible signs and symptoms, such as the development of a cold sore. There are several stages to the development of a cold sore. The first stage is a tingling or itchy feeling that precedes the blister, then 12 to 24 hours after the initial tingle, tiny blisters start to form. At this stage, the cold sore is often red and painful. The blisters will ooze fluid which will last a few days. Eventually, a scab will form and crust over. The whole cycle can take up to 15 days and the person is contagious for the entire cycle of a cold sore, which explains why they are so easily transmissible.8

Globally, about 67% of people below the age of 50 years have herpes simplex virus type 1 (HSV-1). This is the virus that most often causes oral herpes.1 The virus is very contagious and is caught through close contact. Once a person has the virus, they will have it for life as it stays latent in the body in nerve endings. The most common areas that people suffer with cold sores are on the lips and around their mouth, but they can also develop on the nose and cheeks.2

Severe infective complications can occur in patients who suffer immune complications. It has been confirmed during a recent study that those with immune complications will be affected by flare-ups five to six times throughout the year, however those with stronger immune systems will notice on average two flare-ups in a year.3 HSV can be triggered when people are rundown, been exposed to the sun, or are particularly stressed, however, dermal filler injections can also exacerbate or trigger HSV due to the skin damage to an active area.4 Therefore, it is important for practitioners to be aware of how to prevent HSV from occurring, or how to treat it should it occur.

The link between dermal fillers and cold sores

During facial dermal filler injections, virus reactivations can be caused by direct damage to the axon by the needle which is being injected into the irritated area.5 In addition to this, tissue manipulation and inflammatory reactions after filler injection could play a role in a viral reactivation within our bodies. The damage is believed to cause infection reactivation, however hyaluronic acid itself has been demonstrated to act as a protective agent, preventing viral replication.5

However, there are not always obvious signs of HSV. Patients may not have any symptoms that they can feel, or the signs of herpes can be extremely mild that they will not notice them at all. It is also quite common for people to confuse herpes symptoms with other skin concerns such as ingrown hairs, the flu, or pimples. Symptoms of herpes can come and go, but that does not always mean that the infection does too, and even though the symptoms are not there, it does not also mean that it cannot spread to other people. It is worth noting here though that if the cold sore presents following treatment, the initial symptoms of cold sores could also look like a necrosis. It is important that you see your patient in person, to make the differential diagnosis and be able to treat the patient accordingly. According to guidelines published by the Aesthetic Complications Expert Group World, when a blistering reaction occurs outside of the areas typical of herpes eruptions or in a high-risk area for necrosis, vascular compromise should be seriously considered.5

Dr Natalie Geary discusses how to diagnose herpes simplex virus in your patients and what to consider before injecting

During facial dermal filler injections, virus reactivations can be caused by direct damage to the axon by the needle

Prevention

To begin with, I always ask about cold sores in the medical history section during the initial consultation.5 If one of my patients frequently suffers with cold sores, or had any recently, then I would suggest prescribing an antiviral drug such as acyclovir two before the treatment, as a prophylaxis. It is recommended that patients take 400mg of the drug two times a day (or three times if immunocompromised).5 If my patient does not suffer from cold sores regularly and the cold sores are not showing as active at the time of the appointment, I would still prescribe antiviral medication to ensure that the bacteria is kept under control. Aciclovir is widely used to treat infections caused by certain types of viruses, including outbreaks of herpes on the mouth or on other areas of the body. In those with frequent outbreaks, aciclovir is used to help reduce the number of future flare-ups. It is an antiviral drug; however, it is not classed as a cure. The viruses that contribute to these infections will continue to live within our bodies even between outbreaks with the use of Aciclovir. However, the drug does decrease the severity and longevity of these outbreaks, and it enables the sores to heal faster whilst keeping new sores from forming and eventually reducing the pain and itchiness patients get from them.9 Aciclovir can be taken orally without the consumption of food. The most frequent side effects with aciclovir are abdominal pain, diarrhea, and vomiting; and so if these side effects occur, practitioners may want to look into prescribing an alternative such as Valaciclovir.5

constantly kept clean for the next 24 hours is recommended to avoid any further infection in the open wounds, and I would advise to avoid using lip products or facial products that have already been opened, such as lip balms or foundation. This is so any bacteria build-up within the products is not transferred on the open wounded area.

HSV and other aesthetic treatments

It is worth noting that it is not just injectables that can trigger cold sores, and other treatments that puncture or wound the skin such as botulinum toxin, threads, laser, or radiofrequency can also cause reactions when used on the face. As such, I do not do any facial aesthetic work on any patient with an active cold sore as there is always a risk of spreading the virus to other areas, which can be a lot more complicated and painful for the patient. As we know that most cold sores have a cycle of 15 days, as with dermal fillers, I will invite my patients back to the clinic after two to three weeks following the initial symptoms and perform the treatment when I know that the flare-up has gone down. I also prescribe antivirals to prevent an outbreak, as you can never be too cautious and always want to ensure the safety of your patient.

Minimise risk

Practitioners should take a thorough medical history prior to treatment and prescribe patients with antiviral medication for two to five days should they have an active infection or regularly experience flare-ups. The medication should also be prescribed for five to seven days after treatment. As always, practitioners should be ensuring they are performing treatment in a safe, sterilised environment to avoid any infection. If your patient suffers a reaction after injection, you should ensure that you prescribe the correct medication for them to use at-home to subside the effects.

Dr Natalie Geary is medical director of the Light Touch Clinic in Surrey and founder of the Consentz patient record app. Dr Geary previously trained at the American Academy of Anti-Ageing Medicine, completing courses in bio-identical replacement therapy, gastroenterology exercise and physiology, brain health and microbiome.

Qual: MBBS, BA Hons, A4M

REFERENCES

When you do treat the patient, I would advise that when injecting you should avoid the area which flares-up, if possible. You should also be ensuring that the area is sterilised as usual and ensure you are using a separate needle when injecting into a different area. If your patient is having lip fillers, the flare-up area is hard to avoid as is where cold sores typically present, so you should only treat them once the HSV has subsided and isn’t flared-up already.

Following filler treatment

Upon completion of the treatment, I always recommend that my patients follow the general protocols of dermal filler aftercare, such as ice on the area if required, no lying down for four hours post-procedure and avoidance of hot water, steam rooms and saunas.

In addition to these protocols, I would recommend continuing taking the antiviral medication two times a day for five days to ensure that there are no severe reactions after the treatment. Alongside the two days prior, the medication should also be taken five to seven days after the initial treatment.5 Ensuring the area is

1. World Health Organisation, Two Third of the Population under 50 are Infected with Herpes Simplex Virus, 2015, <https://www.who.int/news-room/detail/28-10-2015-globally-an-estimated-two-thirds-ofthe-population-under-50-are-infected-with-herpes-simplex-virus-type-1>

2. Jill Sheladi Schuman, How Many People Have Herpes, 2020, <https://www.medicalnewstoday.com/ articles/how-many-people-have-herpes>

3. Denise J. Wedel M.D., Terese T. Horlocker, Infectious Complications, Complications in Regional Anesthesia & Pain Medicine, 2007

4. Kenneth M. Kaye, Herpes Labialis; Herpetic Gingivostomatitis, <https://www.msdmanuals.com/en-gb/ professional/infectious-diseases/herpesviruses/herpes-simplex-virus-hsv-infections>

5. Martyn King, Prophylaxis and Treatment of Herpetic Infections, <https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5300736/>

6.

