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VOLUME 7/ISSUE 9 - AUGUST 2020

YOU

DESERVE IT

©2020 Allergan. All rights reserved. Model treated with JUVÉDERM®. Individual results may vary. Material developed and produced by Allergan.

WITH THE WORLD’S LEADING BRAND OF HYALURONIC ACID FACIAL FILLER*,1 Follow us on

@juvedermuk

*Based on healthcare professional (HCP) tracking market research, from over 1,000 HCP’s in the largest 13 aesthetic markets worldwide. 1. Allergan. Unpublished Data. INT/0771/2016(2). JUVÉDERM®, the world’s leading brand of hyaluronic acid fillers/ Feb 2019. Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.

UK-JUV-2050193 | June 2020

19500 UK JUVEDERM Aesthetics Journal August Cover Advert.indd 1

Understanding Myomodulation CPD: Mr Ali Juma explores muscle action and hyaluronic acid filler

Hydrating Skin with HA Dr Zunaid Alli discusses skin hydration and biorevitalisation

Consulting for Dermal Fillers Dr Raj Acquilla shares his ideas for successful patient consultation

13/07/2020 14:24

Overcoming Anxiety after COVID-19

Psychologist Kimberly Cairns considers stress in the workplace


Contents • August 2020 07 News

The latest product and industry news

15 Advertorial: Profiloplasty For All Patients With Stylage Fillers

Dr Ellie Sateei discusses profiloplasty to blanace patients’ profiles

16 News Special: Industry Voices Concerns About APPG

Aesthetics explores concerns raised by the specialty about the APPG BAW

18 Conference: Registration for CCR 2020 is NOW open!

Learn about CCR 2020 taking place on October 1-2

21 Funding Missions and Improving Education

Raising funds for Facing the World charity

22 Advertorial: Powering Up Your Business Post Lock Down With Thermage FLX®

The ‘new normal’: an opportunity to rethink the patient experience

CLINICAL PRACTICE 23 CPD: Understanding Myomodulation

Mr Ali Juma explores how muscle action may be influenced by HA filler

27 Hydrating Skin with HA

Dr Zunaid Alli evaluates skin hydration and biorevitalisation with HA

32 Conducting a Successful Consultation for Filler Treatment

Dr Raj Acquilla shares his concept for successful patient consultation

36 Treating Acne Using Botulinum Toxin

Dr Magdalena Szymanska Bueno explores botulinum toxin for acne

40 Case Study: Lower Face Rejuvenation

Nurse prescriber Nina Prisk describes her treatment approach to create a more balanced profile

42 Treating Hollow Temples with Filler

Dr Ciara Abbott shares techniques for treatment of the ageing temple

47 Case Study: Treating the Female Jawline with Threads

Nurse prescriber Yuliya Culley describes improving jawline definition

51 Assessing the Eye Before Blepharoplasty

Miss Elizabeth Hawkes discusses the ageing of the eye area

55 Introducing Carboxytherapy

Dr Olha Vorodykhina introduces carboxytherapy in aesthetics

59 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 61 Overcoming Anxiety Following COVID-19

Psychologist Kimberly Cairns considers stress in the workplace

64 Hiring a Clinic Coordinator

Nurse prescriber Julie Scott provides tips for recruiting a new team member

67 Understanding Telemedicine in Aesthetics Practitioners explore the use of technology for consultations 70 Assessing Your Clinic using Service Design

Business consultant Jack Garnham discusses the use of service design to improve aesthetic businesses

73 In Profile: Mel Recchia

CPD: Understanding Myomodulation Page 23

Mel Recchia shares her journey from performing arts to aesthetics

74 The Last Word: Body Dysmorphic Disorder Dr Danielle Davy discusses performing treatment on patients with BDD

Clinical Contributors Mr Ali Juma is a consultant plastic and reconstructive surgeon with 18 years’ experience. He served as an honorary lecturer at the University of Liverpool for nine years and as an examiner for the Royal College of Surgeons for seven years. Dr Zunaid Alli is an aesthetic practitioner with a background in general medicine, emergency medicine and oncology. Dr Alli is a key opinion leader and masterclass trainer for VIVACY UK and is the lead clinical trainer for Glow Aesthetic Training. Dr Raj Acquilla has more than 18 years’ experience in facial aesthetic medicine. He is a UK ambassador, global KOL and masterclass trainer for Allergan for botulinum toxin and dermal fillers. He has lectured and trained in more than 40 countries. Dr Magdalena Szymanska Bueno graduated in medicine at the Poznan University of Medical Sciences in 2009 and is a specialist in dermatology and venereology. She is a fellow of the European Board of Dermatology-Venereology (FEBDV). Nina Prisk is an aesthetic nurse prescriber, concentrating solely on injectables. She practises from her clinic Update Aesthetics in the South West, as well as at The Banwell Collective in Harley Street. Dr Ciara Abbott is the medical director and coowner of Barstable Medical Clinic in Essex and has worked in the aesthetic industry for the past nine years. She is an associate member of the British College of Aesthetic Medicine. Yuliya Culley is a registered general nurse and the founder of the Novello Skin clinic. She has experience in emergency, cardiology and dermatology nursing. Culley currently provides training through 4T Medical. Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon at the Cadogan Clinic in Chelsea, London. She also leads the emergency eye care service for the Royal Berkshire NHS Foundation Trust. Dr Olha Vorodyukhina is a dental surgeon and the clinical lead of Cosmetic Courses in the Midlands and a regular speaker at aesthetics conferences. Dr Vorodyukhina is a member of Save Face and the British Dental Association.


A healing touch Give a better class of aftercare to encourage more patients

Include Oxygenetix in your clinic 1. Pre-procedure Going through any procedure can be worrying. You can help relieve patient concerns by letting them know Oxygenetix can conceal signs of skin redness and bruising. Your patients will be able to walk out of a treatment happily covered and protected by Oxygenetix.

2. Post-procedure Apply Oxygenating Hydro-Matrix to kill bacteria, soothe burning sensations post CO2 laser resurfacing, and replenish moisture loss following treatment. Then apply Oxygenating Foundation to conceal damaged skin and aid the production of collagen and elastin. It creates an 85% breathable barrier, acting as a second skin to keep moisture in and bacteria out.

3. Everyday care Help patients recover faster and continue with their lives as they heal. Daily use will help to soothe their skin and promote healing. This is often the most important part for the patient. And with the best aftercare, you’ll deliver an even greater service that people will want to recommend.

Distributed by Meeting the needs of your business, delivering high satisfaction to your patients THE CLINICSOFTWARE.COM AWARD FOR AESTHETIC PRODUCT DISTRIBUTOR OF THE YEAR

Call us on 01234 313130 | info@aestheticsource.com www.aestheticsource.com


Editor’s letter Welcome back to your printed copy of Aesthetics! It’s been a difficult few months, so we’re very excited to see clinics reopening and companies getting back to business. We’re even more delighted that the Government has given the green light for Chloé Gronow events to go ahead from October, meaning Editor & Content we’ll be able to catch up with you in person at Manager CCR on October 1 and 2. Of course, the CCR @chloe_aestheticseditor operations team is working extremely hard to ensure we have all the necessary safety precautions and social distancing measures in place. Read more on p.18. In other good news, we’ve extended the Aesthetics Awards entry deadline to August 21! We know how busy you’ve been with getting your clinics ready to reopen, so thought an extra three weeks may ease the pressure. As always, we recommend making time to draft answers offline beforehand and ask a friend or colleague to proofread before you submit! If you have any questions don’t hesitate to get in touch.

One of the hot topics this month has been the All-Party Parliamentary Group on Beauty, Aesthetics and Wellbeing (APPG BAW). The group of parliamentarians formed last year, but has recently gained attention thanks to its inquiry into non-surgical aesthetic procedures in the UK. While many agree it’s great to see more action being taken to regulate the specialty, numerous medical professionals have raised concerns with the group’s funding and its joint approach with the beauty industry. With almost 700 practitioners signing a letter addressed to Matt Hancock on the subject, it is certainly something to follow in the coming months. Key details are covered on p.16. With patients returning for treatment (hopefully now with beautiful skin after the extra care they’ve given it throughout lockdown!), we decided to dedicate our clinical articles to injectable procedures. Statistics from manufacturer Cynosure indicate that 63% of consumers plan to return for aesthetic treatments within three months, while 85% said they will be back within the year. That’s not including new patients you may reach who, after spending months on video calls, are eager to address the ageing concerns they’ve now started to notice! So, let’s stay positive, practise safely and support one another as we move forward.

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

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

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 18 years’ experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer for botulinum toxin and dermal fillers.

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

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon at the Cadogan Clinic in Chelsea, London. She specialises in cosmetic eyelid surgery and facial aesthetics. Miss Hawkes also leads the emergency eye care service for the Royal Berkshire NHS Foundation Trust.

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

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

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

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

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

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

#Peels @ulianagout Such a pleasure to launch the inaugural International Peeling Society webinar series! Thanks to the 300 attendees from over 40 countries!!! Congrats to IPS president @oliverkreyden for organising such a fab event! #Training @cosmeticcourses We’re back! Midlands Clinical Lead @dr_olha teaching her first delegates at our Nottingham training centre #training #aesthetics #aesthetictraining #lovetolearn #welcomeback #Virtual @britishcollegeofaestheticmed WOW!! 100 Members in attendance for our first Member’s Zoom meeting. Thank you! We hope you found it useful. @ulianagout @glenedenmedicalaesthetics @skinwessex @ermeclinic @katybeardie @drmyers99 @paulcharlson #Diversity @dr_ifeoma_ejikeme This morning I spoke on sky news about the need for medical education to change to ensure doctors are properly trained to recognise diseases on darker skin types. There is a gap in medical education which means that most case studies are taught on Caucasian skin. #useyourvoice #allskintypes #skynews #medicaleducation #DrEjikeme #Mentor @leewalker_academy Amazing to have these beautiful people back in Liverpool on the mentorship program! #leewalkeracademy

Clinisept+ Mouthwash now available to aesthetic practitioners The UK distributor of Clinsept+, AestheticSource, is now supplying aesthetic practitioners with Clinsept+ Mouthwash. Previously only available to dental clinics, Clinisept+ Mouthwash is designed to deliver antimicrobial protection against bacteria in the mouth and can be used when performing perioral procedures, according to AestheticSource. Ross Walker, commercial director at Clinical Health Technologies, manufacturer of Clinisept+, commented, “Clinisept+ Mouthwash contains the same unique high purity hypochlorous chemistry as the Clinisept+ Prep & Procedure and Aftercare but at a concentration tailored specifically for intraoral use. As with all the Clinisept+ products, it provides highly effective oral cleansing and antimicrobial protection – for patients and practitioners. It is available in 600ml bottles to allow patients to rinse before and after their procedure.” Communications

Kendrick PR launches marketing toolkit Communications consultancy Kendrick PR has created a bespoke clinic marketing toolkit, available for practitioners to pay to download from the company’s website. The toolkit includes step-by-step guidance and tips to jumpstart clinic marketing, template materials for patient newsletters and blogs, as well as a bonus tool to support ongoing business growth and new revenue. The company explains that the toolkit is aimed at helping business owners to enhance customer engagement and their brand profile at this challenging time. Julia Kendrick, founder and CEO of Kendrick PR, said, “PR and marketing play a crucial role in launching and growing an aesthetic business, however many entrepreneurs struggle to find the time, budget and expertise to work ON the business whilst working IN it. With this in mind, we created this toolkit to help clinics back to their feet following lockdown, with a blend of expert marketing guidance, how-to instructions and ready-to-use templates to make re-starting clinic PR and marketing as easy as possible.”

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Celebration

New location revealed for the Aesthetics Awards

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Vital Statistics 65% of patients said botulinum toxin type A was the procedure they wanted most when clinics reopen (American Society of Plastic Surgeons, 2020)

The upcoming Aesthetics Awards, taking place on March 13, will be hosted in the glamorous ballroom of the Royal Lancaster Hotel, London. This will be the first time the location of the prestigious ceremony has moved in its seven-year history, offering a fresh and exciting evening for both regular attendees and those new to the specialty. The Awards will take place after the second day of the Aesthetics Conference and Exhibition (ACE), held at the Business Design Centre (BDC), with sessions finishing early to allow delegates plenty of time to get glammed up! This is the first time that the Awards and ACE will be held together, promising to make it the biggest weekend in the aesthetics calendar. Attendees can easily travel from the BDC to the Royal Lancaster Hotel by taking the tube from Angel station to Paddington station, or a short 25-minute taxi journey. Alison Willis, director of Aesthetics Media as part of Easyfairs, said, “We are very excited to be moving to a new venue this year. The Royal Lancaster is renowned as one of Europe’s leading venues, located right next to Hyde Park with excellent transport links. The stylish ballroom has recently been refurbished and will be the perfect setting to bring the aesthetics specialty together for a fabulous evening of celebration and entertainment. The Aesthetics team looks forward to seeing you all there!” Entry to the Aesthetics Awards has been extended to August 21. Visit aestheticsawards.com for more information and to book your tickets to the ceremony.

94% of 2,352 respondents said they wanted to keep remote consultations and follow-ups after lockdown to reduce the amount of contact time with practitioners (Save Face, 2020)

The use of Instagram as a news source has doubled since 2018 (Reuters, 2020)

60% of 10,000 participants spent longer on their skin routine during lockdown (Glossybox, 2020)

Lip enhancement

VIVACY UK launches new competition Aesthetic product manufacturer VIVACY UK has launched an international competition for practitioners to submit their best lip enhancement results using STYLAGE Lips and STYLAGE M. All entries will be assessed by the CEO of VIVACY Michel Cheron; VIVACY chairman Waldemar Kita; marketing and communication director for VIVACY international, Vera Tual; key opinion leader Dr Zunaid Alli and general surgeon Dr Mimi Ehrenraich. The winner will be offered an all-inclusive trip to the VIVACY factory in Archamps. Camille Nadal, VIVACY UK director, said, “We are very excited about all the positives changes happening at VIVACY UK. We think this competition is a great way to create a positive campaign after the lockdown, expose our brands to a wider audience and generate more demand from patients!”

Only 1 in 7 American women have heard about breast implant-associated anaplastic large-cell lymphoma (Plastic and Reconstructive Surgery, 2020)

More than 12,000 Instagram posts were removed per quarter in response to guidelines over botulinum toxin advertising (ASA, 2020)

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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

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

www.merz-aesthetics.co.uk M-BEL-UKI-0740 Date of Preparation January 2020

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


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Events Diary

1 & 2 October, ExCeL www.ccrlondon.com

1 2 RCH & 1 3 12 M A&R C H 2 02 L O N D ON ON MA 13, 20 2 11 |/ LOND AESTHETICSCONFERENCE.COM

Dermal filler

Restylane Kysse receives positive feedback

Hyaluronic acid dermal filler Restylane Kysse, produced by global pharmaceutical company Galderma, received high subject and partner satisfaction, according to new phase 4 study results. The phase 4 ‘Kissability’ study, conducted by Galderma, collected questionnaires sent to 56 subjects older than 21 who had been in a steady relationship for at least six months. Their partners also completed the study. It evaluated a subject-assessed Global Aesthetic Improvement Scale eight weeks after the procedure, as well as photographic review of naturalness of expression, age and lip texture. According to the survey, 98% of subjects reported they were satisfied with the ‘kissability’ of their lips, 96% of subjects found their lips had a natural look and 87% felt more attractive after the fillers. The filler was approved by the FDA for lip augmentation and the correction of upper perioral rhytids in May this year.

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Conference

CCR to become first UK aesthetic conference to go ahead CCR will be one of the first conferences in the UK to be held since March following the UK Government’s recent announcement allowing business events, conferences and events centres to reopen from October 1. CCR, as part of Easyfairs, will take place on October 1 and 2 at the ExCeL centre in London and has signed an agreement with SGS, the world's leading inspection, verification, testing and certification company to ensure the safety of all delegates attending the conference. Easyfairs explains that in order to create the safest possible environment for attendees, SGS will verify CCR and ExCeL’s hygiene and disinfection protocols, validate training plans for employees on implementation of the enhanced health and safety protocols and develop a control and monitoring program to ensure these standards are maintained. Alison Willis, director of CCR as well as Aesthetics Media, as part of Easyfairs, commented, “Health and wellbeing are our top priority, and we are doing everything to make our conference the cleanest and safest place to meet and do business. We want to be sure that everyone who attends CCR not only has an easy visit, but a safe visit. To this end, we are putting our trust in SGS, the global benchmark for quality and integrity.” The SGS agreement will also apply to next year’s Aesthetics Conference and Exhibition, taking place on March 12 and 13 at the Business Design Centre, Islington. Jeremy Rees, CEO at ExCeL London, said, “Having played a full role in supporting the NHS we are now looking forward to playing an equally active role in the nation’s economic recovery. We look forward to hosting safe, secure, and successful business events and conferences from October 1 onwards.” Recruitment

InMode announces new KOL Medical device manufacturer InMode has appointed Dr Munir Somji as a key opinion leader for the company. Dr Somji is founder and chief medical officer of DrMediSpa, which he launched in 2014. Dr Somji said, “I’m excited to work with InMode’s products, showcasing and teaching new techniques and indications. Having worked with their portfolio for a number of years, I’ve discovered a novel approach to combining the InMode platforms for optimal patient results.” Neil Wolfenden, general manager at InMode UK, commented, “We are pleased to have Dr Somji on board as a key opinion leader for our radiofrequency FaceTite and Morpheus8 technology, and draw upon his wealth of clinical experience in facial/body contouring and skin tightening.” Education

AestheticSource launches online CPD-accredited training Aesthetic distributor AestheticSource has launched a new website section to continue to provide its customers with evidence-based, CPD-accredited online webinar training. The courses available include: Understanding Topical Retinoids and their Effectiveness in Skin Rejuvenation with nurse prescriber Anna Baker, Consulting with your Skin of Colour Client with aesthetician Dija Ayodele and The Science of Personal Change and Wellbeing: Finding Your Flow For Success with ophthalmologist Dr Daksha Patel. Vikki Baker, marketing manager at AestheticSource, commented, “Our focus at AestheticSource is to share our educational content with our customers and give some breathing space away from live webinars, allowing them to concentrate on getting their businesses back in shape as lockdown is eased.” Additional practical and post-lockdown courses will made available on the site, such as an RRS Refresher for RRS-trained practitioners.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Dermal filler

BioScience filler range gets CE mark extension Aesthetic product manufacturer BioScience GmbH has received the European Commission approved CE mark extension for all its hyaluronic acid based dermal filler ranges HYAcorp, Genefill and HYAprof. The CE mark is a symbol applied to products to indicate that they conform with relevant EU directives regarding health and safety or environmental protection. Dr Eyad Al Mchrif, CEO of BioScience, said, “The extension of the CE mark is not only an important milestone for our company but also a validation to the critical need for verified products in the aesthetics industry. We believe that the growth of our industry should be primarily about the quality, not quantity and only demanding legislation and tight regulations can ensure that.” COVID-19

Survey indicates patients are eager to resume treatments A survey conducted by laser manufacturer Cynosure has suggested that the majority of consumers are eager to resume treatments after lockdown, with 85% of global respondents indicating they plan to return to aesthetic treatments within 12 months of restrictions being lifted, and 63% saying they would be willing to return to practices within three months of restrictions being lifted. The Return of Aesthetic Patients Post COVID-19 report is based upon the responses of 3,000 aesthetic patients across the US, the UK, Spain, South Korea and Australia. The company also evaluated the best ways for clinics to make patients feel safe, with 36% of patients saying they would feel more reassured if people in waiting rooms were required to wear masks, and 34% would like to receive proactive communications and reassurances around in-office disinfection and safety procedures from their practices. Hyaluronic acid

Mesoestetic launches new filler Pharmaceutical company Mesoestetic has launched the mesofiller periocular, a new cross-linked HA dermal filler. The company explains that the product contains 15 mg/ml of fully cross-linked hyaluronic acid which is designed to give a softer filling, greater adaptability to high-gesticulation areas and can be used for correcting the frontal and periocular area. Mesoestetic performed a clinical study on 16 volunteers for rejuvenation of the periocular area, which they state showed a 100% improvement of the patients and achieved a long lasting result after 12 months. The company noted that treatment safety was evaluated immediately after treatment and after 100 days, with only local, mild and transient skin effects. According to mesoestetic, the mesofiller range is developed using densiMatrix technology, which binds HA molecules by BDDE, has a process to remove the unused BDDE that did not react and measure its residual concentration, and creates gel fractionation into particles.

1 + 2 OCTOBER 2020 | EXCEL LONDON

J O I N US AT CCR The UK’s only multidisciplinary event for surgical and non-surgical aesthetics

REGISTRATION FOR CCR NOW OPEN The time has come for us to get back to business, open clinics, and start to shift from the virtual world to live face-to-face learning. So, CCR will return this October where the non-surgical and surgical medical aesthetics community can re-ignite business, discuss mutual challenges and give their clinics a kickstart for a successful 2021. Visitor registration is officially open for the meeting which will take place at its new location, ExCeL, London. The event is all set for 1 & 2 October 2020 with enhanced safety, sanitary and social-distancing measures in place. You can find the full safety protocols on the website: ccrlondon.com.

SHOW HIGHLIGHTS CCR will feature world-class education from leading surgical and non-surgical experts in the field of aesthetics. There will be new speakers, new masterclasses, PR and media learning opportunities, networking events, and more. The agenda currently includes a one-day video cadaver training course with industry guru Dr Tapan Patel; facial aesthetics masterclass with Dr Bob Khanna; how to run a clinic on a shoestring budget with aesthetic nurse Emma Coleman; and a practice management theatre featuring interactive sessions to help get business back on track.

SPEAKERS SAY… We spoke to Dr Bob Khanna who commented: “I can’t wait to host The Dr Bob Khanna Aesthetic Masterclass at CCR this year. It will be the first time the aesthetics community comes together after a long time and finally seeing people for face to face learning will be fantastic. I know that lots of companies are waiting for CCR to launch their exciting new products and hence there’s a lot of new educational material, in terms of techniques and updates to teach the delegates. It will be an event to remember...”

c c r lo n d o n . c o m

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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

MEMBERSHIP The BACN has been overwhelmed with the number of new practitioners joining the association, along with a fantastic response from those renewing their membership. Thanks to each and every nurse who has joined or renewed – the BACN can only exist by the support of its members, and we remain committed to supporting aesthetic nurses through the COVID-19 pandemic and beyond. If you haven’t renewed yet, you can do so by logging into the BACN website and following the instructions.

RESOURCES The Nursing and Midwifery Council (NMC) recently recommended aesthetic nurses seeking advice on reopening their clinics refer to guidance issued by the BACN. There are a number of resources produced to aid members, including webinars of key financial issues to consider when returning to business. The BACN has also been busy submitting responses to Health Improvement Scotland (HIS) on its consultation on the role of medical and non-medical practitioners in aesthetics, along with a detailed response to the All-Party Parliamentary Group (APPG) on Beauty, Aesthetics and Wellbeing on the future of non-surgical treatments. All resources and responses can be found in the members’ area of the BACN website.

REGIONAL DIGITAL CONFERENCES The BACN regional meetings are hugely popular and for this Autumn, all regional events will be moved to a virtual conference platform. Events have remained within a regional structure so that members have a familiar setting for peer-to-peer review, sponsors can introduce members to the relevant company representatives and regional leaders can present news and information from HQ. Members are encouraged to book any conference they are able to attend. More details of each digital conference can be found via the BACN website under Events, or by contacting Tara Glover, BACN Events Manager at tglover@bacn.org.uk. This column is written and supported by the BACN

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Healthcare

COVID-19 screening bot launches for aesthetics Moneypenny, a telephone answering and live chat provider for healthcare sectors, has launched a new online COVID-19 self-screening bot. The company explains that the tool will help clinics and surgeries check that members of the public are in good health before they visit. This will be done by asking whether the potential patient is self-isolating, has any COVID-19 symptoms, has come into contact with anyone who has or is suspected of having the virus, or if they have been feeling unwell. Healthcare providers can choose to integrate the bot into their online booking system, or share a link to a brand-customised page which hosts the bot. Users access full analytics via their own individual portal and receive a real-time response email for every completed questionnaire to their chosen email address. Joanna Swash, chief executive officer of Moneypenny, said, “We’ve developed this tool specifically to offer extra reassurance and give confidence to the sector and because it seemed a very natural extension to the support we already offer healthcare businesses. This is not a substitute for observing social distancing and extra hand hygiene, but an extra layer of safety and due diligence to help the healthcare sector operate safely. With an incredibly simple set up that takes less than 24 hours and no long-term contracts, we expect the screening bot to be a very welcome tool.” Online learning

Merz launches new webinar series Global pharmaceutical company Merz Aesthetics has announced its next series of webinars, taking place throughout August. Each webinar will focus on using BELOTERO in clinical practice, with practitioners sharing their clinical insight and experience as well as delivering evidence-based presentations. This will then be followed by injection technique videos of cheeks, chin, nasolabial folds and marionette lines. The webinars will be hosted by nurse prescribers Julie Redmond and Emma Chan, and aesthetic practitioners Dr John Tanqueray and Dr Kim Booysen. The talks will be taking place on August 4 and 11 at 10am, August 18 at 8pm and August 25 at 12pm, and will each count towards one CPD point. Industry

Allergan appoints new UK general manager Fernando Alvarez has been appointed as the new UK and Ireland general manager for global pharmaceutical company Allergan Aesthetics. Alvarez joined Allergan seven years ago in the Iberia team, previously working as Iberia country manager. He commented, “As I step into this new role, I am truly excited for the future of Allergan Aesthetics, now an AbbVie company, and I have no doubt that the acquisition will positively impact the future of this company, our customers and patients. We are extremely proud of everything we have accomplished so far, and for the broad portfolio of products that we continue to manufacture and sell. Now, as we operate as a dedicated aesthetics company, within AbbVie, we can focus on being even more innovative and committed to excellence.”

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Health

VIVACY appoints new product specialist Aesthetic product manufacturer VIVACY UK has appointed Victoria Van Herp as its new product specialist for the north of England. Herp has been working in the beauty industry for the last five years. She commented, “I am extremely excited to announce that I have joined the VIVACY UK team supporting the north of England. I am proud to be part of such an innovative and familyoriented company at the forefront of the global hyaluronic acid market. Camille Nadal, UK director at VIVACY, said, “We are delighted to welcome Victoria in our team! I have no doubt that she will be a great addition to the sales team and that she will be a perfect fit for the VIVACY family that I am proud to see growing!” Virtual consultations

BAAPS issues warning against online consultations The British Association of Aesthetic Plastic Surgeons (BAAPS) has reported an increase in demand of 60-70% for virtual consultations, but urges patients and surgeons not to place convenience over safety. BAAPS vice president and consultant plastic surgeon Miss Mary O’Brien said, “If patients are booking Zoom consultations with surgeons based a significant distance away from where they live, there needs to be consideration of where the actual surgery will take place and how they can access post-operative care in the event of a complication if they have been treated a long distance away.” In order to encourage patients to come into the clinic, BAAPS advises making protocols clear. For example, a period of isolation before surgery and taking nasal swabs two days before an operation. BAAPS president and consultant plastic surgeon Mr Paul Harris commented, “These extra layers of protection from reputable surgeons ensure that patients get good outcomes while at the same time preserving their safety. This may result in more inconvenience for patients and staff, however, these factors are inherent in maintaining safety for patients in the new coronavirus world.”

ZENii launches new supplement Skincare and supplement company ZENii has launched a new food supplement called Immune Defence that aims to help boost the immune system. Immune Defence contains vitamin C, vitamin D, vitamin B6, vitamin E, zinc, magnesium, selenium, lactobacillus acidophilus, acerola cherry, black pepper, olive leaf, turmeric, cayenne, astragalus root, reishi mushroom and ginger. Dr Johanna Ward, founder of ZENii, commented, “In early March I set out to create a supplement that would help to powerfully support the immune system and help to create immune resilience. Our new supplement Immune Defence is a full spectrum immune support supplement that blends scientifically evidenced vitamins, minerals, probiotics and herbs that are known to have a beneficial impact on the immune system. Immune Defence takes the guess work out of trying to figure out what combination of supplements to take for immune support and in two convenient capsules a day gives you valuable peace of mind.” Injectables

Croma submits toxin for EU approval Pharmaceutical company Croma Pharma has submitted its botulinum toxin drug file to the German Federal Institute for Drugs and Medical Devices (BfArM), for approval for the treatment of glabellar lines in the EU. The company explains that the submission is based on two completed Phase III pivotal trials conducted with a total of 917 subjects in the EU and the US. Keeli Wetton, sales business manager at Croma UK, said, “Croma Pharma UK are delighted with the news that our new toxin is one step closer to obtaining its license for use across Europe. With excellent efficacy results in the preliminary clinical trials, we are very much looking forward to bringing this product to market in 2021. We have a very experienced sales team who have all previously sold botulinum toxin and understand the needs of the healthcare professional very well.” Complications

Harley Academy launches online complication course Training provider Harley Academy has introduced a new e-learning course on preventing and managing dermal filler complications. The six-hour online course covers anatomy and pathophysiological concepts, as well as the latest management guidance on how to recognise side effects versus complications. According to Harley Academy, it will also outline the full spectrum of complications from early infection to neural problems, and how to manage complications in both critical and non-critical scenarios. In addition, real-life case studies will be presented by CEO and founder of Harley Academy, Dr Tristan Mehta and clinical director Dr Emily MacGregor. Director of education, Dr Kalpna Pindolia said, “We should never be afraid to learn from complications that happen to us and our colleagues, which is why we use real-life case studies that we’ve encountered at Harley Academy. You learn as the patient is managed and progresses, allowing you to embed a methodical approach to enable you to manage complications more confidently.”

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Skincare

Venus Viva becomes FDA cleared Global medical aesthetic company, Venus Concept, has received FDA 510(k) clearance to market and sell Venus Viva MD, a portable and versatile table top device. The company explains that the device can offer ablation and resurfacing treatments for conditions such as acne scars, dyschromia, striae and enlarged pores. Domenic Serafino, chief executive officer and director of Venus Concept, said, “The Venus Viva MD is a product we designed specifically for dermatologists and plastic surgeons, which leverages our strong skin rejuvenation offerings in Venus Viva and Venus Versa, but offers differentiated features that allow clinicians in the traditional medical aesthetics community to treat a wider range of skin conditions.” Venus Concept has stated that the Venus Viva MD will become available in the UK, but a release date it yet to be set. Online learning

ZO Skin Health training goes digital Distribution company Wigmore Medical has announced changes to its training programme for skincare range ZO Skin Health in response to COVID-19. According to the company, all theory-based learning will now be moved online permanently, including the core training webinar and tutorials on specific products, protocols and indications. Wigmore Medical is also introducing the ZO Business Faculty; an online resource available only to delegates with ZO accounts that will provide support for topics such as branding, website design, social media and marketing. The company states that all training will be CPD accredited. Raffi Eghiayan, product development and marketing manager, commented, “Due to the pandemic we at Wigmore had to adapt to the needs of the industry. We feel that with this change of emphasis we will not only improve the standard of training but also increase our outreach to new accounts. It also enables clinics/practitioners to learn from home and use this downtime as an opportunity to upskill. With all the new initiatives we are planning we will be able to support new/old customers alike with fresh new content and support over the coming months.” Digital

Aesthetic Nurse Software introduces new feature Clinic management system Aesthetic Nurse Software has introduced a new online feature which allows clinics to send forms directly to patients via email, prior to their appointment. The company explains that these can then be completed remotely and submitted back to the clinic; designed to reduce the time patients have to spend in clinic and therefore reduce contact when re-opening. Practitioners can request patients to complete a COVID-19 wellness screening checklist, along with medical history questionnaires and consent forms. This allows the practitioner to assess any risks prior to the treatment date and therefore adhere to government and industry guidance. Co-founder of Aesthetic Nurse Software, Max Hayward, said, “We were inundated with requests for a feature that reduced the amount of contact between the practitioner and their patient, which included completing questionnaires and consent forms. I am proud that we have been able to give practitioners a solution that can assist them with reopening safely and support them to put new measures in place through these uncertain and worrying times.”