8. NHS, Cold Sores, <https://www.nhs.uk/conditions/cold-sores/>

9. NHS, How and When to take Aciclovir, <https://www.nhs.uk/medicines/aciclovir/how-and-when-totake-or-use-aciclovir/>

The initial symptoms of cold sores could also look like a necrosis

Why consider connect certification?

Don’t just take our word for it! The programme has already been completed by some of our most trusted and experienced UK HydraFacialists!

3-Level Training Course

designed to develop the knowledge and skills of aesthetic professionals

with the tools to provide an exceptional level of service for their clinic

Uk pilot member testimonials

“This is the only program that offers such a broad range of beauty, aesthetic, skincare, business information from both industry professional, clinic owners & team members.”

Joanna Pepper, United Kingdom

“The whole course is revolutionary, complete package of everything I need to know to carry through my career.”

All-encompassing training programme

that extends beyond the HydraFacial treatment

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ideal for busy professionals allowing them to pause & resume as needed

Comprehensive study to HydraFacialists, aestheticians, spa therapists, aesthetic nurses & clinic owners

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the course is suited

“I feel as an aesthetician we never stop learning. The industry is always changing. The HydraFacial CONNECT Program was exactly the learning program I was looking for! It’s so much more than a beauty course. It really takes you to the next level in your career. Not only will you have a better understanding of the aesthetic industry but you can also maximise your commission in clinic. Every therapist needs to do this course!”

HydraFacial is registered in the United States Patent and Trademark Office by Edge Systems LLC. Copyright © 2022 Edge Systems LLC. All rights reserved. CS5074 05/21 hydrafacial.co.uk/connect/

Maureen Hayden, United Kingdom

Understanding the Revanesse® Portfolio

Prollenium® | One of the fastest growing competitors in the aesthetic space for a reason… Aesthetics heavy weight Prollenium®, founded in 2002, today is one of the fastest growing dermal filler companies in the world and the only manufacturer of HA dermal fillers in North America. Producing its best-in-class HA dermal filler, Revanesse®, since 2011, designed for the ultimate filler experience for practitioners who choose not to compromise patient safety for product performance. Revanesse® is made using state-of-the-art production methods, optimised materials and rigorous testing. Particles are uniquely wet milled giving them a

smooth, spherical shape, proven to reduce inflammation, integrate smoothly and break down slowly over time. The sophisticated collection of HA gels differs in rheology due to innovative manufacturing decisions such as reducing linear HA in place of additional BDDE to create projecting products such as Revanesse® Shape, and the new launch for later this year Revanesse® Outline.

But don’t just take our word for it! We asked the following injectors to try Revanesse® dermal fillers for themselves and here’s what they found:

Practitioner perspectives

Dr Nina Bal, TV personality and multi-award-winning cosmetic dental surgeon and advanced facial aesthetics clinician based in Tempus Belgravia, London said, “I’d heard of Revanesse® and I was very intrigued to see what it was like. Honestly, I think it’s amazing. I couldn’t believe how much projection I can get with so little product and in a 1.2ml syringe, there is less wastage too.”

Dr Marcus Mehta, cosmetic doctor and trainer, co-founder of STORY clinics in Southwell, Nottinghamshire and Marylebone London and director of the UK’s largest aesthetic medicine training school Harley Academy, noted, “Revanesse® dermal filler provides impressive projection without an increase in BDDE which is reassuring, plus with its spherical particles to reduce inflammation and produce an extremely smooth injection, it’s one of the most exciting developments I have seen in dermal fillers in a long, long time. It has certainly set the bar high.”

Professor Firas Al-Niaimi, world-renowned and multi awardwinning professor in dermatology, based in London’s Harley Street commented, “Prollenium® has created a good dermal filler portfolio with Revanesse®; I like using the products, they are very patient-centric. There is less swelling than other filler products and a very low inflammatory response which is music to an injector’s ears as well as my patients. Using this product, you are very much in control and unlikely to need follow-up top-ups as what you see is what you get.”

What’s next for Prollenium®?

With the recent acquisition of SoftFil, Parisian-based medical device manufacturer, Prollenium® UK has launched the world’s first topical hyaluronidase. The product will be available through Healthxchange Pharmacy alongside the distribution of SoftFil. Multi-award winning Topilase is indicated for the superficial adjustment of HA dermal fillers. It is most commonly used for lip filler migration and tear trough correction.

Dr Emily Mehta, medical director of Harley Academy and STORY Clinics said: “I think that

Topilase is a revolutionary and exciting product that will improve cosmetic results whilst also reducing the need for further invasive procedures.

Topilase is a skin serum that contains small amounts of an enzyme complex that can dissolve hyaluronic acid filler which allows such minor filler imperfections to be corrected without

further risk or trauma. It is particularly useful in the under-eye and lip areas which is where I see more than 90% of filler problems anyway. Both areas are easily over treated by less experienced practitioners and also can occasionally cause product migration. The process is completely painless — it is simply a serum that is rubbed into the area where filler needs to be reduced or removed.”

Topilase is available to purchase now.

Register your interest in Topilase through Healthxchange Pharmacy: https://www.healthxchange.com/topilase

This advertorial was written and supplied by Prollenium®

For more information about Prollenium® and Revanesse®, please contact: info@prollenium.co.uk.

Practitioners detail their thoughts on the Revanesse® range of dermal fillers and the company reveals their exciting new launch

A summary of the latest clinical studies

Bi-Bi Technique for Lip Augmentation: A Retrospective Study on 30 Cases

Title:

Authors: Smarrito S, et al.

Published: Journal of Cosmetic Dermatology, July 2022

Keywords: Lips, Cannula, Hyaluronic Acid

Abstract: Hyaluronic acid (HA) lip augmentation procedures are performed either superficially or deeply with a needle or cannula, and only one type of HA is used. The authors’ objective was to evaluate the feasibility, safety and satisfaction level of a procedure combining two anatomical injection plans, two injection modes (i.e. cannula and needle) and two types of HA filler. The retrospective study included 30 patients who underwent intramuscular retrotrace injections of Stylage M (Vivacy Laboratories) conducted through a 27-gauge cannula in the upper and lower hemi-lip, and intradermal injections of Stylage Lips (Vivacy Laboratories) using a 33-gauge needle on the lip border and cupid’s bow. Subjects were asked to evaluate satisfaction and the fillers’ effect over time. Elastic and viscosity moduli of HA fillers were measured with a rheometer (AR2000, TA Instruments) prior to and after extrusion through a 33-gauge needle. Rheological assessment showed that passage through this needle did not alter the fillers’ viscoelastic properties. After the procedure, no vascular incidents or side effects were observed except standard post-treatment bruises and edema. Overall patient satisfaction was high, with long-lasting effects. The study demonstrated that dissociating the anatomical zones of the lip during the injection procedure by means of different HAs in the muscular and dermal planes would efficiently and safely provide both lip projection and fullness for a natural and lasting effect.

Title: Pathogenesis-Oriented Therapy of Psoriasis Using Biologics

Authors: Boehncke W, et al.