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News in Brief Cutera announces new KOL Aesthetic technology manufacturer Cutera has appointed Renée Lapino as a key opinion leader for the Secret RF fractional radiofrequency microneedling device. Lapino is an aesthetician and founder of Renée Lapino Clinics. She commented, “I am delighted to work alongside Cutera to launch this exciting new treatment to the UK market, and help raise awareness of its outstanding clinical capabilities. The Secret RF is a new treatment concept that complements my integrated approach to skin health, and perfectly fulfils a niche in my treatment offerings.” Lynton Lasers puts webinars online Equipment manufacturer Lynton Lasers has made its weekly webinar series available on demand for aesthetic practitioners. The series features talks from aesthetic practitioners Dr Ahmed El Houssieny and Dr Askari Townsend, consultant dermatologist Dr Nicholas Lowe, clinical director of Lynton Lasers Dr Samantha Hills and more. Hayley Jones, sales and marketing director at Lynton Lasers, said, “We are so proud of the success our webinar series has had in these uncertain times, with more than 2,500 viewers tuning into our lockdown webinars. The positive feedback from our viewers has been phenomenal.” Medical-Up launches new website New medical device and services distribution company, Medical-Up, has rebranded its website. The company explains that the new platform provides information about Medical-Up, its portfolio of products and the benefits to patients. Mickey Carlin, managing director of MedicalUp, said, “Our updated website truly is a reflection of where we are moving as an organisation. We hope that this new, sleek and modern website will help our customers to navigate our product portfolio and find information about us in a more accessible manner. After a challenging few months following the government lockdown, we’re now excited to be back in action.” Fagron hires new account manager Pharmaceutical distribution company, Fagron UK, has appointed Sharon Bosworth as its new account manager. Bosworth commented, “I’m really excited to have joined Fagron UK and have the opportunity to work with a product as innovative as TrichoTest.” Fagron UK general manager, Peter Batty, added, “We’re delighted to welcome Sharon on board. She has a wealth of experience in the aesthetic sector and is well placed to help us bring our innovative products to patients and clinics in the UK.”

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Advertorial VIVACY UK

Profiloplasty For All Patients With Stylage® Fillers Dr Ellie Sateei discusses profiloplasty to balance the profile of both older and younger patients Profiloplasty is a non-surgical, non-invasive treatment used to create a more balanced appearance to the face. Instead of surgery, dermal fillers are used for chin augmentation, rhinoplasty, and lip enhancement. Together, these alterations result in more balanced facial proportions for different age ranges. This is especially true for older patients who loose volume in their mid-lower face and wish to restore balance between their nose, cheeks, lips and chin. My preferred choice of fillers for projection are STYLAGE® L and STYLAGE® XL. I find that both these fillers move graciously with the muscles and mimic the area of injection without looking stiff. STYLAGE® L works wonders for older patients, as well as those with thinner faces, due to it being very soft, while achieving a beautiful lift as it is still very mouldable. STYLAGE® XL is hydrophilic, therefore the projection given is natural, as it adapts with the tissue. What’s especially great is that the STYLAGE® fillers do not swell. This leaves patients happier as their downtime is much less than any other products which I have used. To achieve profiloplasty, three to four sessions is recommended. I try not to inject too much at once, to allow the product to accommodate in the tissue, while respecting the patients’ natural features. Before

I tend to assess my patients based on the consultation; alongside their age, lifestyle, job, and ethnicity, which affect the target areas: cheekbones, lips, chin, forehead, and nose. What’s nice about the STYLAGE® Volumizer range is that the different products are composed of a specific rheology to suit a variety of patient profiles. There are softer products for mature patients and harder products for younger patients, which lifts and moulds it beautifully. This range of STYLAGE® products helps me plan a bespoke treatment for patients based on their age group, type of skin, elasticity and even their ethnicity. Profiloplasty demand is increasing due to patients leading very busy lives, who prefer not to go under the knife. Alongside the rise in online lifestyles, on Zoom meetings for example, where individuals are left looking at themselves from all angles. Therefore, injectables are the go-to solution for many people with multiple different reasons, as it really does cater to all. Individuals with a subtle change in mind could be treated with injectables and the other extreme of patients who wish to be reshaped completely, could also be treated by injectables. Dr Ellie Sateei is a UK aesthetic practitioner with more than 13 years of experience. She is also a VIVACY UK brand ambassador.

After

This advertorial was written and supplied by Vivacy VIVACYLAB.COM Medical Devices Class III, regulated health products bearing the CE marketing (CE 0344) in accordance with Medical Device Regulation.

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Concerns Voiced About APPG Aesthetics explores the concerns raised by the medical aesthetic community about the All-Party Parliamentary Group on Beauty, Aesthetics and Wellbeing It’s been an interesting month, to say the least. On July 3, the UK Government caused great confusion within the specialty by stating that ‘beauty salons’ were to remain closed, clarifying that this includes any premises providing ‘cosmetic, aesthetic and wellness treatments’.1 Just a few days later, the Government acknowledged there is a difference between medical aesthetics and beauty for the first time in history.2 The Department of Health and Social Care (DHSC) provided a statement to the British Association of Cosmetic Nurses (BACN), the British College of Aesthetic Medicine (BCAM), Save Face and the Joint Council for Cosmetic Practitioners (JCCP) clarifying that its COVID-19 regulation on remaining closed from July 4 did not apply to medical aesthetics.2 Throughout the COVID-19 pandemic, the All-Party Parliamentary Group (APPG) on Beauty, Aesthetics and Wellbeing has been active in liaising with the Government regarding the reopening of the industries.3 However, members of the medical aesthetic community have voiced concerns with the AAPG representing the specialty.

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Recent activity The APPG has been particularly active during recent months through COVID-19,6 and in the leadup to the July deadline of its call for evidence for its inquiry into UK non-surgical cosmetic procedures.7 This inquiry aims to review the scope and scale of botulinum toxin or similar anti-wrinkle injectables, dermal fillers, polydioxanone (PDO) threads and PDO cogs. It also looks to assess the adequacy of the regulatory and legislative structures and training around non-surgical cosmetic treatments in the UK, review the case for registration of practitioners, and consider the media and consumer environment for products.7,8 Following the inquiry, the APPG states that it will present a report to Government with recommendations for how to ensure necessary and professional standards are in place. Harris and Cummins said, “We are seriously concerned by the complete lack of robust, consistent and enforceable standards for undertaking treatments such as toxin and fillers. To make matters worse, there is no accountability or consequence for malpractice.” They added, “While the aesthetics industry continues to grow at a rapid pace, the absence of standards leaves practitioners with no support and customers with no guarantee of safety. We look forward to hearing further evidence in our inquiry on what action must be taken to address these issues. The Government has a duty to take action which is long overdue.”

About the APPG An APPG is a politically neutral crossparty group of Parliamentarians who are concerned about a particular issue; in this case, beauty, aesthetics and wellbeing. This APPG aims to promote, support as well as challenge the beauty industry in Parliament through regular meetings, and provide a platform that highlights and celebrates the industry. The group states that it also aims to provide a forum that explores the challenges impacting the industry, facilitating discussion, debate and action to overcome such issues. The APPG Parliamentarians include co-chair Carolyn Harris MP, co-chair Judith Cummins MP, vice chair Alberto Costa MP, vice chair Jessica Morden MP, vice chair Jackie Doyle-Price MP, treasurer Peter Dowd MP, secretary Nick Smith MP, and honorary member and former MP Jenny Chapman. The secretariat is run by public affairs consultancy firm Interel Consulting UK, which has experience in lobbying, and is funded by the National Hair & Beauty Federation (NHBF).4,5

Concerns from the medical aesthetic community Aesthetics has been made aware of a number of concerns raised by medical aesthetic practitioners in regards to the APPG. The concerns have been spearheaded by aesthetic practitioners Dr Tapan Patel and Dr Steven Land, who have sent a letter on behalf of medical professionals in the field to the Secretary of State for Health and Social Care, Matt Hancock MP. The letter had just under 700 signatures of support from medical aesthetic doctors, dentists, nurses and surgeons.9 Dr Patel says that although he and his colleagues welcome the APPG’s recognition that there needs to be improved standards around non-surgical cosmetic procedures, they believe there needs to be strict limitations to those with medical, dental or nursing degree, as the bare minimum. He explains, “We strongly object to the grouping together of the beauty industry and aesthetic medicine. The two may be associated but there are clear distinctions and we propose that these

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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distinctions be made clear in law.” He explains that there are significant differences between the aesthetic medicine field and the beauty industry. “Aesthetic medicine is performed in healthcare facilities. Beauty therapy is conducted in salons. Medical aesthetic clinics have patients, beauty salons have clients. The practices of medicine, dentistry and nursing are professions requiring a university degree. Applicants need to fulfil entry criteria, be selected by an institution, undergo training and then have the option of specialisation. Aesthetic medicine is one such field and is NOT an industry,” he voices. Another prime concern raised is the APPG’s funding. Dr Patel says, “Interel Consulting UK has been paid by the NHBF to act as secretariat. This is a huge conflict of interest.” He explains that he and his colleagues believe the conflict is particularly apparent in the circumstance of the APPG’s inquiry, as the NHBF appears to support members of the beauty industry injecting fillers and toxin.10,11,12 Among other points, Dr Patel and Dr Land are proposing to separate the APPG into two distinct entities; one for aesthetic medicine and one for the beauty industry. They also want to introduce and protect by law specific terminology that distinguishes treatments performed by a healthcare professional and those done by the beauty industry, ensuring that aesthetic treatments like toxin, threads and fillers can only be performed by a medical practitioner.9 As well as sending the official letter to Matt Hancock, Dr Patel and Dr Land have also submitted their concerns and evidence into the APPG’s inquiry on behalf of 20 of their colleagues. Thoughts from the associations Aesthetics spoke to associations within the medical aesthetic specialty to hear their thoughts on the APPG. Sharon Bennett, chair of the BACN, said, “In this unregulated field, the APPG is doing the right thing by looking at making the aesthetic profession safer and I applaud that they are reviewing education, training and products.” She adds, “However, it appears that the APPG lacks insight in that injectable aesthetic treatments and other high-risk aesthetic treatments are medical procedures which, at the most basic level, warrant an initial qualification to that of other medical specialties. The BACN does not support non-medical injectors because the dangers to patients are too great, they do not have the ability to medically assess nor understand underlying medical conditions, health or medications, and are not accountable to a

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statutory regulator.” The BCAM states that the Board has provided a detailed submission to the group’s inquiry into non-surgical cosmetic procedures and provided passionate oral evidence from Dr John Curran, past president of BCAM, at the most recent evidence hearing on July 7.8 The BCAM said in a statement, “The preponderance of non-medical beauticians engaged with APPG underscores the importance of the doctors and dentists of BCAM being the ‘go-to’ body for information, advice and guidance on medical aesthetics.” Clinical director of Save Face and aesthetic nurse prescriber, Emma Davies, stated, “Save Face cannot fault the intention and shares the concerns and frustrations of the APPG. However, with the greatest respect for any individual or organisation attempting to do something constructive to affect positive change, there needs to be a clear understanding of the political, policy and legislative process. Save Face does not feel the APPG is an effective platform to achieve the very specific goals the specialty needs as voiced by Dr Patel.” Aesthetics approached the APPG with the concerns raised and received the following response from APPG Secretariat Louise Abraham, “The APPG on Beauty, Aesthetics and Wellbeing is a cross-party group of Parliamentarians. The Group is run by and for the Parliamentarians, who consult a range of external organisations. All views expressed are those of the Group. The Group launched its inquiry into non-surgical cosmetic procedures to investigate how standards for undertaking treatments such as botulinum toxins and dermal fillers can be improved to protect public safety. Members of the APPG have heard representations from both medical and beauty practitioners to better inform the findings of the inquiry, with a view to raise standards for all in the industry.” The APPG did not respond to specific questions regarding its funding and concerns with combining ‘aesthetics’ with ‘beauty’ in the wording of the group.

The future of medical aesthetics Dr Patel believes that now is the time to lobby the Government for regulatory change. “It is vital the Government take action now or it may seem to be complicit in the next complication caused by a lay injector. Having a cosmetic procedure should be an informed decision but the availability of the procedures is getting uncontrollable. It is not too late to act now, but we do lose precious time with every passing day,” he says. Conversely, Davies isn’t so

sure that now is the right time for change. “Currently, the Government and policy makers have been consumed, first by BREXIT and now, by a global pandemic. Is now the best time to insist Government address this complex issue and the legislation we require? We must look at the steps we can take ‘inhouse’, to change public perceptions and influence public choices. We must focus on establishing a very clear distinction between beauty aesthetics and medical aesthetics. We need to gain more respect, by earning more respect.” Bennett also acknowledges that there is much the medical aesthetic community needs to do to ‘clean up the industry’ before the issues raised will be taken seriously by Government. She says, “Although we are medical professionals delivering medical treatments we must, as a community, demonstrate the seriousness of these medical procedures which has sadly been lost over the years by many medical professionals working outside of medical settings. The ideal would be to work collectively in medical/clinical settings moving away from other models of practice. This will, in time, shift public perception and normalise the delivery of these treatments back where they belong into the safe hands of medically-qualified accountable professionals, with the ability to manage complications in clinical settings.” REFERENCES 1. Kilgariff, S, New COVID-19 rules cause industry confusion about reopening, Aesthetics, 4 July 2020. <https://aestheticsjournal. com/news/new-covid-19-rules-cause-industry-confusion-aboutreopening> 2. Kilgariff, S, DoH informs associations that new COVID-19 regulations do not apply to medical aesthetics, Aesthetics, 6 July 2020. <https://aestheticsjournal.com/news/doh-informsassociations-that-new-covid-19-regulations-do-not-apply-tomedical-aesthetics> 3. The All Party Parliamentary Group On Beauty, Aesthetics & Wellbeing, 2020. <https://baw-appg.com/> 4. Parallel Parliament, Beauty, Aesthetics and Wellbeing APPG, 01/07/2020, <https://www.parallelparliament.co.uk/APPG/ beauty-aesthetics-and-wellbeing> 5. NHBF Welcomes Re-Launch Of Mps Cross-Party Group On Beauty, Aesthetics And Wellbeing, NHBF, 29 January 2020 <https://www.nhbf.co.uk/news-and-blogs/news/nhbf-welcomesre-launch-of-mps-cross-party-group-on-beauty/> 6. APPG BAW, News, 2020. <https://baw-appg.com/news/> 7. APPG BAW, Inquiry Call for Evidence, 2020. <https://baw-appg. com/inquiry-non-surgical-cosmetic-procedures/> 8. APPG BAW, Meetings, 2020. <https://baw-appg.com/meetings/> 9. Dr Tapan Patel letter to Rt Hon Matt Hancock MP Secretary of State for Health and Social Care. Sent on behalf of around 700 medical aesthetic practitioners. Letter On File. 10. Setting Up Your Own Beauty Business <https://www.nhbf.co.uk/ news-and-blogs/blog/setting-up-your-own-beauty-business/> 11. NHBF, The NHBF Urges Salons To Get Their Clients Clued Up On Cosmetic Procedures, 2019. <https://www.nhbf.co.uk/ news-and-blogs/news/the-nbf-urges-salons-to-get-their-clientsclued-up-on-cosmetic/> 12. Speech by Caroline Lawresy, director of National hair and beauty federation, BAW APPG inquiry into non-surgical cosmetic procedures: Session 2 – Standards and Qualifications, YouTube, July 17 2020, 12:30. <https://www.youtube.com/watch?v=Onz2df2JKWo&amp;feature=share&amp;fbclid=IwAR0gk8anaa0ysTgzJKFzekYSA2rusdq08OdGVPUY_ic-tejPhgIeEbr9D9c>

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Conference & Exhibition CCR

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1 + 2 OCTOBER 2020 | EXCEL LONDON

Registration for CCR 2020 is NOW open! CCR 2020 is firmly in the diary. It’s the first opportunity for the aesthetics specialty to come together, and preparation to deliver a safe and successful meeting is well under way. With an unprecedented level of interest from exhibitors and delegates, we’re looking forward to an exceptional programme and bumper turnout this year. There is an array of new and exciting elements added to this year’s CCR schedule; the UK’s largest annual meeting of surgical and non-surgical disciplines. There’s never been a more pressing time to register. Look out for the annual Aesthetics Awards winners announced at the event, the NEW CCR Aesthetics Press Conference, the web networking event, plus new speakers and hours of CPDaccredited educational content. Plus, after months of lockdown, CCR will provide the platform to more industry launches than ever before. It continues to be THE place to meet and network with peers and relevant aesthetic businesses and to find the latest equipment, products, techniques and more.

Calling all presenters Taking the stage this year we have industry stars such as Dr Bob Khanna, Dr Tapan Patel and aesthetic nurse Emma Coleman. Currently the content team at CCR is looking for both surgical and non-surgical practitioners to submit abstracts with a view to speaking at the event. If you would like to take part, please don’t hesitate to get in touch ASAP as speaker slots are limited. Visit ccrlondon.com to submit your abstract and find out more. The agenda currently includes the following highlights: • One-day video cadaver training course with industry guru Dr Tapan Patel of London’s renowned PHI Clinic • Facial masterclass with Dr Bob Khanna • Aesthetics journal editor Chloé Gronow will be putting together content with a clinic management focus to help get aesthetics businesses back on track post lockdown. The Practice Management theatre will be more important than ever featuring social media workshops, PR clinics, latest clinic software and technology, and safety and regulation updates.

Aesthetics Awards Finalists announced at CCR For the first time, the finalists for the prestigious Aesthetics Awards will be announced at CCR. Numerous clinics, practitioners, companies and products will be recognised and celebrated, in advance of the glamorous ceremony on March 13.

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CCR Press Ambassador Francesca White, Tatler Editor at Large and Editor of the Tatler Beauty and Cosmetic Surgery Guide “The new press conference element that I will be chairing for this year is hugely exciting, and will provide the first and only press-specific closed event to obtain news of all the pioneering and most cutting-edge research, launches and advancements in the aesthetics market. I expect it to be a hot ticket for 2020 and the subsequent years!”

CCR Safety Measures This year, CCR has incorporated new safety, sanitary and social distancing measures, so you can visit CCR with complete peace of mind. You can expect:

Allocated registration times

The NEW CCR Aesthetics Press Conference With an unprecedented amount of media interest at CCR last year, including representatives from BBC Breakfast, Talk Radio, This Morning, The Guardian and BBC Radio to name a few, CCR has developed a more structured press briefing format, open to any registering journalists. This unique closed event for consumer and trade health and beauty journalists offers a concise trend forecast and briefing at the first annual CCR Aesthetics Press Conference. With a Q&A session to follow, involving some of the industry’s most recognisable names, CCR is set to provide a completely unique and interactive forum to update and inform key, influential journalists. If you have a new launch, new protocol, compelling research or anything you feel could change the future of the aesthetics specialty please contact the head of the CCR Aesthetics Press Conference organisation team, Kate Zadah at kate@mantelpiecepr.com.

Directional walkways around the ExCeL halls

Sanitary measures including masks and hand sanitiser on entry and within the exhibition halls

Smart badge contactless technology which requires no physical contact

A Note for Your Diary Look out for our CCR networking event in August, held in a webinar format this year: • Hear what our Press Ambassador Francesca White, Tatler Health & Beauty Editor a Large and Editor of the Tatler Beauty and Cosmetic Surgery Guide, has to say about the future trends in the aesthetics specialty • Gain top tips on how to maximise the impact of your presence at CCR with PR and marketing advice from Mantelpiece PR’s founder Kate Zadah, and CCR’s own Easyfairs Head of Marketing, Aleiya Lonsdale • Learn about the 1st CCR annual press conference and find out how to get your brand in front of the national press at the show

For more information about CCR 2020 or for your complementary visitor’s pass, please visit the CCR website.

CCR 2020 brought to you by

www.CCRLondon.com

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Charity Facing the World

Funding Missions and Improving Education Raising funds for Facing the World charity The annual cost of medical care for children with birth defects averages $1.4 billion.1 While this is a staggering amount, small donations still make a huge difference to those affected. Facing the World explains that money raised go towards donating essential equipment, as well as funding missions for experienced medical professionals from the UK, US and Canada to go to Vietnam and treat these children in need. Most importantly, the donations give Vietnamese doctors and surgeons the opportunity to complete fellowships abroad to learn how to successfully treat facial differences and take their skills home to teach their peers. Did you know, it can take more than 19 medical professionals to treat one child? Significant facial disfigurements require various specialist treatments, ranging from surgery to psychology. A typical UK team consists of: • • • • • • • • • •

Craniofacial surgeon Otolaryngologist Neurosurgeon Anaesthetist Oculoplastic surgeon Paediatrician Paediatric dentist Audiologist Orthodontist Prosthodontist

• • • • • • • • •

Speech pathologist Psychologist Clinical geneticist Dressing nurses Intensivist Ophthalmologist Orthoptists Optometrists Theatre staff

Latest missions

Vietnamese professionals, they assessed 66 patients who were triaged and had treatment plans developed for them. Of the 66, 15 patients were operated on across both sites. Conditions treated included cleft lip and palates, hemifacial microsomia, traumatic injuries to the face and salivary gland tumours.

Figure 1: Images show just one example of successful treatment that has taken place on a Facing the World mission. Before and after bimaxillary surgery to address severe malposition of the jaws.

Facing the World is raising money to fund these missions to Vietnam. Show your support and help our chosen charity by donating today.

In November last year, a team of medical professionals from Canada visited the 108 Military Hospital to treat 11 patients in the space of a week. They worked with the hospital’s plastic surgery, anaesthesia, neurosurgery and ophthalmology departments to develop their skills and understanding of procedures. Conditions treated included nasal clefts, fronto-nasal dysplasia with bilateral cleft nasal deformity and hypertelorism, Treacher Collins syndrome, mid-line nasal cleft, right unicoronal synostosis and a bilateral ear reconstruction. In 2017, consultants from the UK visited the Hong Ngoc Hospital and Viet-Duc University Hospital. Together with a team of

To donate to this special charity scan the QR Code using the camera on your phone or visit www.justgiving.com/fundraising/aestheticsmedia

REFERENCES 1. Katrin Kandel, Vietnam Training Program, Facing the World <https://facingtheworld.net>

Aesthetics | August 2020

21


Advertorial Thermage FLX®

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Powering Up Your Business Post Lock Down With Thermage FLX® The ‘new normal’: an opportunity to rethink your patient experience In the world of medical aesthetics, safety and efficacy have always been top priorities for patients and clinicians alike. That said, clinics are having to adapt to the latest social distancing requirements now in place post lockdown; rethinking everything, from welcoming patients, to the treatments themselves – infection control is of even higher importance and is shaping all of our behaviours, personally and professionally. While these new conditions of care are set to become the “new normal”, customers are still looking to their clinicians to deliver effective aesthetic solutions, safely. Treatments and technologies that are particularly ‘post-pandemic friendly’ are those that are multi-area, quick, non-invasive, non-aerosol generating, and, critically, those that can be relied upon to give great results.

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while enhancing and expanding the practice of medical aesthetics for physicians. Solta Medical’s devices address a range of skin treatments under the industry’s premier brands: Thermage®, Fraxel® and Clear + Brilliant®, as well as offering precise body contouring and sculpting with Vaser® Lipo.

Thermage FLX® – a pioneer in skin tightening Thermage FLX® from Solta Medical®, is a non-invasive radiofrequency (RF) therapy that smooths, tightens and contours all skin types in a quick, comfortable way to provide an overall natural, younger-looking appearance that lasts. The new fourth-generation system uses patented monopolar RF technology to create a uniform heating

A simple way to ‘wow’ your patients without compromising safety In light of the new infection control, treatments that offer efficacy without compromising safety are highly attractive to patients. Thermage® is one of these non-invasive solutions, combining efficacy and limited risks of contamination, offering multiple advantages which are more important than ever in the new world in which we operate: Single session

Thermage FLX® delivers visible results after a single treatment. As the body kick starts the collagen renewal process, as a natural response to the treatment, these results gradually increase two to six months’ post-treatment1 and, depending on the skin condition and ageing journey of the patient, can last years. Each Thermage FLX® tip is for single use only – limiting any risk of contamination.

Faster treatment

The new “Total Tip 4.0” delivers energy that can penetrate as deep as 4.3mm under the skin to heat the dermal tissue up to 75°C. The heat is evenly distributed over the entire skin area, allowing a multidimensional tightening effect. The new tip covers 33%*, more surface skin area than the previous design, and so the duration of the session is reduced by 25%*, improving patient comfort, satisfaction and allowing more time to treat multiple parts of the body.

Enhanced comfort**

The system also features a new multi-directional vibrating hand-piece to help enhance patient comfort1 for the body and face, making the treatment much more comfortable than the previous version.

Versatility

Thermage FLX® is an extremely versatile treatment as it can be used with the same handpiece on any area of the face and body where loose skin and sagging are of concern. Thermage FLX® can be used to treat fine lines and wrinkles, and tighten up the skin around the eyes, face, neck, arms, hands, abdomen, thighs and buttocks.

Rapid recovery

Thanks to the fact that Thermage FLX® uses a non-surgical RF technology, which apart from having a proven safety profile, non-invasively treats the deep layers of the skin with limited to no downtime. Since there is no surgery involved patients can generally return to normal activities immediately following the procedure, although most prefer to take a little time to relax and recover post-treatment.

A trusted partner: committed to delivering results for you and your patients Thermage® set the standard for non-invasive skin tightening and continues to be one of the most popular, trusted treatments among patients and clinicians due to its proven results and versatility. For years, Solta Medical® has invested in the advancement of the Thermage® technology to help aid in patient comfort and improve the experience for the practitioner. Solta Medical® offers effective solutions with a good safety profile for patients * All comparisons are made with Thermage CPT® and its components. ** The vibrating function is not available for the eyelids treatment when using the Eye Tip 0.25cm2. 1. References are available online at www.aestheticsjournal.com

22

Aesthetics | August 2020

effect in the deep collagen-rich dermal layer. The heat stimulates existing collagen to achieve an immediate skin tightening effect.1 It also promotes the growth of new collagen for results with continual improvement. Featuring the innovative AccuREP™ technology, new Thermage FLX® ensures perfect personalisation of each treatment to address and improve the skin condition of each patient. The treatment delivers natural looking results with little to no downtime – on all skin colours – on and off the face, all in a single procedure. Pioneer in skin tightening treatment since 2007 with more than 13 years clinical use, Thermage® has demonstrated a good safety profile with more than 50 published clinical studies.

This advertorial was written and supplied by Solta Medical®

www.thermage.co.uk Thermage FLX®, Thermage CPT®, Thermage®, AccuREP™ and Solta Medical® are trademarks of Bausch & Lomb Incorporated or its affiliates. ©2020 Bausch & Lomb Incorporated or its affiliates. THR.0023.UK.20


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Understanding Myomodulation Consultant plastic and reconstructive surgeon Mr Ali Juma explores the mechanism of action and benefits of influencing muscle action with hyaluronic acid filler The dynamics of facial mimetic muscles and their impact on ageing is complex to say the least. There is abundant literature on the changes affecting soft tissue, fat compartments and facial bony skeleton leading to facial ageing.1,2 However, there is lack of concordance in accepting the postulated mechanisms influencing facial mimetic muscle/s changes with ageing and their response to treatment with facial fillers. The literal meaning of myomodulation is the exertion of a modifying or controlling influence on function or activity of muscle/s. The modulation of muscle/s can be as a result of a chemical influence as in the use of neuro-toxins such as botulinum toxin A, in which case it is known as neuro-modulation.3,4 The other type of modulation is when facial fillers like hyaluronic acid (HA) are injected adjacent to mimetic muscles, known as myomodulation, as discussed in this article.5-7 The aim of this article is to consider the literature on myomodulation, and to constructively analyse it to better understand how myomodulation can be achieved and the pathways involved. This may enable the aesthetic injector to consistently and reproducibly influence mimetic muscles in achieving a less tired, rejuvenated and balanced look, with improvement of affect and emotional attributes.

Myomodulation mechanisms The mechanism/s of how injecting HA facial filler adjacent to mimetic muscle/s influences the muscle/s activity has two schools of thought.5,7 One belongs to the mechanical hypothesis of pulleys and lever-arm systems.5 The second belongs to the mechanoreceptor hypothesis, which includes indirect and direct influences resulting from slow-acting Eye Corrugator Orbicularis oculi

Scalp Frontalis

Muscles of mastication Temporalis Masseter

Mimetic muscles The ageing face is influenced by bony skeleton resorption; the deep fat compartments lose volume and deflate causing the facial mimicry muscles and the hypertrophied superficial fat compartments and skin to sag, thus creating folds and shadows.1,2,9 Imbalance of mimetic muscles can result from congenital deficiencies like Parry-Romberg syndrome, otherwise known as progressive hemi-facial atrophy,10 or in acquired cases following tumour resection involving the facial nerve, which supplies the muscles of facial expression.5 The mimetic facial muscles differ from skeletal muscles in their anatomical relationship to bone and other structures. Not all originate in bone; however, most insert into other muscles and skin.9 The skin insertion in some could be direct and in others through ligaments. They do not have tendons â&#x20AC;&#x201C; except in the sphincteric muscles Eye Corrugator Orbicularis oculi

Nose Procerus Nasalis Levator labii superioris alaeque nasi Levator labii superioris Mouth Buccinator Orbicularis oris Risorius

Cheeks Zygomaticus minor Zygomaticus major

mechanoreceptors in the skin and muscles, respectively.7 The one matter the two schools of thought agree on is the ability of facial fillers to influence the activity of mimetic muscles, leading to alteration of facial expressions and emotional attributes.5-7 Limitations in seeking answers to the mechanism/s involved in myomodulation with facial fillers result from the complexity of facial muscle/s movement dynamics, their interaction with other muscles, the influence of the skin elasticity, in addition to the proprioceptors and neural pathways in both. Although available in the laboratory setting, demonstrating these interactions and activities in real-time 3D models is currently not practical in a clinical scenario.8

Neck Platysma

Scalp Frontalis Nose Procerus Nasilis Levator labii superioris alaeque nasi Levator labii superioris Cheeks Zygomaticus minor Zygomaticus major Mouth Buccinator Risorius Orbicularis oris

Chin Depressor anguli oris Depressor labii inferioris Mentalis

Figure 1: Diagram of a female face exhibiting facial mimetic muscles including topographical skin markings on the left side of the modelâ&#x20AC;&#x2122;s face.