Published: Expert Opinion on Biological Therapy, July 2022

Keywords: Biologics, Personalised Medicine, Psoriasis

Abstract: Psoriasis is currently regarded an immune-mediated inflammatory disease. The central pathogenic axis comprises interleukin-23, TH17-lymphocytes differentiating under its influence and interleukin-17A as a key effector cytokine of these T-lymphocytes. All of these can be selectively targeted using biological therapies, thus potentially increasing efficacy and reducing adverse events when compared to conventional systemic therapeutics. We review the current concept of psoriasis as an immune-mediated inflammatory disease, assessing the evidence regarding elements of the innate and adaptive immune system. We then correlate the pharmacological effects of biologics in psoriasis in the light of the known physiologic and pathophysiological role of the respective targets. This is done based on extensive literature search of publications since 2018 which describes the role of the abovementioned elements in health and disease, or the effects of blocking these as an attempt to treat psoriasis. Biologics targeting the abovementioned central pathogenic axis provide a particularly effective and safe way to treat psoriasis. Given the impact of comorbidities on therapeutic decision-making, and the efficacy of some biologics on certain comorbidities, these drugs represent a first step towards personalised medicine in the management of psoriasis.

Title: Skin of Colour Skin Care Needs: Results of a Multi-Centre-Based Survey

Authors: Geisler, A, et al.

Published: Journal of Drugs in Dermatology, July 2022

Keywords: Diversity, Inclusivity, Skincare

Abstract: Barriers to responsible health information include exposure to sources or lack thereof, insufficient knowledge, inadequate proximity to stores, cost and marketing of products that are not suitable for all skin types. We conducted a survey to characterise the skincare practices, concerns and habits of people of colour and non-Hispanic whites to evaluate barriers and influences on product choice and behaviours.

One-hundred-and-twenty respondents self-identified as nonwhite, while 31 self-identified as non-Hispanic white. The top skincare concerns in the skin of colour (SOC) population were acne and blemishes, dry skin and pigmentation/dark spots. In the non-Hispanic white population, the top concerns were fine lines and wrinkles, acne and blemishes and dry skin. When questioned about barriers to dermatologic products, SOC respondents were more likely to cite lack of available products for their skin type compared to white respondents. SOC respondents identified internet and social media as major sources of dermatologic information compared to white respondents. Healthcare disparities can be heightened by targeted marketing and the media, which have a major impact on patient health literacy and consumer choices. Dermatologists should be aware of this when addressing knowledge gaps, minimising bias and increasing inclusivity for all skin types.

Title: Botulinum Toxin Injection as a Single or Combined Treatment with HA Gel for Neck Rejuvenation

Authors: Noormohammadpour P, et al.

Published: Dermatologic Therapy, July 2022

Keywords: This study evaluated the efficacy of botulinum toxin injection as a single or combined treatment with Profhilo gel for neck rejuvenation during ageing. Patients were randomly divided into two groups, and initial clinical scoring based on the Wrinkle Severity Rating Scale (WSRS) and a Multi Adaptor System (MPA) were performed. Dysport botulinum toxin was injected for all participants, but one group (intervention) received Profhilo gel injections after two weeks. Three months later, patients were evaluated according to the GAIS (global aesthetic improvement scale) by two blind dermatologists, and skin biophysical parameters were measured by MPA including TEWL, hydration, thickness, density, elasticity and firmness. Nineteen participants in the control (Dysport) and intervention (Dysport + Profhilo gel) groups were evaluated. Before treatment, the two groups’ WSRS scores and biophysical skin parameters were similar. Three months after treatment, hydration and skin thickness in the intervention group were significantly higher than the control group. Similarly, the intervention group’s GAIS scores were significantly better. Profhilo gel following Dysport botulinum toxin can be considered a safe and more effective treatment of neck ageing than botulinum toxin injection alone.

Awards Entries Now Open

Celebrating continued success

The Aesthetics Awards 2022 was undoubtedly a night to remember. Hosted for the first time on the second day of ACE, it was our most highly attended ceremony and the largest gathering of medical aesthetic professionals that recognises and celebrates the success of this industry. So much so that it is moving to the most prestigious awards venue in London, Grosvenor House, for 2023. With a rigorous, multi-layered judging process, industry voting element and the heritage the Awards have gained after many years, it remains at the pinnacle of industry excellence to be shortlisted for an Aesthetics Award. With entries for next year now open, it is a good time to look back on some of the incredible Winners from 2022 to note their successes, and to see if The Aesthetics Awards are truly worthy of the nickname ‘the Oscars of Aesthetics’.

Local celebrities Hampton Clinic is a centre for excellence in aesthetics, nestled in the woodland estate of Hampton Manor. In the year leading up to their win of the Best Clinic Midlands and Wales in 2022 they saw significant growth and secured a second premises in Knowle Town Centre. Since receiving the Award, Hampton Clinic has continued to go from strength to strength. Their second branch is thriving, they have welcomed new team members and expanded their treatment offering with a range of new devices. Dr Lorraine Hill, founder and director, comments, “We were so proud to have won the Award that no expense has been spared when it comes to sharing the news. We have had a huge sign installed on the wall outside the clinic and have been in all the local publications!”

A respected member of the aesthetics community

Julie Scott is an independent nurse prescriber, Level 7 qualified aesthetic injector and trainer with more than 25 years’ experience. The entry that awarded her The SpringPharm Award for Aesthetic Nurse Practitioner of the Year was testament of her dedication to her craft. It highlighted her strong passion for learning, teaching and sharing years of experience with the new generation of practitioners, which she stated as a fulfilling and rewarding part of her growth.

She reflects, “Personally, it’s just lovely and humbling for me to see the Award when I walk into my clinic. It’s great for new patients, and current patients, to see that they have made a good decision in choosing

What does it mean to be award-winning?

“It’s great for new patients, and current patients, to see that they have made a good decision in choosing my clinic, and that they are in safe hands.”

Julie Scott, independent nurse prescriber and Winner of The SpringPharm Award for Aesthetic Nurse Practitioner of the Year

my clinic, and that they are in safe hands. Lastly, this process has highlighted that I am a respected and valued member of the aesthetics community, for clinical ability, authenticity and support I bring to my peers and patients.”

Starting with a dream Thriving in the heart of the Twickenham community with a following of patients from across the UK, the Thames Skin Clinic team work as one to make patients feel comfortable. With outstanding patient reviews, incredible growth and a patient-led experience, it was undoubtedly deserving of The ReLife Award for Best New Clinic, UK & Ireland. Founder Dr Anna Hemming says, “I was blown away to win the Award. I made the bold step creating Thames Skin Clinic and looked into the future with a dream to make it into the most beautiful, patient-focused, caring environment. To win this award through hard-work, communication and the best industry partners we have built the most amazing environment for my patients.”

International recognition

The tribe of women that drive Acquisition Aesthetics are united by a shared passion for aesthetic medicine and a common mission in training. With courses that display robust protocols and methodology in scientific education, their delegates applaud the expert level of teaching delivered through state-of-the-art means. Winning The Clinisept+ Skin Award for Independent Training Provider of the Year twice in a row is not common, but Acquisition Aesthetics did it, and continue to gain momentum as they go from strength to strength.

Since their consecutive wins, directors Dr Priyanka Chadha and Dr Lara Watson travelled to Monaco with their Award for AMWC, where Dr Chadha spoke globally on behalf of Galderma. Dr Chadha says, “We have worked tirelessly not only to improve industry standards and increase safety through training, but also to build a family that loves working together, and we really have managed to do that through respect and collaboration.”

Dr Watson adds, “This Award reminds us that our commitment to ensuring academically rigorous materials, an unparalleled faculty of expert trainers and a truly exceptional delegate experience, is recognised and valued by the wider industry.”

Start your entry engines

Despite still being on a high from The Aesthetics Awards 2022, this industry does not rest. Esteemed Winners and Finalists from this year’s ceremony are still enjoying their success, as they should be, but the entry process now starts for next year. Entering the Aesthetics Awards is an incredible opportunity to not only be recognised, but to be positioned as industry-leading, and to have the hard work and achievements of you and your team celebrated.

Entry to The Aesthetics Awards is completely free of charge to all Aesthetics journal Full, Print and Digital members. If you are not already a member, you can do so for as little as £60 per year. Entry closes on September 30.

SCAN HERE TO VIEW THE CATEGORIES AND ENTER!

Dealing

Every aesthetic practitioner I’ve ever spoken to has difficult days. Days when they want to quit the industry and never administer another treatment again, when they feel patient after patient is asking for a discount, wants another free ‘top up’ of their toxin treatment, or says their expectations weren’t met when the before and after photos clearly show an excellent clinical outcome.

When these frustrations mount, it can be difficult for some practitioners to stand their ground and do what is best for their patients and their practice. In fact, when I had days like this in my early years of practising, I used to say I wanted to quit aesthetics and open a cake shop! However, in the nearly 20 years since I first opened my practice, I have developed some strategies and methods for not being a ‘patient-pleaser’, and therefore operating in both the patients’ best interests and mine. For those who perhaps also struggle with managing difficult patients, allow me to suggest the following.

Set boundaries

When colleagues ask me about how to best approach challenging patients, often the best tip I can give them is to set boundaries. It seems obvious, but this can sometimes be hard to do when faced with a highly sensitive, anxious, or needy patient who may have unrealistic expectations or just ask for too much. In these cases, I’ve often found that these patients simply need to hear what they don’t want to hear, for their own best interest. “Easier said than done,” I hear you say! Remember that as medical practitioners, we have a code of conduct to uphold, and it’s important to explain to patients why we can’t and shouldn’t chase every line, how all humans are naturally asymmetrical and how we are striving for

improvement, not perfection. When unrealistic expectations, for example, make these reality check conversations necessary, the best way to approach setting a boundary is to respect and acknowledge the patient’s concerns, but then bring the conversation back to what, in reality, can be achieved. I tend to focus on the positives – for example, what we can do first – but then gently explain what they don’t want to hear, whilst reminding them that as their medically-qualified practitioner, I am actually best placed to advise on what can be accomplished realistically and safely. When done with respect and positivity, even the trickiest patients respond well to receiving what they may have perceived as bad news in the first instance.

After all, remember that to be the best practitioner possible, it is necessary to act as the patient’s advocate, not their friend. If a patient is asking for too much, try to gently re-draw that patient-practitioner line by redirecting the conversation after addressing their concerns so that the boundaries remain clear.

I recognise that for those practitioners who are naturally accommodating (such as myself), it may not come easily, but boundaries are so important to caring for ourselves as practitioners so that we can then provide our best selves and services to our patients. Assertiveness – not aggression, as these are two very different things – and consistency are key for ensuring boundaries are respected. That’s why I urge ‘people-pleaser’ practitioners to not become ‘patient-pleasers’ – I promise you don’t have to be both, which leads me on to my next point.

To be the best

possible it is necessary to act as the patient’s advocate and not their

Create a separate work persona

If you read my above point and thought ‘ok, but Julie, I’m NOT an assertive person’ – that’s fine. You don’t naturally have to be, but you should lead your patients to believe that you are. That’s why I recommend dividing your individual personality from your business persona – separate who you are from who you act like at work. When you step through the door of your clinic, become your alter ego.

If this sounds like a formidable task, it may be one of those situations where you have to ‘fake it till you make it’. You should still be your authentic self at your core, but take on another persona that is more suited for a clinical environment. To do this, I find it helps to visualise myself physically changing my hat – for example, every morning I take off my ‘mum’ hat, and put on my ‘work’ hat. If I tried to wear two hats in real life, they wouldn’t fit! This is the same when it comes to creating that work persona. Regardless of what is going on in my life, my patients have a certain expectation of me, which I need to meet – so for them, as soon as I step into my clinic, I become Nurse Julie.

In addition to becoming a more assertive, clinically minded Julie, I also leave anything non-work related at the door, to become my best practitioner self for my patients. And in turn, this helps me maintain that professional distance and clear boundaries whilst simultaneously building trust with my patients.

Build and utilise your network

Lastly, it is so important for every aesthetic practitioner to build a network. This can be an isolating industry, and dealing with demanding, sensitive, specific, needy and/ or anxious patients can take its toll. It’s no wonder that many of us want to take to the hills at times. Some practitioners do indeed end up leaving the industry due to fear of complications, the stress of patient complaints and general burnout. Even if they are the most skilled injectors, some haven’t focused on developing the skills to address difficult patients.

I would surmise that a large part of this is due to practitioners being on their own in practice, especially those who no longer work in the large multidisciplinary teams of the NHS. These fears, worries and negative experiences fester and result in mental

exhaustion and feeling drained. With a support network, however, these things don’t have to fester and it is far easier to avoid making a mountain out of a molehill. It is then possible to air any concerns about certain patients, or discuss with experienced colleagues more clinically difficult cases. Finding one’s tribe is one of the most important things to do when getting started in the industry. You can do this by connecting with local practitioners via associations like the British Association of Cosmetic Nurses (BACN) or the British College of Aesthetic Medicine (BCAM), and joining the complications groups such as the Complications in Medical Aesthetic Collaborative (CMAC) or the Aesthetic Complications Expert (ACE) Group World. You can also find mentor or coaching groups, or simply meet up with similar practitioners at conferences such as ACE and CCR.

Reflection on one’s practice with colleagues leads is also a huge help – it leads to empowerment and feeling more capable of facing challenges head on. Furthermore, this reflection can lead you to realise what you want to work on in your practice and your skillset. There are courses you can attend where you can not only develop skills and address your trigger points, but connect with the other delegates on the course who are motivated to learn the same skills as you are.

Don’t be disheartened by the difficult patient

Overall, we all know that in any industry, there are occasionally frustrating interactions between those receiving a service and those providing it – in fact, when I used to feel that I wanted to leave aesthetics and open a cake shop, my friend reminded me, “That would be nice,

until you give someone food poisoning!” In an industry such as aesthetics, though, when we are dealing with patient insecurities and changing their physical appearance, this can be heightened. I have found that practitioners need to not only be skilled with a needle in their hand, but have the people skills and the courage to guide patients and address difficult situations. It is important to know, though, that you don’t have to be born with these skills; they can be developed over time with some mental shifts and behavioural changes and lots of practice over time in implementing the tips above, for example. It is a huge undertaking, but I feel that anyone who doesn’t think they need to hone in on these skills is a bit misguided. I made these changes in my own practice, and 20 years later, I’m still here, changing my hats. I never did open that cake shop after all.

Julie Scott is an independent nurse prescriber and Level 7 qualified aesthetic injector with more than 25 years’ experience in skin rejuvenation. Scott is a clinical trainer, aesthetic mentor, and recently won the SpringPharm Award for Best Aesthetic Nurse Practitioner at the 2022 Aesthetics Awards. She has owned Facial Aesthetics Ltd since 2003.