Muscles of mastic Temporalis Masseter

Chin Depressor anguli oris Depressor labii inferioris Mentalis Neck Platysma

Figure 2: Diagram of a male facial expression muscles with mastication muscles.

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Normal/youth

Skin

Levator

Fat

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– and they also lack muscle spindles, which are in abundance in skeletal muscles and muscles of mastication.11,12 Mimetic muscles have variation in shape in different parts of the face.13 More recently, Ruffini-like slow adapting mechanoreceptors, in addition to free nerve endings, were identified in mimetic muscles. One such example is the zygomaticus major muscle; a key muscle in facial ageing. This finding is important in understanding the mechanisms of the mechanoreceptor hypothesis of myomodulation.7,11,12

How myomodulation works Anchoring point

Depressor

Mechanical hypothesis

Ageing

Sagging skin

Levator

Fat

Anchoring point

Depressor

Filler Injection

Skin

The practical aspect of achieving myomodulation with facial fillers in skilled hands appear less complex than the postulated mechanism/s of how this myomodulation is achieved on anatomical, cellular, and physiological levels. The two hypotheses that are currently in circulation include the mechanical hypothesis and mechanoreceptors hypothesis.5,7 The mechanical hypothesis postulates that movement of facial expression muscles is represented in three key domains including length-tension relationship, muscle pulley/s and lever arm systems, in addition to action of functional muscle groups.5,7

Levator

Filler bolus

Anchoring point

Depressor

Figure 3: Ageing and hypothetical treatment effects on muscle action. Image adapted from de Maio 2018.5

Length-tensions relationship The muscle contractile component is represented by the active tension and the passive action exerted by the elastic component. If the muscle fibre length is altered, then the peak force produced by the contractile component of the muscle is reduced.5 Skin elasticity and connective tissues are the primary sources for the elastic component of the length-tension relationship for mimetic muscles. This is further influenced by volume loss in the deep fat compartments. Bony resorption and remodelling, in addition to facial sagging, lead to further muscle/s length alteration.5 Muscle pulley/s and lever arm systems In this system, the pulley alters the direction the muscle travels and the lever arm increases the muscle mechanical advantage, thus increasing the force or displacement.5 In ageing, resorption of bone and deep fat compartment volume, with ptosis of the latter, impacts the length of the muscle/s thus reducing the force of the muscle/s and diminishes their ability to lift the corner of the mouth, as in the case of zygomaticus major muscle.1,2,5 Functional muscle groups Functional muscle groups working in harmony are important aspects of facial youthful appearance. The elevator and depressor muscles work such that appearance of the static and dynamic expression is balanced in youth.5 Gravity and depressor muscle activity create a downward force, which balances the action of the elevator muscles unless there are structural deficiencies or ageing. Hence, if the elevator muscle loses power, the depressor then acts along with gravity to cause a negative and undesirable imbalance.5,7 An example of such negative imbalance is when the zygomaticus major loses support, causing reduced lift of the angle of the mouth. However, the risorius muscle role increases in the smile causing a horizontal look to the smile. As the zygomaticus major muscle’s ability to lift the angle of mouth reduces further with ageing or structural deficiency, the depressor muscles – especially depressor anguli oris action – increases, leading the angle of the mouth to point downward, giving the sad look and a negative emotional attribute.5 Mechanoreceptors hypothesis The mechanoreceptors hypothesis takes into consideration the presence of slow adapting mechanoreceptors; Ruffini-like capsules and sensory nerves afferents in the mimetic muscles and skin of the face.7,12,14 These somatosensory afferents travel through the trigeminal nerve division communicating with the facial nerve that innervates the mimetic muscles.12,14 This makes for one pathway for proprioception in mimetic muscles. Hence, placing the filler next to the muscle/s triggers these slow adapting mechanoreceptors in the muscle and thus modulates its activity through a higher centre in the brain.7,12,14 The skin mechanoreceptors can be triggered as a result of the skin deformation,14,15,16 which can be influenced from the outside, as was demonstrated in an experiment using a mask that exerted pressure on the skin of the peri-orbit, leading to improvement of the glabella lines.17 Injection of facial filler under the frontalis muscle to replace volume in the forehead leads to raising the brow to a more balanced position, giving a more relaxed look as the activity of this muscle, unlike other elevators, is inhibited.6,7 On the other hand, it is postulated that in the case that filler is injected superficially above one of the mimetic muscles it leads to inhibition of the activity of that particular muscle, therefore exerting a local modulating effect.5,7

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Clinical applications of myomodulation Irrespective of the mechanism/s of myomodulation action, the fact remains that facial filler is a powerful tool in the armamentarium of an experienced medically qualified aesthetic injector. This technique can be used as a sole method or in combination with neuro-modulation of muscles to achieve a youthful and more balanced look with positive emotional attributes.5,18 For example, the mentalis muscle, the only lower lip elevator, also rotates the chin. In an overactive muscle, this can cause pulling on the chin skin giving the appearance of dimpling.5 This effect can be improved with botulinum toxin A by weakening the action of mentalis. This treatment leads to reduced ability to elevate the lower lip and everts it.5 In the case that facial filler is injected in the labiomental crease and superficial to mentalis, its action is modified such that the chin rotation is reduced with lesser action on the skin, minimising the dimpling effect whilst preserving the ability to elevate the lower lip; a more natural balanced outcome. Authors have noted that combining modalities of neuro-modulation and myomodulation in some patients can achieve excellent natural results,5,19 and in my own experience I also believe this to be true. Other applications of myomodulation can be used in cases of congenital structural deficiencies like Parry-Romberg progressive facial atrophy syndrome,10 and in acquired conditions like damage or involvement of the facial nerve as a result of acoustic neuroma excision in the middle ear, causing a facial palsy with mimetic muscles weakness.5 In selected patients with facial nerve damage and synkinesis, the use of HA facial fillers along with facial muscle exercises and botulinum toxin A to weaken the stronger side, can also be a powerful tool to obtain a functional balance which is cosmetically pleasing.18

Discussion Based on the literature it is fair to stipulate that myomodulation is too complex a sequence of actions to be facilitated by one or two mechanisms or pathways.5,6,7 The mimetic muscles exhibit variation in anatomy, shape, depth, insertion, size of compartment, and attachment to skin.13 These factors most likely contribute to the way the muscles act in youth, ageing, other conditions and when influenced by facial fillers. One such control pathway is processed through higher centres in the brain mediated by the trigeminal nerve.11,12 It is feasible to say that altering the length of a mimetic muscle/s by creating a pulley and lever arm when depositing a bolus of filler on the bone at the level of its insertion improves the muscle ability to perform its action (Figure 3). This is noted in the zygomaticus major and by lifting the angle of the mouth. However, what is less clear is why injecting filler in the soft tissue above a muscle inhibits its action. The current explanation of a simple mechanical effect on the muscle impeding its movement seems too simple to justify when applied to all mimetic muscles, irrespective of their variations. Based on the available literature and considering either scenario, it is difficult to ascertain how much dermal filler is deposited either side of the muscle or intramuscular with a direct influence on the action on the muscle fibres, especially when the muscle is small and in close proximity to the skin – as in the case of the procerus and corrugator supercili. Unexpectedly, filler injected deep to frontalis muscle inhibits its action;6,7 however, based on the literature I would have expected that replacing the volume lost improves the convexity of the resorbed skull giving better support, hence, it ought to improve the mechanical action of frontalis. Nonetheless, the brow still responds to the volume adjustment, by elevation. A powerful combination is neuro-modulation with botulinum toxin A and myomodulation using HA facial fillers to treat the ageing and the structurally deficient face, to create a

balanced and youthful look with positive emotional attributes. From personal experience and as supported by literature, this treatment algorithm gives natural results with longevity.18 It is also concluded from the literature that although the science of neuro-modulation is understood, the science of how myomodulation works using facial fillers is yet to be fully understood. This is partly due the complexity of the anatomy and neurophysiology of mimetic muscles, and the lack of real-time 3D modelling in the clinical setting. Added to this is the complexity of designing an animal model to emulate the muscles of facial mimicry. Hence, until such models exist, clinical observation will remain the norm from a practical perspective. Mr Ali Juma is a consultant plastic and reconstructive surgeon with 18 years’ experience. He served as an honorary lecturer at the University of Liverpool for nine years and as an examiner for the Royal College of Surgeons for seven years. Mr Juma’s experience included teaching on the safe use of non-surgical treatments through cadaver courses, as well as participating in scientific research and writing. Qual: MB BS (Lon), FRCS (Plast)

Aesthetics Clinical Advisory Board Member Dr Tapan Patel says... Congratulations to Mr Juma for providing an excellent article on the theories and clinical experience to date on myomodulation. This has become a topic of much discussion amongst practitioners and one that throws up more questions than answers. The article highlights existing theories and critiques some of the observed anomalies. It will be a useful read for advanced practitioners who recognise that the clinical effect we obtain cannot be very fully explained by volume replacement alone. REFERENCES 1. Rohrich RJ, Pessa JE. The fat compartments of the face: Anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg (2007) 119: 2219-2226. 2. Fitzgerald R, Carqueville J, Yang PT. An approach to structural facial rejuvenation with fillers in women. International Journal of Women’s Dermatology 5 (2019) 52-67. 3. Laskawi R. The use of Botulinum Toxin in head and face medicine: An interdisciplinary field. Head & Face Medicine 2008 4:5, 1-8. 4. Kane MAC. Nonsurgical treatment of Platysmal bands with injection of Botulinum Toxin A. Plast Reconstr Surg (1999) 103:656. 5. De Maio M, Myomodulation with injectable fillers: An innovative Approach to addressing facial muscle movement. Aesth Plast Surg (2018) 42:798-814. 6. Kane MAC, Commentary on Myomodulation with injectable fillers: An innovative approach to addressing facial muscle movement. Aesth Plast Surg (2018) 42:1360-1362. 7. Harris S, Myomodulation the mechanoreceptor-filler hypothesis. Prime Journal. May/June 2019, 34-39. 8. Data-Driven 3D Facial Animation. Editors Zhigang Deng and Ulrich Neumann. Published 2008, publisher Springer. 9. Ezure T, Hosoi J, Amano S, Tsuchiya T. Sagging of the cheek is related to skin elasticity, fat mass and mimetic muscle function. Skin Research & Technology 2009: 15 299-305. 10. Mingyul JO, Hyosang A, Hyeyoung P, Jisook Y, Min-Soo K, Mihn-Sook J, Kwanghyun C. ParryRomberg Syndrome augmented by hyaluronic acid filler. Ann Dermatol Vol 30, No 6, 2018: 704-707. 11. Cobo JL, Francesco A, De Vicente JC, Cobo J, Vega JA. Searching for proprioception in human facial muscles. Neurosci Lett (2017) 640: 1-5. 12. Cobo JL, Sole-Magdalena A, Cobo JT, Vega JA, Cobo J. The proprioception in the muscles supplied by the facial nerve. Open access peer reviewed chapter, published 13th May 2019. 13. Anatomy of facial expression. Author Uldis Zarins. Publisher Anatomy Next, first edition 2017. 14. Cobo JL, Sole-Magdalena A, Menendez I, De Vicente JC, Vega JA. Connections between the facial and trigeminal nerves: Anatomical basis for facial muscle proprioception. JPRAS Open, 12 (2017) 9-18. 15. Siemionow M, Bassiri Gharb B, Rampazzo A. The face as a sensory organ. Plast Reconstr Surg (2011) 127: 652-661. 16. Johansson RS, Trulsson M, Olsson KA, Westberg KG. Mechanoreceptor activity from the human face and oral mucosa. Exp Brain Res (1988) 72: 204-208. 17. Harris S, Reduction of glabellar lines using a silicone eye mask. Prime November/December 2016, 36-39. 18. Weiner A, Touiloei K, Glick BP. A novel long-term therapy of facial synkinesis with Botulinum neurotoxins type A and fillers. The Journal of Clinical and Aesthetic Dermatology. March 2011Volume 4, number 3: 45-49. 19. Coleman KR, Carruthers J. Combination therapy with Botox and fillers: the new rejuvenation paradigm. Dermatologic Therapy, vol.19, 2006, 177-188.

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Hydrating Skin with HA Dr Zunaid Alli explores skin hydration and biorevitalisation with hyaluronic acid-based injectables Hyaluronic acid (HA) is a widely used biocompatible component in aesthetic injectables due to its safety and efficacy. It is one of the main components of the extracellular matrix and ground substance and is therefore indispensable for the cellular framework.1 HA is capable of hydration, lubrication and returning of elasticity to the skin, maintaining the shape of tissues and strengthening tissue tone.2 The greatest amount of HA is present in the skin and comprises around half of the

body’s total volume of HA.3 This article will focus on HA as the main component for skin biorevitalisation and hydration in areas of the face, neck, décolletage and dorsum of the hands using mesotherapy techniques.

Hyaluronic acid for skin hydration and biorevitalisation The majority of HA used in skin hydration and biorevitalisation is non-cross-linked. As the product is injected into the dermoepidermal

junction, it aids to add HA to the layers undergoing mitotic division, hence producing better quality keratinocytes.4 As HA is watersoluble, in non-cross-linked form its effects only set in upon epidermal and/or superficial intradermal administration.4 If injected into the hypodermis, the non-crosslinked HA is transported away from the skin and metabolised, with little to no effect.4,5 Technological advances have improved the viscoelastic properties of HA skin biorevitalisers by adding cross-linked HA products such as Viscoderm Hydrobooster6 and Stylage Hydromax7 to existing dermal filler ranges to treat wrinkles and improve elasticity in dynamic areas of the skin. In my view, practitioners should consider using non-cross-linked HA when applying a full-face protocol for skin hydration, and a cross-linked HA using a linear thread technique to treat wrinkles such as those in the periocular region or the area below the cheeks. As the skin’s ability to protect, regenerate and restore itself declines with age, in combination with genetics and added environmental stressors such as ultraviolet light exposure, stress, pollution and diet, increasing oxidative stress results in tissue damage and the production of reactive oxygen species (free radicals).8 These are capable of protein, DNA and lipid damage.9 Volume loss and repetitive muscle movements that cause wrinkles and folds have further been described as additional factors in skin ageing.10 The intradermal benefits of HA are that it can: • Bind large numbers of water molecules, improving tissue hydration and cellular resistance to mechanical damage11 • Enhance extracellular domain of cell surfaces and stabilise skin structures12

Manufacturer

Non cross-linked HA

Cross-linked HA

Allergan

NA

• Juvéderm Hydrate (13.5mg/ml HA with 0.9% mannitol) • Juvéderm Volite (12mg/ml HA Vycross + lidocaine 3mg)

IBSA

• • • •

Galderma

NA

• Restylane Vital Light (12mg/ml NASHA +/- lidocaine) • Restylane Vital (20mg/ml NASHA +/- lidocaine)

Teoxane

• Teosyal Meso (15mg/ml HA) • Teosyal Puresense Redensity I (15mg/ml HA + lidocaine 0.3% + 14 skin nutrients)

• Teosyal RHA 1 (15mg/ml cross-linked HA + non cross-linked HA = lidocaine 0.3%)

Vivacy

• Stylage Hydro (14mg/g HA + mannitol)

• Stylage Hydromax (12.5mg/g IPN-like HA + sorbitol)

Viscoderm 0.8 (8mg/1ml HA) Viscoderm 1.6 (16mg/1ml HA) Viscoderm 2.0 (20mg/1ml HA) Viscoderm bio, trio, maxx

• Viscoderm Hydrobooster (deep hydration and superficial stretching)

Table 1: Summary of commonly used HA-based mesotherapy products as part of existing dermal filler ranges that the author has used. These products aim to hydrate and revitalise the skin. There are others available.6,7,16-18