Qual: RGN, NIP

Divide your individual personality from your business persona and separate who you are from who you act like at work

Storing Before and After Images

Business director Jo Hayward discusses how to store patient photography appropriately

One aspect of an aesthetic treatment that every practitioner will be familiar with is taking before and after photos. However, there is a lot more to consider than just pulling out your phone and snapping a few pictures.1 Some important questions to ask yourself include: are you storing photos securely? Why is it important to have robust processes in place to manage them? Are you adhering to all your legal requirements for insurance and General Data Protection Regulation (GDPR), and are they in line with the standards of your professional bodies such as the General Medical Council (GMC), General Dental Council (GDC) and The Nursing and Midwifery Council (NMC)?

This article will aim to give you some points to consider and offer advice on how to manage before and after photos appropriately within your clinic.

Why is it important to take before and after photos?

Before and after photos are an essential part of your patient’s record. They should be carefully and meticulously taken using consistent photography parameters, such as lighting, angles, facial expressions and more.2,3

Your pictures should clearly show the patient’s changes across their treatment journey, including the appearance before the treatment, and the results during and following treatment, reducing any doubt the patient may have about their outcome. These photos can also provide supporting evidence for your insurance if a complication or complaint is made against you. As well as forming part of your treatment documentation, before and after photos are a great way to showcase the transformation your patient has received and can have a positive impact on patient satisfaction, especially if you’re able to create and send a before and after comparison to them. With the correct consent (as discussed below), you can also use before and after images for training purposes, clinical research, publication in medical journals or for marketing.

What are your responsibilities?

Storage and security of your before and after photos (and your patient’s data in general) leads onto the requirements you have as a medical practitioner and business owner. It is your responsibility to protect your patients’ information. You must be aware of the responsibilities required to ensure you comply with government legislation, your insurance policy and professional bodies.

General Data Protection Regulation

GDPR sets out the way that you should process, use and store personal data about your patients.4 As an aesthetic practitioner, you handle a lot of your patients’ personal data. If your before and after photos are not stored in a secure system, how can you be confident that they aren’t at risk of being lost? Often, the most common place that practitioners store photos, especially when they’re just getting started, is on a mobile phone. However, this method of storage raises concerns for data security and potentially can breach GDPR.4 If you fail to comply with the GDPR requirements, then the penalties for breaching these regulations can be severe – the maximum fine is either 4% of your total annual worldwide turnover or £17.5 million, whichever is higher.5

Storing patient photos on your phone puts them at risk of being lost or exposed. What if your phone went missing or was stolen? If your phone was to break, would you have a backup of all those photos, or would they be gone forever?

Whilst it is a quick and convenient way to take photos on your phone, this is not where they should be stored to ensure they are secure. Patient photographs should be stored in a secure cloud-based system. Somewhere that acts as a back-up to protect your photos from being lost forever, as well as protecting them from unauthorised access. There are several generic cloud-based storage options including Google Drive and Dropbox. However, I would recommend storing these against a patient record by using a secure clinic software system such as Aesthetic Nurse Software, e-clinic or Pabau, with other brands available. You want to use a system that is encrypted with a robust security protection such as Secure Socket Layers (SSL). This means that all photos are protected between the server and the web browser or device you are accessing them on.

Insurance

It’s common practice for insurance policies to state that before photos must be taken with all injectable treatments. For example, upon contacting Hamilton Fraser, they have advised me that without before photos, the policy conditions will not have been met, so the practitioner is running the risk of the underwriters declining to assist if a claim is brought against the policyholder. Hamilton Fraser also strongly advises that it is best practice to take after photos to show the results. Clear notes and photos are the best form of protection when it comes to defending a claim. This emphasises just how important it is to ensure you include before and after photos within your records, making sure you have documented evidence should there ever be a claim made against you. Not only that, but if your photos have not been stored securely and they get lost, you may not be covered by your insurance. Hamilton Fraser always recommends that the policyholder reads the terms and conditions and policy wording so that they are familiar with all the conditions they need to adhere to, in order for full cover to be in force.

Professional bodies

As a medical professional your responsibilities are no different when it comes to your aesthetic patients. Section 10 of the NMC’s code states that all qualified practitioners must keep clear, accurate and secure records.6 Section 119 of the GMC ethical guidance for ‘Managing and Protecting Personal Information’ insists you must make sure any personal information about patients that you hold or control is effectively protected at all times against improper access, disclosure or loss.7 Section 4.5.1 of the GDC guidance maintains that you must make sure patient information is not revealed accidentally and that no one has unauthorised access to it by storing it securely at all times. You must not leave records where they can be seen by other patients, unauthorised staff or members of the public.8

Are

your

before and after photos accessible?

After you have got a secure storage system in place to keep your photos safe, you want to be able to access your patients’ images quickly and easily. Are you scrolling through photos on your camera roll, whilst hiding your screen from patients to stop them from seeing other patients’ photos?

This not only looks unprofessional and breaks GDPR regulations, it’s also extremely time consuming. Being able to gain access to your photos in a timely and organised manner will make life a whole lot simpler, even easier if they are attached to a patient record. In addition to the above, article five of the GDPR states that all data you keep needs to be in a format which makes it easy for you to locate, and must be stored securely whether it be in hard copy or electronic format. It should not be accessible to unauthorised people and should be stored in such a way that it cannot be accidentally lost, damaged, or destroyed.9 Your patients’ before and after photos should only be accessible to people within your business that have a legitimate reason to view them such as the treating practitioners.

The GMC’s good medical practice guidance states that you should not share passwords or leave patients’ records, either on paper or on screen, unattended or where they can be seen by other patients, unauthorised members of staff, or the public.10 You should make sure that any staff you manage are trained and understand their responsibilities when it comes to handling patient photos.

When do you need consent and why?

Before and after photos are taken primarily for the purpose of treating that particular patient, and forms part of their patient record. Consent to having these photos taken and stored should form part of the patient’s treatment consent. Images of this kind are considered necessary for treatment to be carried out.11 However, if you are looking to use your patients’ photos for other purposes, then you must obtain explicit consent from your patient detailing how and where photos will be used. By showcasing your results to potential patients, this highlights your work and helps to bring in new enquiries.11

You should explain to your patient that you would like to use their photos for marketing purposes, being transparent and clear about where they may be used, for example on social media, your website or on leaflets.12 It is important that you obtain explicit consent, via a consent form which includes their signature with a date and time stamp. The consent form should explain where and how you intend to use their photographs, in clear language that patients can understand. This gives you written evidence that your patient has agreed for the photos to be used. It’s important that the consent form includes a confirmation statement validating they have understood what you have explained. By doing this, you protect yourself from issues that could occur if a patient changes their mind about your right to using their image. In this situation, you must make it easy for patients to withdraw consent at any point; you can do this by having a clinic software in place which gives patients the option to click a button to withdraw their consent which is recorded with a date and time stamp. This leaves you with an audit trail for the period of time where the patient was happy for photos to be used.13 The British Association of Cosmetic Nurses (BACN) highlights in its ‘Code of Professional Conduct’ that a written informed consent from the individual to whom they provide treatment before capturing images.14

Protect yourselves and your patients

It is important your business has a robust photo process in place. Remember these photos not only support the professional image of your business, but provide protection against your professional register and insurance. Photos should be accessible and stored on an encrypted server which cannot be accessed by unauthorised parties. In addition, a clear photo consent which outlines your photo policy that allows patients the freedom to accept or withdraw consent should be introduced. By regularly reviewing your processes within your business, a solid foundation can be created that not only supports GDPR but also your insurance policy. TO VIEW THE REFERENCES GO ONLINE AT WWW.AESTHETICSJOURNAL.COM

Jo Hayward is an aesthetic nurse prescriber and the founder of Aesthetic Nurse Software (ANS), a clinic management system designed specifically for aesthetic practitioners. Hayward has practised in the aesthetics industry for more than 10 years, alongside building ANS to support other aesthetic practitioners to manage and grow their business. Qual: RGN, NIP

Understanding Marketing Automation

Benefits of automation

There are no fewer than eight (fairly interrelated) good reasons for automation and the value it can bring to your business:

1) It saves time – and that’s the one commodity that aesthetic practitioners constantly tell us they don’t have!

2) It cuts errors – everyone makes mistakes, and we all know what it’s like to take a double booking, for example. Automated systems reduce errors like this.

3) It means you can do more of the things you’re good at – aesthetic practitioners are trained professionals. You became an aesthetic practitioner to practise your expertise, not to be an accountant, marketer or customer service agent (although most of us enjoy some of these aspects of the job, too). Automations buy you back time to do the parts of the job which most appeal to you.

4) It improves the patient experience –today, we all expect to be able to make bookings and understand the services on offer online from our phones, for example. If you can’t offer that, then you’re not looking after your patients and probably losing business too.

Being an aesthetic practitioner can be extremely busy. You already have to spend hours on CPD-accreditation to stay on top of clinical developments and, attend conferences and events, as well as the usual clinic hours. Working on the business is an extra burden, and marketing and software can be particularly challenging. Today, there are more than 9,000 pieces of marketing software, so even professional marketers don’t have time to understand the whole landscape.1 And yet, it’s a crucial discipline for building a healthy flow of customers. That’s why the marketing buzzword of 2022 is automation: ways to get those big marketing jobs done in less time, and even keeping the business moving while you’re asleep. In fact, 80% of automation users see their leads increase, directly improving profitability.2

In this article, we’ll look at the software and strategies even the smallest practice can put in place to unlock more sales with less effort.

What is automation?

Automation is a catch-all term for a raft of technologies which are united by the fact that they reduce the need for human intervention in getting everyday jobs done.

Once upon a time, that automation meant robots in factories. That is, unsurprisingly, expensive – and not particularly useful for aesthetic practitioners. In future, it will mean technologies right at the cutting edge, like artificial intelligence. Right now, that, too, is expensive and complicated (although it won’t be forever).

Today, though, there is luckily an easier middle-ground. We are in a perfect moment where technology has advanced enough to make a range of essential activities simpler at an exceptionally low cost – the sorts of activities which aesthetic professionals need to do on a regular basis: finding customers and marketing to them, categorising your relationships with customers and taking bookings and payments, for example.

5) It promotes consistency – a brand (which is what you’ve created in launching your clinic, and your personal profile) is all about providing a consistent service. The first growth attempted by an aesthetic practice is usually to employ a front-of-house employee. Even the best employee isn’t going to be as committed as an owner, so automated processes enforce a greater degree of consistency to your patient-facing offer, bringing up standards in every customer interaction.

6) It cuts repetition – the most soul-destroying tasks are the repetitive manual ones which eat up time. They’re also the most error-prone. Automations minimise these tasks – freeing you up for more high-value activities which will move the needle on your profitability.

7) It extends your skills – following on from the previous point, given that time is what we all lack, buying it back with automation means you can get round to some of the jobs that would otherwise simply always drop off the end of your to-do list.

8) It works when you’re asleep – you can’t send out marketing emails or appointment confirmations by hand at 2am (and if you do, you’re headed for burnout). However, automated systems can.

Digital consultant Rick O’Neill explains how automation can make marketing and patient onboarding more effective

What? Brands Cost

Social media marketing Buffer Hootsuite Social Studio

Social media design

Booking/patient management software

Email marketing

£0 - £240 per year

· Canva Around £100 per year

· Collums

· Clever Clinic

· Bookmyclinic

· Aesthetic Nurse Software

· Campaign monitor

· Mailchimp

· Keap

Table 1: Some examples of automation website brands

Discovering automation opportunities

Varies. Circa £1,200 a year

personalised marketing, and with the messenger interface, you can encourage customers to get in touch – also setting expectations with a friendly automated response as to when you’ll be able to get back to them (useful if it’s 1am!). Better still, you can build chatbots which operate within messenger, and which will answer the questions you regularly face. You can even reply with videos from your team to offer a friendly and human answer to these questions. As this is likely the first time you’ll have had contact with a prospective customer, these unexpected touches can be hugely engaging and prevent walk-aways.

£0 - £350 per year

Booking management software

Booking or patient managements software allows online customers to directly book and cancel slots, and make those slots available with a single click on your website or social media. Most good systems will also:

All of this then begs the question: what should I aim to automate? Automation isn’t always a good thing. Last time you visited your doctor’s surgery, for example, you might have been pointed to a terminal in order to register your arrival. This is useful for the GP practice – it allows them to manage scarce resources around appointments. But the personal service and warm welcome at the reception desk is a crucial part of the customer experience in aesthetics. Digital tools are powerful – but not always the answer. Following on from the above list, take a little time to audit your typical activities across a day (e.g. appointments), week (e.g. marketing) and month (e.g. accounting reconciliations) and look for activities which are repetitive, error-prone, wasteful, boring, or which deliver a patient experience which is below what you would like to offer. The automation services which will solve these challenges are almost all:

• Digital: managed and delivered online.

• Pay-as-you-go: available for a reasonable monthly fee, so that you can budget predictably and assess the value to your business when compared to the cost of your time.

Automate marketing for more leads and more profits

Marketing is a particularly fertile ground for automation. Here are just some of the options on offer, broadly in the order of the sales process:

Social media marketing

You can use websites to automatically schedule your social media posts, meaning that you can post at times that suit your customers (such as 9pm on a Sunday evening), even when you’ve got better things to do!

It also enables you to post to all the main social media platforms, including Facebook, LinkedIn, Twitter, Pinterest, TikTok and Instagram, schedule a month or more of social media posts in one go, and see key statistics and insights on how to improve engagement.

Social media design

Social media design sites aren’t really an automation, but they’re still a huge time-saver, and it’s important that we cover them. They allow you to design eye-catching social media posts without any previous design experience and format your designs automatically for different social media platforms.

Facebook business pages

When a customer lands on your Facebook business page, the site knows who they are. This means Facebook is exceptional for

• Send calendar invites to customers, so that their appointment shows up on their phone diaries

• Send a personalised reminder by text message

• Email important information (such as patient questionnaires or cancellation policies)

Email automation

These tools automate the sending of emails on a timeline which you define. Connected to your booking system, you can automatically ask your patients to leave reviews on Google or Facebook (an important part of your ongoing marketing) a few days after they book, or indeed:

• Send aftercare information

• Invite them back, say, four weeks after a consultation

• Upsell them further services

• Get in touch if you haven’t heard from them for a while

• Send them interesting content periodically

• Send a ‘how did we do’ survey

• Ask if they can refer a friend

All of these are ways to maintain contact with customers and can also be customised according to their purchases or experience.