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• Stimulate fibroblasts to express collagen type I, matrix metalloprotease-1 and tissue inhibitor of matrix metalloproteinase-18 • Have a positive effect on reepithelialisation and stimulate migration and proliferation of kerationcytes13 • Promote the release of growth factors, increasing production and lengthening of collagen fibres14 • Stimulate collagen synthesis and inhibit collagen degradation2 • Enhance expression of elastin14 The addition of antioxidants, vitamins, minerals and amino acids injected into the skin may promote fibroblast stimulation.14 As HA injected into the skin stimulates fibroblast activity, the synergistic action of the additives has been demonstrated to increase in vitro fibroblast activity significantly.15

Treatment areas and techniques for HA using mesotherapy Mesotherapy is a minimally-invasive procedure that includes various sets of techniques that delivers active substances such as HA, vitamins, minerals, amino acids and peptides into layers of either the dermis, epidermis or both. The efficacy of the treatment is based on the physical stimulation that the treatment elicits, the pharmacological effect of the components and the dose of the components delivered into the skin. Mesotherapy techniques are largely delivered by hand using specialised needles, or by pneumatic or injector devices. They include nappage (picotage), serial puncture (point-by point or multiple microinjections), superficial linear thread, infiltration into the dermis and mixed techniques19 where the use of a blunt intradermal cannula may be used for more viscous or cross-linked HA biorevitalising products.4,20 Face The entire face is suitable for treatment with HA. A grid is either drawn or observed with distance between injection points being 1cm apart. A common approach for this technique follows the skin surface, which is injected in a point-to-point fashion where the needle is inserted into the skin at between 30-45o, aiming for 2-3mm in depth, which is sufficient to reach the dermal layers.4 Small aliquots of the product are injected into a papule before moving onto the next area. This ensures that the product is placed into the dermis where fibroblast activity is found. This is continued throughout the area of the face except for the nose, as direct injection on

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the surface of the nose may be painful.4 Here, the suggested method of injection would be the nappage technique where the bevel of the needle faces up, the syringe is held at 30-45o and the bevel is used to penetrate the skin creating microchannels where the HA is able to be massaged into them for absorption.20 This is a superficial technique and is confined to the epidermis 1-2mm depth, yet delivers HA to the skin on the nose without causing discomfort. The treatment plan may be modified to treat areas of the face where skin hydration, rhytid improvement and skin thickening is needed, such as the periorbital region. I find that serial puncture or superficial liner thread with a 30 gauge (or higher) needle may be used to inject HA into the dermis, especially in the area adjacent to the periorbital/suprazygoma where neurotoxin may not be used. As the rhytids may extend over and below the zygomatic area, in my experience, a thicker cross-linked HA is best to inject using a superficial linear thread technique. Mesotherapy using HA is of benefit when treating the perioral rhytids (barcode lines). I often use a combination treatment approach in this area, combining both serial puncture and superficial linear thread techniques to inject the HA to plump out the skin and smooth out individual rhytids.

to treating the dorsum and digits should be considered for successful results. While the serial puncture technique could be used, due to the superficial network of vessels on this part of the hand, I recommend a cannula technique. A single entry point just distal to the wrist is sufficient for cannula insertion with the ability to linear thread in a fanning arrangement over the dorsum with a crosslinked product so that loss of volume can be addressed. For treatment of the digits, serial puncture technique of a non-cross-linked product, 1cm apart is usually used to prevent unnecessary swelling of the digits.

Neck Treatment of the neck in younger patients may require HA for the purpose of hydration of the skin, improvement of tonicity and to prevent ageing. A serial puncture technique of injections 1cm apart over the entire surface of the neck is commonly used.20 I find that in older patient, or patients who wish to treat horizonal neck bands, a cross-linked HA may be beneficial and can be injected using a superficial linear thread technique. If lack of hydration and tonicity is an issue, a combined approach can be successful.

Side effects and special precautions

Décolletage Vertical rhytids that descend from the clavicle down to the centre part of the anterior chest between the breasts and crepey skin over the chest are commonly treated areas. If the rhytids are mild, serial puncture covering the entire area should be used,20 with technique as described for the face (1cm apart). For the vertical lines, superficial linear thread may be done using needle or cannula with a crosslinked product as the rhytids may be deeper. Hands In my experience, a combination approach

Treatment protocols Each manufacturer would provide treatment protocols for their products, which will slightly differ. The general consensus amongst all is a multiple treatment plan, usually two-tofour weeks apart for three-to-four sessions done once or twice a year depending on the severity and area being treated, which will lead the injector to choose non cross-linked HA or a cross-linked product.13 In younger patients, visible benefits can usually be seen after just one session.13 However, multiple treatments sessions have shown significantly lower transepidermal water loss and improvement in skin texture, pores and wrinkles.21

Generally, I find that mesotherapy treatments cause minimum discomfort, but I do choose to use topical or local anaesthesia to minimise patient discomfort. The most common side effects encountered are pin-point bleeding and bruising, mild oedema around the injections site and persistence of HA papules more than 24 hours after injection.4 Most side effects occur at the first treatment and are transient. Intravascular injection risk is low as these products are less viscous when compared with higher cross-linked HA fillers. Practitioners should obtain training to ensure that the appropriate techniques are used for the specific area being treated. Inappropriate technique is linked with poor patient satisfaction, as described in a study that compared intradermal versus nappage techniques where more than 90% of patients had skin that was improved/very improved at day 60 post treatment.5 Product knowledge and training is also important in obtaining the desired results. As mesotherapy with HA requires multiple treatment sessions, patients are not likely to return if their expectations are not managed and significant improvements are not seen.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Mesotherapy case study 1 A 53-year-old female who has regular neuromodulators wished to improve the crepey lines around her eyes and under her cheek. She had moderate to deep rhytids in the inferolateral orbital region and subzygomal area on dynamic movement. The treatment plan was to use a cross-linked HA (Stylage Hydromax) 1ml split between the two areas done three weeks apart for three sessions. The patient needed hydration and biorevitalisation of the general area, as well as specific treatment to the dynamic lines. The area was treated using the supplied 30 gauge needle and superficial linear thread technique. Post injection there was mild erythema and oedema with no obvious signs of bleeding. Improvement of the treated area was noticed three weeks after the first treatment. There was visible improvement to the depth of rhytids and smoothness of Before Immediately After 3 weeks after the skin was noted. The results will continue to improve with subsequent sessions. The recommended plan following the initial treatment is for a session at day 21 and if required, a third session at day 42.

Figure 1: Before, immediately after and three weeks after HA mesotherapy treatment. Note that although the patient expression varies between images, I believe images demonstrate improvement.

Mesotherapy case study 2 A 48-year-old female requested hand rejuvenation due to occupational wear-andtear and frequent hand washing. To improve both the volume loss and skin texture, a combination approach was used with a cross-linked HA (Stylage Hydromax) 1ml to the dorsum of each hand via a cannula technique to address volume loss, and serial puncture technique using a non-cross-linked HA (Stylage Hydro) for the digits with a 1ml total split between the fingers of both hands. Before

After

Dr Zunaid Alli is an aesthetic practitioner with a background in general medicine, emergency medicine and oncology. Dr Alli is a key opinion leader and masterclass trainer for VIVACY UK and is the lead clinical trainer for Glow Aesthetic Training. Qual: MBBCh, BSc, BScHons (Psychology), MBA REFERENCES 1. Fraser JR, Laurent TC, Laurent UB. Hyaluronan: Its nature, distribution, functions and turnover. J Intern Med. 242 (1997), 27-33. 2. Keen MA. Hyaluronic Acid in Dermatology. SKINmed. 15 (2017), 441-448. 3. Juhlin L. Hyaluronan in skin. J Intern Med. 242 (1997), 61-66. 4. Knoll Britta, The active substances, in Illustrated Atlas of Esthetic Mesotherapy, ed. By Gerhard Sattler (London: Quintessence Publishing, 2010) pp. 13-26 (p.16) & pp. 36-38 (p.36). 5. Taieb M, Gay C, Sebban S, Secnazi P. Hyaluronic acid plus mannitol treatment for improved skin hydration and elasticity. J Cosmet Dermatol. 2 (2012) 87-92. 6. HA-Derma – Viscoderm Hydrobooster <https://ha-derma.co.uk/ products/viscoderm_hydrobooster/> 7. Stylage: Skin hydration and elasticity improvement <https:// vivacylab.com/en/products/stylage/> 8. Fabi S, Sundaram H. The potential of topical and injectable growth factors and cytokines for skin rejuvenation. Facial Plast Surg. 30 (2014), 157-171. 9. Savoia A, Landi S, Baldi A. A new minimally invasive mesotherapy technique for facial rejuvenation. Dermatol Ther. 3 (2013), 83-93. 10. Brandi C, Cuomo R, Nisi G, Grimaldi L, D’Aniello C. Face rejuvenation: a new combinated protocol for biorevitalization. Acta Biomed. 89 (3) (2018), 400-405. 11. Salwowska NM, Bebenek KA, Zadlo DA, Wcislo-Dziadecka DL. Physiochemical properties and application of hyaluronic acid: a systematic review. J Cosmet Dermatol. 15 (2016), 520-526 12. Stern R, Maibach HI. Hyaluronan in skin: Aspects of aging and its pharmacological modulation. Clin Dermatol. 26 (2008), 106-122 13. Belmontesi M, De Angelis F, Di Gregorio C, Iozzo I, Romagnoli M, Salti G, Clementoni MT. Injectable non-animal stabilized hyaluronic acid as a skin quality bootster: An expert panel consensus. J Drugs Dermatol. 17(1) (2018), 83-88 14. Deglesne PA, Arroyo R, Fidalgo López J, Sepúlveda L, Ranneva E, Deprez P. In vitro study of RRS Silisorg CE Class III medical device composed of silanol: effect on human skin fibroblasts and its clinical use. Med Devices (Auckl). 11 (2018) 313-320. 15. Prikhnenko S. Polycomponent mesotherapy formulations for the treatment of skin aging and improvement of skin quality. Clin Cosmet Investig Dermatol. 8 (2015) 151-7. 16. Restylane Skin Boosters Information <https://www. consultingroom.com/Treatment/restylane-vital> 17. Juvederm Hydrate skin mesotherapy treatment information <https://www.consultingroom.com/Treatment/juvederm-hydrate> 18. Teosyal Products. Teoxane Laboratories <https://www.teoxane. com/uk/dermal-fillers/teosyalr-products> 19. Gooneratne, M, ‘Understanding the Efficacy of Mesotherapy’, 2020. <https://aestheticsjournal.com/cpd/module/ understanding-the-efficacy-of-mesotherapy> 20. Sivagnanam G. Mesotherapy - The french connection. J Pharmacol Pharmacother. (2010) 1(1):4-8. 21. Cheng H, Chen Y, Wang M, Zhao J, Li L. Evaluation of changes in skin biophysical parameters and appearance after pneumatic injections of non-cross-linked hyaluronic acid in the face. Journal of Cosmetic and Laser Therapy. 20(7-8) (2018) 454-461.

Figure 2: Pre-treatment photo indicating dry hands, lock of hydration and tonicity of the skin and after image shows immediate hydration benefit.

Conclusion HA possesses a multitude of properties that hydrate the skin and stimulate collagen and elastin production to a desired outcome producing skin that is firmer, brighter and hydrated. There are a number of dedicated mesotherapy injectable products in use in the UK which can utilise HA alongside a wide range of additional components such as vitamins, minerals, amino acids and peptides.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


When you reveal beauty, weâ&#x20AC;&#x2122;re by your side.

Croma offers a wide range of state-of-the-art products in minimally invasive aesthetic medicine. This allows you to combine techniques for personally tailored treatment and ideal results. Learn more about Cromaâ&#x20AC;&#x2122;s products and services at croma.at HA Filler | Threads | PRP | ACA & SVF | Skincare

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particular are outperforming g heavily in in-house markets in aesthetic medicine. In elopment of new Advertorial May 2017, the Dermalfiller Princess the company’s @aestheticsgroup @aestheticsjournaluk Aesthetics aestheticsjournal.com Croma VOLUME was approved in China through innovation. by the CFDA. Croma-Pharma was roma also promotes the first European company to do maceutical research so. Almost at the same time, the more than 90% of company signed with Sihuan Pharma ed from products Becoming a global player with minimally invasive aesthetic medicine. ch.

Croma-Pharma: Made in Austria

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New headquarters and production ntler Croma-Pharma GmbH, is an international pharmaceutical company based in plant as a clear commitment to free Leobendorf, Austria. For over 40 years, expansion and location ures Croma has been developing and producing Due to the dynamic development of the are so innovative drugs and medicalLtd. a for long-standing licenseand and devices company, the construction expansion of hat they can be distribution agreement. the fields of ophthalmology, orthopedics the headquarters andThis anotherjoint fully automatic a lunch venture the third-largest and break) aesthetic dermatology. Croma is very withproduction facility at the Leobendorf site was proud to have made such an important initiated in 2015. The new headquarters was ive the patient Chinese pharmaceutical company contribution to improving health and inaugurated in September ance. The expert is aimed at the approval of 2017. further quality of life for more than four decades. ferent technologies products and the nationwide Founded in 1976 by pharmacist Gerhard Innovations as a result of intensive and creates a longdistribution of these products in Prinz, Croma is now managed by his sons research and development or relationship. mainland Martin and Andreas Prinz. Since 2005, the China. Croma is investing heavily in in-house aesthetic medicine company has been driven forward through research and development of new products ge growth potential In 2014, Sustainability and social rapid internationalisation. the to drive the company’s long-term growth strategic sale of the Ophthalmology and through innovation. In this context, Croma uty market. In responsibility Orthopedics divisions took place, since then also promotes medical and pharmaceutical offers a steadily the company has specialised in minimally research in Austria. Today, more than 90% dinated portfolio As a family business, Croma invasive aesthetic medicine. Currently, of sales are generated from products of our goal is a “full-face pursues a corporate policy based Croma has 12 international offices in Brazil, own research. r doctors and on ecological, economic and social European Union and Switzerland and nearly solutions for allworldwide. sustainability. For many years, Croma 500 employees Aesthetic dermatology as a a single source in dynamic future market is sponsor of the international Leading HA expert in Europe aesthetic medicine, the trend ble quality. organizationIn modern “Light for the World”. Today Croma is a global player in the is moving from large, irreversible surgical With generous product donations dynamically growing segment of minimally lifts to smaller but more frequent, shorter Croma makes an important e course for invasive aesthetic medicine and is a leading and, above all, gentler treatments. Pain-free contributionlunchtime to the eye care in the S market European processor of hyaluronic acid. The procedures (treatments that are so poorest regions of the company sells nearly six million hyaluronic straightforward thatworld. they can be performed 8 Croma-Pharma acid syringes (injectables) annually through during a lunch break) are designed to affiliates and a network of strategic give the patient a relaxed appearance. stablishing a joint partnerships and distributors in more than 70 The expert combination of different with its long-time countries. Production takes place exclusively technologies optimises results and creates c. to develop and at the company headquarters in Leobendorf a long-term patient-doctor relationship. ulinum toxin, HA near Vienna, Austria. Besides a broad Minimally invasive aesthetic medicine has ead products in US, Contact above-average growth potential in the range of HA fillers from the own production a and New Zealand. site, Croma markets PDO lifting threads, global beauty market. In this area, Croma s its development GmbH a Platelet Rich Plasma (PRP) CROMA-PHARMA system and a offers a steadily growing, well coordinated in its coreHöhn portfolio of products. The goal is a ‘full-face tivitiespersonalised with a skincare technology Stefanie markets. orderstrategic to prepare Cromazeile 2approach’ to offer doctors and patients the e successful market A-2100 Leobendorf gic partnership Phone: +43 676 846868 Aesthetics |190 August 2020 ntinue Croma‘s Mail: stefanie.hoehn@croma.at

best solutions for all indications from a single source in familiar and reliable quality.

Croma sets the course for entering the US market In September 2019 Croma-Pharma GmbH (Croma) establishded a joint venture company with its long-time partner Hugel, Inc. to develop and commercialise botulinum toxin, HA filler and PDO thread products in US, Canada, Australia and New Zealand. Thus Croma unites its development and marketing activities with a strong partner in order to prepare and implement the successful market entry. The strategic partnership with Hugel will continue Croma‘s international expansion efforts and further strengthen Croma‘s market position.

Milestones product approval and joint venture in China Asia in general and China in particular are outperforming markets in aesthetic medicine. In May 2017, the dermal filler Princess VOLUME was approved in China by the CFDA. Croma-Pharma was the first European company to do so. Almost at the same time, the company signed with Sihuan Pharma Ltd. a long-standing license and distribution agreement. This joint venture with the thirdlargest Chinese pharmaceutical company is aimed at the approval of further products and the nationwide distribution of these products in mainland China.

Sustainability and social responsibility As a family business, Croma pursues a corporate policy based on ecological, economic and social sustainability. For many years, Croma has been the sponsor of the international organisation “Light for the World”. With generous product donations Croma makes an important contribution to eye care in the poorest regions of the world. Learn more about Croma’s products and services at croma.at Phone: +44 (0) 7442341 227 Orders: customerservice.uk@croma.at Website: www.croma.at This article is written and supported by Croma-Pharma

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Conducting a Successful Consultation for Filler Treatment Dr Raj Acquilla shares his concept for successful patient consultations and presents a case study using multiple treatment sessions This article will take you through a journey of how to assess your patients’ multiple needs and detail the importance of taking into consideration the mood and health perception of your patients, and the fourth dimension; expression and communication with other people. This is ultimately what we’re trying to optimise at the highest level to improve our patients’ lives.

Discover your patient To generate higher levels of satisfaction, the first conversation with our patients should be about finding out who they are. This includes not only their age, but what they do for a job, what their relationship status is, and what they are hoping to achieve in life. How we inject our patients should relate to them personally, so during the consultation it is really important to get to know them. For example, do they want to look innocent, or do they want to have a more edgy/ dangerous side to them? Greater structure

generates higher degrees of impact, which I believe in some individuals may potentially influence a higher level of perceived power, danger and dominance.1,2 It can be a big mistake to make someone look more dangerous and edgy if it does not fit with their role in life and work. A primary school teacher, for example, may be better suited to an innocent and cute look to relate to her young students, whereas a company CEO might want a look that suggests power and firmness.

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Taking this approach during the consultation is highly effective; for the first time you are making aesthetic medicine about life, not beauty. For example, when patients come in saying they want 1ml in their lips, having typically seen something on social media that makes them believe they need this volume in this particular area, being confident in explaining why this isn’t suitable and how you can offer a better result, personalised to them, will make you stand out from the crowd. This will help you build a loyal database of patients who respect your unique approach. Of course, we have a responsibility both clinically and ethically to make sure these impressionable men and women are guided in the right direction. We have to educate and guide our patients within the consultation to what is truly achievable. In my clinic I have a very clear policy when it comes to injectables; I will always take a bespoke full face approach. This creates somewhat of a filtering system in that individuals who enquire and are simply price hunting for a single syringe or treatment area will not book themselves in for a consultation, or I will politely say that I am not the practitioner for them. However, if people come to us and they are able to get past the questions around cost into a quality discussion, it means every consultation is an opportunity for us to educate the patient. This is particularly relevant for young patients to ensure we set a positive impression of medical aesthetics moving forward. We need to give quality and uncompromising excellence through effective assessment, rather than our focus being on making money.

Four parameters of assessment When assessing patients, we need to utilise a logical and objective approach to identify what they are seeking, along with what you believe they need to achieve this, according to your clinical judgement and aesthetic eye. We can then find the solutions to make them the best version of

To generate higher levels of satisfaction, the first conversation with our patients should be about finding out who they are

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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themselves. Some of the symptoms that we want to work on are to try and correct emotional deficiencies that we perceive in the face, but also any health-related parameters like the appearance of stress or tiredness. It is my view that it’s our responsibility to identify all these factors in the patient’s face during the consultation. We look at the face in totality, dealing with four aspects of correction: mood, health, anger and sagging, while also considering how best to beautify the patient’s face, which is largely based on the relationship of light and shade. So, the confluence of light and shade, the unification of facial compartments, and also making our female patient look feminine and the male patient look masculine (if that is their desire, of course) by adhering to simple guidance with geometry of angles, ratios and proportions. This will be discussed in more detail in my next article to be published in the Aesthetics journal. In my experience, the way to achieve the best results is to influence facial muscles, which impact facial expression, through myomodulation of depressor muscles. The concept of myomodulation has been discussed on p.23.3 Different expressions are caused by different muscles. Signs of happiness, for example, are not apparent just from the mouth through a smile, they also come from the eyes. As we age, we start to see negative facial vectors,4,5 which generally make patients look sad, moody, tired and can influence increased perception of stress and meanness. When assessing a patient’s face you need to know not just which muscles impact Before

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When assessing a patient’s face you need to know not just which muscles impact dynamism in the face and therefore facial expression, but, most importantly, where the origin of the muscle is and where the insertion point lies dynamism in the face and therefore facial expression, but, most importantly, where the origin of the muscle is and where the insertion point lies. When we inject patients, we inhibit the hyperdynamism of the depressor muscle using myomodulation and therefore promote the paradoxical activity of the elevators.3,6 During the consultation it is important to educate the patient on how we have achieved the result to elevate nerves. This is not just important in any consultation to ensure the patient understands the treatment, but to also re-enforce that you are an expert within the field. Working through the symptoms of mood and health disturbance systematically, we can then find the solutions and link that with an injection strategy or a treatment plan, which is associated with specific products, depths, quantities and mechanism of

After

Before

action. Through a careful strategy involving projection and uniting facial compartments, we can generate great results with a low volume of product.

Objective aesthetic scores I use my own scoring system to help manage patient expectations and communicate my treatment plan to the patient. I firstly ask the patient to give themselves an aesthetic score out of 10. I then perform my own assessment, identifying the number of injection points I believe they require to get them to a 10, which is the best version of themselves. Of course, the number of injection points vary from patient to patient. I aim to derive an objective aesthetic score for the patient by removing 0.1 for every correction point that they require. Therefore, I calculate my own aesthetic After

Figure 1: My 40-year-old patient before and after treatment.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Treatment plan SESSION 1 Grey points: Mid-face foundation using 1ml of Juvéderm Voluma (T1 0.5, CK1 0.1, CK2 0.2, CK3 0.2) Blue points: Mandibular structure using 1ml of Juvéderm Volux (Jw1 0.3, M1 0.3, M2 0.1, C2 0.3) SESSION 2 Purple points: Dynamic contouring using 0.5ml of Juvéderm Volift (C1 0.2, ML1 0.2, NL2 0.1) SESSION 3 Pink points: Refinement and beatification using 0.5ml of Juvéderm Volbella (F1 0.1, F2 0.1, TT1 0.1, TT2 0.1, Lp1 0.1) Green points: Skin texture improvement using Juvéderm Volite

Figure 2: The 19 injection points identified for this patient. Treatment plan involves three sessions.

score by subtracting the number of injection points required for optimum aesthetic outcomes (0.1 for every correction point) from 10, exemplified below. This generates very clear end points if we use the right products, the right technique, the right depth and the right amounts, but we need to have the treatment plan from the assessment to be able to achieve this.

Case study: 40-year-old woman For this 40-year-old patient I identified several factors that needed addressing, such as hollows in the forehead, temple, cheek, tear trough and mid-cheek groove, a loss of definition in the mandible and a loss of projection of the chin and labial mental crease. She had soft tissue deficit of the nasolabial fold and crease, as well as skin textural issues (Figure 1). As detailed above, I aim to remove a score of 0.1 for every correction point. I identified 19 points in total that would need addressing, so in my assessment tool, we deduct 1.9 from 10 giving an aesthetic score of 8.1. I would say that 19 is actually quite a high number for someone of this age; usually for young, beautiful patients there may only be four points, and with those older there could be around 24, but again it’s very bespoke to each individual patient. In concept, I can then take her from 8.1 to 10 by executing the 19 points (Figure 2). However, if the patient needs 19 points to get to a 10 then that’s going to be expensive because it takes a lot of product and is going to involve a lot of injections. It’s not realistic to do all of that in one treatment session, so we explain in the consultation that we are

going to break it down over several sessions according to structure, soft tissue correction, and then into textural considerations and refinement. If agreed, the next part of the consultation is to talk the patient through the technical strategy, outlined below. For my treatment approach, I recommend that practitioners inject the products with the highest molecular weight for deep structural improvements first, then follow through your range in descending order to the more superficial areas. Note that this patient was treated live at an international conference in one treatment session, however optimally, each session should be spaced one month apart as this amount of time allows for good tissue integration and also helps with patient finances. Session 1 – structural First of all, I aimed to treat the underlining support structures, which will involve deep injections down to bone with a needle. In my opinion, you need to use a product with a high G-prime and lift capacity. For this patient, I used Juvéderm Voluma in the temple and the cheekbone. Then, Juvéderm Volux was used for the angle of the jaw, pre jowl sulcus, the lateral labiomental crease and the chin. Session 2 – contouring The next stage is to achieve contouring, which will involve injections into subcutaneous fat. The product of choice here needs to be softer, so I chose Juvéderm Volift to address the nasolabial fold and labiomental crease.

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Session 3 – refinement and texturising This session looks to improve skin texture and refine the results previously achieved. For this patient, I injected to the bone in the forehead, in the tear trough, the lateral lid cheek junction and also in the lip using Juvéderm Volbella. I then moved to texturising using very small quantities of Juvéderm Volite in the subcutaneous tissue for the perioral lines, the lower cheek and also those fine, feathery lines that we see in the chin.

Summary The type of changes seen in this case study are usually life-changing for the patients who previously could not imagine results like these could be achieved with injections alone. A good consultation is the key to optimising your practice for longevity so that you have life-long partnerships with your patients, rather than a ‘revolving door’ relationship where a patient comes in, has a commoditised treatment and walks straight out, because ultimately they can get it cheaper down the road. Full facial harmony and balance which makes our patients look and feel healthier, rested, fresh, happier and more beautiful means they will always keep coming back. Dr Raj Acquilla has more than 18 years’ experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Medical Aesthetic Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer for Allergan for botulinum toxin and dermal fillers. He has lectured and trained in more than 40 countries and six continents to audiences over 40,000 healthcare professionals. Dr Acquilla also runs RA Academy, Masterclass and Summit Online Training. Qual: BM REFERENCES 1. Little, AC, et al., Facial attractiveness: evolutionary based research, Philos Trans R Soc Lond B Biol Sci. 2011 Jun 12; 366(1571): 1638–1659. 2. Shawn, N et al., Evidence from Meta-Analyses of the Facial Width-to-Height Ratio as an Evolved Cue of Threat, July 16, 2015. <https://journals.plos.org/plosone/article?id=10.1371/journal. pone.0132726> 3. Juma, A, ‘CPD: Understanding Myomodulation’, Aesthetics journal, August 2020. 4. Kalach-Mussali, AJ, et al., Botulinum Toxin, edited by Nikolay Serdev. 5. Niamtu, JP, Vectors of Facial Aging and Their Reversal, Plastic Surgery Products, 2008. <https://www.lovethatface. com/files/2013/04/VectorsofFacialAgingandTheirReversal_ June2008_PlasticSurgeryPro1.pdf> 6. Bertossi, D et al., Non-surgical Facial Reshaping Using MD Codes, J Cosmet Dermatol. 2020 Jul 5.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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0.7 0.3 C l eve r C l i n i c e n s u re s p a t i e n t c o n s u l t a t i o n s a re e a sy, c o m p l i a n t a n d c o n s i st e n t f ro m fi rst c o n t a c t , a l l t h e wa y t h ro u g h t o o rd e r i n g t h e p ro d u c t s yo u a n d yo u r p a t i e n t s l ove . A g a m e - c h a n g i n g a p p, C l eve r C l i n i c t ra n s fo r m s a n d s i m p l i fi e s eve r y a s p e c t o f yo u r c l i n i c a l l i fe , f re e i n g yo u u p t o p ra c t i c e w i t h t h e u p m o st exc e l l e n c e a n d s a fe t y. E ve r y. S i n g l e . T i m e .

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Free for Healthxchange customers. Visit cleverclinic .co.uk to find out more Pre fe re n t i a l p r i c i n g a va i l a b l e w i t h a n A l l e rg a n Co m m e rc i a l Po l i c y. Co m m e rc i a l Po l i c i e s n ow i n c l u d e V YC RO S S ® a n d U LT RA® p a c ka g e s, a n y fi ve m i x & m a t c h . E xc l u s i ve t o H e a l t h xc h a n g e G ro u p.

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Efficacy of botulinum toxin Botulinum toxin type A (BoNT-A) is one of the toxins produced by Clostridium botulinum. This neurotoxin inhibits the release of acetylcholine.4 BoNT-A has been shown to decrease sebum production and reduce pore size in patients with oily skin. In a retrospective analysis of 20 patients treated with BoNT-A, 17 noted an improvement of pores size and sebum productivity at one month after injection.5 However, it is not entirely clear why decreased sebum production follows BoNT-A injections, because the role of acetylcholine on sebaceous glands is not well defined. Most likely it is because the arrector pili muscles and the local muscarinic receptors in the sebaceous glands are targets for the neuro-modulatory effects of BoNT-A.6 This indicates that BoNT-A may block the activity of acetylcholine in sebocytes. In one study, 42 volunteers with forehead wrinkles received 10-20 units of BoNT-A, which was administered in five standards injections. The study suggested that the Dr Magdalena Szymanska Bueno explores the sebum production has a positive correlation use of botulinum toxin for acne and oily skin with the distance from the injection point. It concluded that intramuscular injection The use of botulinum toxin for reducing facial wrinkles is one of of BoNT-A significantly reduces sebum production at the injection the most common treatments in medical aesthetics. However, the site but increases the sebum production of the surrounding skin at potential use of this medication to treat other skin problems such as a radius of 2.5cm at the two, four, and eight-week follow-ups. The acne or oily skin is lesser known. This article aims to explore the way efficacy did not improve with higher dosages.7 in which botulinum toxin could be a used as a tool in future to help Another study evaluated the safety and efficacy of intradermal patients with acne. injection of BoNT-A for the treatment of oily skin. In the study, 25 subjects were treated with BoNT-A injection in the forehead and postAcne vulgaris treatment production of sebum was measured with a sebometer. The As a dermatologist, I have two groups of patients coming to my results showed a significant reduction in sebum production and high practice â&#x20AC;&#x201C; those who seek antiageing and rejuvenation treatments patient satisfaction.8 and those who are suffering from skin conditions. One of the most As we are still learning about the role of acetylcholine in sebaceous common dermatological problems patients experience is acne, and gland function, we can observe that BoNT-A helps to control chronic we need to remember that acne is not only a problem of teenagers. migraine, hyperhidrosis, muscles contractures, cervical dystonia and Research shows that approximately 85% of acne cases occur mostly bladder dysfunction. All of these desirable effects are due to blocking during adolescence, but it can persist into adulthood, with a 50.9% acetylcholine release.9 prevalence rate of acne in ages 20-29 years and 26.3% in ages Acetylcholine signalling plays a significant role in human sebaceous 40-49 years.1 Acne vulgaris is a disease of the pilosebaceous unit. gland biology and authors identify acetylcholine signalling as a There is mix of many factors that play a role in developing acne: overproduction of sebum, seborrhoea, change in keratinisation pattern in the pilosebaceous unit, colonisation of Propionibacterium acnes in sebaceous glands and inflammation.2 The sebaceous gland is an exocrine gland in the skin that produces a mixture of an oily matter that lubricates hair and skin and plays an important role in thermoregulation. The glands can mostly be found on the face and scalp.2 Each hair follicle is surrounded by one or more sebaceous glands, which are encircled by a muscle called arrector pili. Those elements form a pilosebaceous unit. A branch of sebaceous ducts deposit sebum to the skinâ&#x20AC;&#x2122;s surface and the activity of sebaceous glands increases during puberty as a result of higher levels of androgens. Excess sebum production and change in keratinisation in the pilosebaceous unit lead to the formation of comedones, which are one of the first manifestations of acne.3