Utilising automation

You have many options for every conceivable marketing need, and whilst getting to grips with software might not be your top priority, it’s one of the few remaining low-cost ways to genuinely buy back time without employing more people. Marketing is also essential. Aesthetics is a competitive business, and with most customers making a purchase decision on their perception of your online brand and local convenience as well as the services you offer, finding and nurturing those relationships is crucial. Automation will help you manage this essential function and power up your business.

Rick O’Neill is a digital consultant to the medical aesthetics industry, working with brands such as Merz Aesthetics, Lumenis, Crown Aesthetics and many more. O’Neill is also co-founder of The Aesthetic Entrepreneurs, a community and business support platform for medical aesthetic practitioners, and founder and owner of LTF Digital, an award-winning digital agency focused on supporting medical aesthetics brands and clinics in the UK and internationally.

REFERENCES

1. Scott Brinker and others, Marketing Technology Landscape 2022 (US: Chiefmartec.com, 2022) <https://chiefmartec.com/2022/05/marketing-technology-landscape-2022-search-9932-solutionson-martechmap-com/>

2. Andrew Jones, Marketing automation: how to make the right buying decision the first time (US: VentureBeat, 2015) <https://venturebeat.com/2015/06/10/marketing-automation-how-to-make-theright-buying-decision-the-first-time-webinar/>

*Referring to the original CoolSculpting® system, CoolSculpting® is the world’s number one body contouring treatment, based on 2020 HCP tracking market research in Canada, Spain, UK, Australia, China, Japan and Thailand (N=1344), and Q1 2021 US tracking market research.1 2022 data due later on this year. †The CoolSculpting® ELITE System has a more powerful chiller than the original CoolSculpting® system, enabling simultaneous use of a second applicator.2 ‡This is based on the dual applicator feature of the CoolSculpting ELITE system, whereby two applicators can be used simultaneously per treatment, compared with the single applicator usage by the first-generation CoolSculpting® system.2,5 For example, two 35-minute cycles with CoolSculpting® ELITE applicators can be performed simultaneously (42 minutes total for treatment, including a 2-minute massage), whereas the equivalent treatment would be sequential with the first-generation CoolSculpting® system (74 minutes total for treatment, i.e. two 35-minute treatments and two 2-minute post-treatment massages).2,8,9 Therefore, time in the chair is reduced, with twice the number of treatments being performed in the same amount of time.

Important Safety Information

During the procedure patients may experience sensations of pulling, tugging, mild pinching, intense cold, tingling, stinging, aching and cramping at the treatment site.2 These sensations subside as the area becomes numb.2 Following the procedure, typical side effects include redness, swelling, blanching, bruising, firmness, tingling, stinging, tenderness, cramping, aching, itching, skin sensitivity and numbness. Numbness can persist for up to several weeks. A sensation of fullness in the back of the throat may occur after submental treatment.2 These rare and very rare adverse events have the following incidence rates (approximate occurrences per number of treatments): paradoxical hyperplasia (1/3000 [0.033%]), visibly enlarged tissue volume within the treatment area, which may develop two to five months after treatment, surgical intervention may be required; late-onset pain (1/6000 [0.017%]); severe pain (1/6000 [0.017%]); hyperpigmentation (1/11000 [0.009%]); freeze burn (1/15000 [0.006%]); treatment area demarcation (1/20000 [0.005%]); vasovagal symptoms (1/30000 [0 .003%]); subcutaneous induration (1/30000 [0.003%]); cold panniculitis (1/60000 [0.002%]) and hernia (1/185000 [0.001%]).2,10 The CoolSculpting® procedure is not for everyone. Patients should not have the CoolSculpting® procedure if they suffer from cryoglobulinaemia, cold agglutinin disease or paroxysmal cold haemoglobinuria.2 The CoolSculpting® procedure is not a treatment for obesity.3 CoolSculpting® is not a weight loss procedure and should not replace a healthy diet and active lifestyle.

1. Allergan. Unpublished data. INT-CSC-2150321. CoolSculpting market research. June 2021. 2. Allergan. CoolSculpting® system (CoolSculpting® ELITE) user manual. CS-UM-CM3-04-EN-D. February 2021. 3. FDA. K193566. ZELTIQ® CoolSculpting® System. January 2020. 4. Allergan. Unpublished data. INT/0586/2018 CoolSculpting® science and evolution. October 2018. 5. Allergan. CoolSculpting® system user manual. BRZ-101-TUM-EN4-H. December 2016. 6. Allergan. Unpublished data. INT-CSC-2050287. CoolSculpting® ELITE chiller specifications. July 2020. 7. Allergan. Unpublished data. INT-CSC-2050029. CoolSculpting® applicator dimensions and design information. May 2020. 8. FDA. K171069. ZELTIQ® CoolSculpting® system. July 2017. 9. Kilmer SL, et al. Lasers Surg Med 2017;49(1):63–68. 10. Zeltiq Aesthetics, Inc., An AbbVie Company. Full safety information: https://www.coolsculpting.com/pdfs/CSC146039-v2-CoolSculpting_Elite_Full_Important_Safety_Information.pdf [Accessed July 2022]. CoolSculpting®, the CoolSculpting® logo, the CoolSculpting® ELITE logo, and the Snowflake design are registered trademarks of Allergan Aesthetics. CoolSculpting® systems, applicators and cards are medical devices Class I or Class IIa CE0197. ZELTIQ® is part of Allergan Aesthetics, an AbbVie company. © 2022 AbbVie. All rights reserved. The suitability of CoolSculpting® treatment on an individual patient basis should always be considered as part of the assessment and consultation process. CoolSculpting® is not suitable for all patients. Please consult the Directions for Use prior to the procedure. Patient results may vary.

Ltd. UK_medinfo@allergan.com or 01628 494026

Growing up in Brazil, Dr Mauricio De Maio began his medical career at the School of Medicine, University of Sao Paulo. While he originally applied to the medical school to become a psychiatrist, during his fourth year, he became fascinated by plastic surgery and obtained a Master’s and a doctorate degree. “It was during this time that I saw how incredible a surgical transformation could be, and how making changes to a patient’s features that they were unhappy with, on the face or body, could lead to a change internally. I found this to be extremely powerful, so I decided to move into this area of speciality,” he notes. In the mid 90s, Dr De Maio noticed the rise in nonsurgical aesthetic treatments, particularly injectables, and began to branch out into offering non-invasive options.

However, after working in the industry for several years, he found that there was a lack of a systematic approach to performing these injectables. Passionate about both aesthetics and education, Dr De Maio decided to create his own system. “The use of injectables was expanding, but I found that there was a gap. Many patients were unhappy with their results or presented unfavourable outcomes, such as overtreatment. So, the MD Codes were created to bring the awareness that injectables could become an alternative to surgical procedures,” he notes. The MD Codes system are specific anatomical subunits for the injection of HA fillers in the Juvéderm range. Each MD Code includes information regarding the target depth of injection, the proper delivery tool and delivery technique, as well as the minimum product volume recommended to achieve visible, reproducible results.

Dr De Maio also believed that proper education was needed to help other practitioners implement the use of the

MD Codes, and so he also developed a curriculum alongside these. He explains, “Technical upskilling in this field is a long journey, due to the variety of patient faces, age groups, genders, and ethnicities. As a result, the MD Codes curriculum was built to provide support to injectors globally.” Alongside this, Dr De Maio travels around the world with pharmaceutical company Allergan, with whom he is a key opinion leader with, in order to train injectors and share his techniques through masterclasses and demonstrations. His constant travelling has led him to learn new languages, noting, “Learning different languages has enabled me to communicate with individuals from around the world without any barrier and therefore helps the MD Codes to become a universal language.”

In 2019, Dr De Maio launched new specific MD Codes strategies, including the 7/9-point Shape, MD Codes Lip, and MD Codes Look. In the future, he says he plans to continue to provide global education for the industry and notes the importance of all healthcare professionals (HCPs)

Hobbies outside of aesthetics…

I find philosophy very interesting; and I’m currently trying to play the piano.

Favourite treatment to perform… Those that may replace or provide an alternative for surgery, such as the correction of eyebags or the double chin.

Favourite thing about aesthetics… The reaction that the patients have after treatment, I feel like we are bringing back something that they have lost.

educating themselves to improve their skills. “Aesthetic practitioners must learn the best techniques, as well as alternatives, and measure their success rate,” he says, adding, “I believe that this big change will happen when HCPs begin to understand their social responsibility, as it can have a massive impact on patients’ lives. It is also important to remember that no matter what emerges in terms of trends and demands in the facial aesthetics field, education and technical upskilling among physicians is key to achieving optimal outcomes for patients.”

Dr De Maio adds that in the next 10 years, he hopes that the aesthetics industry will become more mainstream. “A bit like dentistry, it would be a dream for me to see medical aesthetics become part of everyday life – just like the way we brush our teeth daily. A report published recently highlighted the inclusive and diverse direction the field is moving towards, making the field more accessible to all.”

On his advice to those starting out in the industry, Dr De Maio explains that over his time in aesthetics he has noticed the importance of practice and truly understanding each individual patient. He says, “Something that I have learnt during my career is that when patients come to our clinics complaining about the things that they don’t like about their face, it doesn’t mean they will be happy with the correction of these tiny details alone. It took me a while to understand that what is important is not to erase lines but to aim to change the unfavourable messages of the face, for example if the patient looks tired, angry, or sad. This for me is the formula for young injectors to start paying attention to and should not take decades to figure out like it took me!”

“It would be a dream to see medical aesthetics become part of everyday life”

In an exclusive interview with Dr Mauricio De Maio, he discusses the creation of the MD Codes and where he sees the industry going in the future

The Last Word

Preventing complications is a hot topic in aesthetic medicine, and practitioners are constantly seeking out new methods for ensuring that they keep their patients safe while obtaining optimal results. In recent years, aspiration has emerged as a technique for avoiding a vascular occlusion, but the effectiveness of the method has been greatly debated amongst practitioners.1 In this article, I will outline what I believe to be the pros and cons of aspiration and discuss whether practitioners should be implementing it as part of their clinical practice.

The benefits

Aspiration refers to the technique where prior to an injection with dermal filler, a practitioner fixes the needle into the position on the skin where they are about to inject, pulling back on the plunger of the syringe (typically for 5-10 seconds) to ensure that no blood has pulled back into the syringe.2 If blood appears in the syringe after doing so, it implies that they might be entering into a blood vessel. This method is considered by some to be extremely useful and important when it comes to complication prevention, because it can serve as an indicator of whether the area is safe to inject or if it could cause a vascular occlusion.2 Personally, I have seen a few positive aspirations throughout my career, which has stopped me from performing an injection that may have been extremely dangerous for the patient. On a separate note, I also find that my patients respond well to me aspirating because they are aware that I’m really taking their safety into consideration. Particularly for my more anxious patients,

explaining what I am doing and why I’m doing it can help to put their minds at ease to see that I am doing all I can to ensure they have no negative outcomes.

The drawbacks

While aspiration can be incredibly useful, some practitioners may be hesitant to use the technique due to the possibility of a false result, which could lead the practitioner into a false sense of security.3 Many things can impact the outcome of aspiration, including the size of the needle or any movement from the initial position.3 In addition, there may be prevention of blood flow due to the type of filler in the needle. This can be affected by product rheology, such as viscosity – those with a higher viscosity may take a few more seconds than other fillers to produce blood after aspiration. There is also the potential for the needle to be sitting in a collapsed blood vessel, which means blood will not be produced during aspiration and therefore the practitioner will think it’s safe to inject into.4 As such, it may be considered that the process of aspirating is unreliable. As well as false negative results, false positives can also be experienced if the needle tip is out of the vessel but continues to draw blood under the skin. However, the risk is minimal.2

Solutions

The choice of aspirating is down to each individual practitioner; however, I personally aspirate every time I inject because it serves as an indicator of whether I’m about to hit a blood vessel. With that being said, I don’t rely solely on aspiration as there is a potential

for a false result. As such, I implement other methods of prevention so that in the rare case of a false negative, I have done everything I can to ensure that the risk of causing a vascular occlusion is minimised. For example, I now always use an ultrasound device prior to dermal filler treatments, alongside aspiration, and ensure I have an in-depth knowledge of anatomy to make sure I am as confident as possible. Of course, ultrasound does come with its own considerations, but these are outside the scope of this article. Practitioners should also ensure that they are up to date on complication protocols should anything happen, and have the correct equipment to be able to deal with any adverse effects.5,6

It is important that all practitioners refine their technique for aspirating as I found that it can be quite difficult to begin with, and this will help to minimise the potential for false positives and negatives. To do so, I recommend that people attend relevant educational courses or training sessions run by experienced practitioners. A key point that I have learnt over the years is to keep a steady hand, which I find comes down a lot to the syringe you use, so practitioners need to find one they’re comfortable with. Practitioners should also take the time to research around their chosen filler and look at how it may react when aspirating so they can interpret the results correctly.

Overall, I believe that aspirating does have value in aesthetic medicine, but that practitioners should also experience the correct training and ensure all other preventative measures for complications are implemented so that in the event of any false results, their patient is still protected from any adverse events.

Dr Joanna Niciejewska has been a dental surgeon since 2002 and started practising aesthetic medicine in 2016.

Dr Niciejewska completed her MSc in Aesthetic Medicine at Queen Mary University London in 2020. She currently works at FTT clinic in Hamilton.

REFERENCES

1. Sepah et al., Aspiration in Injections: Should We Continue or Abandon the Practice, 2017, <https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5333604/>

2. Wang Y et al., 2022, Is Aspiration Prior to Filler Injection Beneficial, Aesthetic Surgery Journal

3. Ahmed El Housienny, Considering Dermal Filler Aspiration, <https://aestheticsjournal.com/cpd/module/considering-dermalfiller-aspiration>

4. Goodman GJ et al.,2022, Aspiration before tissue filler - an exercise in futility and unsafe practice, Aesthet Surg J

5. ACE Group World, Guidelines for the Management of Complications in Aesthetic Practice, 2017

6. CMAC, Guideline for the Prevention, Diagnosis, and Management of Acute Bacterial Soft Tissue Infections Following Nonsurgical Cosmetic Procedures, 2021, < https:// pubmed.ncbi.nlm.nih.gov/34980965/>

Dr Joanna Niciejewska debates the use of aspiration before performing dermal fillers

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Dr Munir Somji, Dr Medi Spa, London

Dr Dev Patel, Perfect Skin Solutions, Portsmouth

Dr Natalie Geary, The Light Touch Clinic, Surrey

Dr Sanjay Parashar, Cocoona Centre for Aesthetic Transformation, Dubai

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