Treating Acne Using Botulinum Toxin

BoNT-A has been shown to decrease sebum production and reduce pore size in patients with oily skin

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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promising target in the management of disorders with increased sebum level such as acne.10 In my clinical opinion, BoNT-A seems to be a safe and effective way to help patients with oily skin and acne, although I think this approach deserves more research. In my practice, I have performed many BoNT-A injections aiming to reduce forehead wrinkles as well as their oily skin and pore size. Therefore, when patients present with both concerns, I recommend this approach, especially in adults as I often find that they don’t tolerate typical acne treatments well due to associated side effects such as skin dryness and irritation.

in smoother skin.15,16,17 The microbotox solution is mixed in the syringe by adding a small volume of lidocaine to the calculated dose of BoNT-A drawn from a standard bottle of BoNT-A prepared with 2.5ml of saline. Each 1ml syringe of microbotox solution contains 20-28 units of BoNT-A per ml of solution and is used to deliver 100-120 injections. The lower face and neck will usually require 1ml per side. The injections are delivered intradermally using a 30 or 32 gauge needle raising a tiny blanched weal at each point.15

An emerging treatment Treatment considerations Not every patient with acne is a candidate for BoNT-A treatment. The main contraindications for BoNT-A include patients with myasthenia gravis, amyotrophic lateral sclerosis, multiple sclerosis, LambertEaton syndrome, women who are pregnant and breastfeeding, neonate and children, patients with focal and systemic infections, patients who are hypersensitive or allergic to BoNT-A and patients who have previously undergone lower eyelid surgery.11 It is not recommended to inject infected skin, so patients with severe inflamed or cystic types of acne should not be treated. In these patients, the inflammation and infection must be reduced with a standard dermatological treatment first, then BoNT-A can be considered. More research needs to be done to establish the correct dosage of BoNT-A in acne management. As BoNT-A is frequently used to treat forehead, glabella and lateral canthal lines, the standard dosage can be administered safely on those zones and help with skin problems in those areas. However, many patients commonly present with acne on other areas such as the cheeks or nose as well, which causes the treatment to be more complicated. Practitioners can’t put standard dosages in those areas as, from my observation, it can cause side effects such as paralysing the levator anguli oris muscle, resulting in a drop of the mouth corner. It’s not only the dosage that is important when treating acne skin with BoNT-A. For an effective treatment, the injection technique and placement are very important. A procedure that facilitates the correct placement into the dermis is inserting the needle at a 75° angle and considering the extrusion of toxin from adjacent pores as an endpoint.12 I believe the ideal BoNT-A treatment protocol for patients with acne would be to use a minimal effective dosage of BoNT-A and be able to administer injections across the whole face in multiple points close to each other.13 The answer could be microbotox, which is also known as mesobotox. This type of treatments involves much lower dosage of BoNT-A than standardly used, allowing practitioners to inject in offlabel indications areas.14 Microbotox is a technique that involves tiny blebs of botulinum toxin, and appears to be a potentially suitable technique to treat acne and oily skin not only on the face, but in areas such as the chest or back.15,16,17 It refers to the injection of multiple microdroplets of diluted BoNT-A into the dermis, or the interface between the dermis and the superficial layer of facial muscles at 0.8-1.0cm intervals.15,16 The intention is to decrease sweat and sebaceous gland activity to improve skin texture and sheen, as well as to target the superficial layer of muscles that find attachment to the under surface of the dermis, causing visible rhytids. The technique has been utilised successfully in the upper face and mid-face, and more recently in the lower face and neck. It also provides the ability to control sweat and sebaceous glands, resulting

BoNT-A for acne treatment is a very interesting concept. Although the dosage we use to treat forehead lines, glabella and lateral canthal lines can also be effective in reducing pore size and sebum production, there is still not enough information and research to be able to safely treat other zones with acne. Outside the forehead and eye area, it seems that the most probable way of treating acne skin would be a microdroplet technique with BoNT-A reconstituted in greater volume of 0.9% sodium chloride, distributed in multiple injection points close to each other. As we can see through available data, the approach looks very promising and in future we could have a new alternative mainstream treatment for patients suffering of acne or oily skin. Dr Magdalena Szymanska Bueno practises in Poland (Warsaw and Poznan) and Spain (Zaragoza). She graduated in medicine at the Poznan University of Medical Sciences in 2009 and is a specialist in dermatology and venereology at Heliodor Swiecicki Clinical Hospital at the Karol Marcinkowski Medical University in Poznan. Dr Szymanska Bueno is a fellow of the European Board of Dermatology-Venereology (FEBDV), member of the Polish Dermatology Association and member of the European Academy of Dermatology and Venereology. Qual: MD, EADV REFERENCES 1. Tan AU, Schlosser BJ, Paller AS. A review of diagnosis and treatment of acne in adult female patients. Int J Womens Dermatol. 2017;4(2):56–71. Published 2017 Dec 23. 2. Lovászi M, Szegedi A, Zouboulis CC, Törőcsik D. Sebaceous-immunobiology is orchestrated by sebum lipids. Dermatoendocrinol. 2017;9(1):e1375636. Published 2017 Oct 17. 3. Martel JL, Badri T. Anatomy, Hair Follicle. [Updated 2019 Jan 30]. In: StatPearls Treasure Island (FL): StatPearls Publishing; 2020 Jan. <https://www.ncbi.nlm.nih.gov/books/NBK470321/> 4. Samizadeh, S, ‘Botulinum Neurotoxin Formulations’, Aesthetics journal, January 2018. <https:// aestheticsjournal.com/cpd/module/botulinum-neurotoxin-formulations> 5. Schlessinger J, Gilbert E, Cohen JL, Kaufman J. New Uses of AbobotulinumtoxinA in Aesthetics. Aesthet Surg J. 2017;37(suppl_1):S45–S58. 6. Kim YS, Hong ES, Kim HS. Botulinum Toxin in the Field of Dermatology: Novel Indications. Toxins (Basel). 2017;9(12):403. Published 2017 Dec 16. 7. Min P, Xi W, et al. Sebum Production Alteration after Botulinum Toxin Type A Injections for the Treatment of Forehead Rhytides: A Prospective Randomized Double-Blind Dose-Comparative Clinical Investigation. Aesthet Surg J. 2015 Jul;35(5):600-10. 8. Rose AE, Goldberg DJ. Safety and efficacy of intradermal injection of botulinum toxin for the treatment of oily skin.Dermatol Surg. 2013 Mar;39(3 Pt 1):443-8. 9. Ney JP, Joseph KR. Neurologic uses of botulinum neurotoxin type A. Neuropsychiatr Dis Treat. 2007;3(6):785–798. 10. Li ZJ, Park SB, Sohn KC, Lee Y, Seo YJ, Kim CD, Kim YS, Lee JH, Im M.Regulation of lipid production by acetylcholine signalling in human sebaceous glands. J Dermatol Sci. 2013 Nov;72(2):116-22. 11. Satriyasa BK. Botulinum toxin (Botox) A for reducing the appearance of facial wrinkles: a literature review of clinical use and pharmacological aspect. Clin Cosmet Investig Dermatol. 2019; 12:223–228. Published 2019 Apr 10. 12. Campanati A, Martina E, Giuliodori K, Consales V, Bobyr I, Offidani A. Botulinum Toxin Off-Label Use in Dermatology: A Review. Skin Appendage Disord. 2017 Mar;3(1):39-56. Epub 2017 Feb 1. 13. Wu WT Microbotox of the Lower Face and Neck: Evolution of a Personal Technique and Its Clinical Effects Plast Reconstr Surg. 2015 Nov;136(5 Suppl):92S-100S. Kim J. Clinical Effects on Skin Texture and Hydration of the Face Using Microbotox and Microhyaluronicacid. Plast Reconstr Surg Glob Open. 2018;6(11):e1935. Published 2018 Nov 12. 14. Woffles T. Wu. Microbotox of the Lower Face and Neck: Evolution of a Personal Technique and Its Clinical Effects. Plast Reconstr Surg. 2016 Dec;138(6):1073e-1074e. 15. Downie JB, Patel A, Heningburg J. Global Updates on the Future Directions of Neurotoxins and Fillers. Plast Reconstr Surg Glob Open. 2016;4(12 Suppl Anatomy and Safety in Cosmetic Medicine: Cosmetic Bootcamp): e1177. Published 2016 Dec 14. 16. Khadiga S. Sayed, Rehab Hegazy, et al., The efficacy of intradermal injections of botulinum toxin in the management of enlarged facial pores and seborrhea: a split face-controlled study, Journal of Dermatological Treatment, (2020).

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Case Study: Lower Face Rejuvenation Nurse prescriber Nina Prisk describes her treatment approach to create a more balanced profile Concerns and consultation A 35-year-old female patient presented to clinic complaining that she felt she had no definition in her lower face, lacked a clear jawline and balanced profile. The patient also noted that her cheeks had become flat, which enhanced the appearance of heaviness to the jowl area. In addition, she was concerned that her chin appeared flat. The patient felt she looked tired and, in general, wanted to appear brighter and fresher. I had previously seen the patient for other treatments and procedures, including botulinum toxin treatment to the orbicularis oculi, glabellar and frontalis muscles, as well as for radiofrequency skin tightening. As such, I was aware of her history, which was documented. I carried out a full and concise consultation for the new potential procedures, including revisiting information on her medical and aesthetic history, confirming once again that she had no known allergies, was not on any medication, and was fit and well. The consultation began with an explanation of the facial ageing process and the translation of the triangle of youth in simple terms to the patient, discussing how a young face will have volume at the top, tapering downwards into a triangle, whilst an older ageing face will see this triangle inverted.1,2 Given the patient’s concerns that she would have puffy, over-filled cheeks if she were to have dermal fillers in this area, I educated her appropriately on the anatomy and physiology of the face. I detailed the structural changes that occur during the ageing process on the surface and subsurface of the skin, how the face loses volume through fat redistribution, as well as how we lose bone density and collagen over time.3 I also explained that by treating the lower face alone, we may accentuate her heaviness in the jowl area. As such, my aim was to lift the area, replace the volume lost, give the cheeks more contour, and fill the hollows of her eyes. Once I had explained everything, the patient was happy to proceed. A range of photographs were taken from different angles, showing a variety of facial expressions for before and after comparisons.

Product selection and technique Mid-face The correct choice of product is especially important when restoring volume. In the mid-face a filler is needed that is going to retain its form but remain flexible on movement. It must integrate well and support the tissue. My preference for this patient was Juvéderm Voluma, which is a thick, viscous hyaluronic acid filler.4 I began by prepping the skin with chlorhexidine and applied anaesthesia topically with LMX4 cream. I then marked out the points of injection using Dr Mauricio de Maio’s MD Codes system,5 as well as marking out the danger zones I wanted to avoid such as the zygomatic facial artery, the infraorbital artery, the buccal nerve, the parotid gland, and the facial artery and vein.

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I injected the filler onto the periosteum, aspirating for 10 seconds first, using a 27 gauge needle onto the CK1 site – the upper lateral, outer part of the zygomatic arch, using a total of 0.3ml in this area. I then injected 0.3ml to the zygomatic eminence (CK2) and 0.3ml to the anteromedial cheek (CK3), which gave a clear, visible lift. Using a blunt cannula with a 25 gauge I injected into the soft tissue in the lower lateral point (CK4) and lower medial point (CK5), using 0.25ml in each area, bilaterally. I used the cannula fanning technique, as this has been found to reduce swelling and bruising, and is thought to be safer for reducing vascular penetration.6 This was used alongside a linear threading technique.7 The procedure gave instantly good results. There was clear volume and lift, with a brighter, less tired look. Lower face I assessed the patient after injecting the cheeks to see whether there was a need to focus on the lower face to address the concerns she had. It was agreed that we did need to go ahead with the lower face rejuvenation. I analysed the lower face, took a further round of photographs and examined them with the patient. During this secondary consultation I suggested that the chin needed more

Figure 1: Before and after treatment to the mid and lower face using Juvéderm Voluma and Juvéderm Volux.

projection and to be brought out more in line with her nose to balance the profile. The patient was experiencing slight sagging in the pre-jowl sulcus. This area is anterior to the jowls and often develops as a result of the ageing process.8 I felt that this needed to be lifted. There was also a lack of definition in the angle of the mandible – the anterior part of the lower jaw bone. The patient was prepped following the same procedure as the mid-face rejuvenation and I once again marked the areas on the face that I’d inject. I used a 27 gauge needle in the lower face, injecting Juvéderm Volux, a product developed specifically to add structure and definition to the jawline and chin,4 with 0.1ml into C1 and 0.2ml into C2 of the chin and 0.3ml to the marionette lines at C6. Following this, I injected 0.3ml to the angle of the mandible down to the periosteum (JW1). I then used a cannula to inject 0.2ml in the soft tissue in the areas along the jawline at points JW3 and JW4. The entire procedure took around 30 minutes and there were no challenges to contend with. The results were positive immediately, however swelling did begin around 15 minutes later which was to be expected.

Aftercare It is worth noting that the environment in which I work is of paramount importance for the comfort of patients and health and safety considerations. As such, I always wear sterile gloves, I use sterile packs and dress in surgical clothing. With any procedure of this nature there is always a risk of vascular

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


occlusion.9 In case of emergencies I have hyaluronidase at my clinic at all times. Following the procedure, the patient was given aftercare advice. I advised no makeup for 24 hours, no direct heat, sunbeds or saunas. I also advised avoiding alcohol for 24-48 hours, to avoid exercise and manipulating the injected areas by touching them excessively. Touching the area can introduce bacteria to the injection sites. Heat can induce additional swelling, and as alcohol is a vasodilator, it could result in additional bruising and swelling, which would also be the case for exercise.10 The patient was told that bruising and swelling could occur, and was also given an emergency phone number direct to me to call if she needed to. She was advised to take oral analgesia if required, such as paracetamol, and to apply ice for swelling if necessary. I recommended arnica tablets and cream, but no other skincare recommendations were made as she was already on a good skincare regime using the Obagi Nu-Derm System. The patient experienced some initial swelling over the next couple of days, which is to be expected. She regularly iced the areas affected. The chin was particularly swollen and sore and took a couple of days to go down.

TOUCH THE FUTURE OF CELLULITE REDUCTION

VISIBLE REDUCTION IN CELLULITE1

ALL SKIN & BODY TYPES

Follow up and results I arranged a follow-up appointment for two weeks after the procedure for review. At this point there was no evidence of bruising and no infection. The patient admitted she had cried in happiness with the results of the treatment. She was exceptionally pleased with the outcome, which gave clear definition to her face. This procedure was an advance injection technique, so it is vital to ensure that proper training has been undertaken to ensure competency. A reputable, accredited, trainer is advised. To get the best results, it is important to intently study the face and have a thorough understanding of the vascular anatomy.

NON-INVASIVE & NO ANESTHESIA

Nina Prisk is an aesthetic nurse prescriber, who trained on Harley Street and now works full time in facial aesthetics, concentrating solely on injectables. Prisk practises from her clinic Update Aesthetics in Cornwall, as well as in Harley Street as part of the Banwell Collective, led by consultant plastic surgeon Mr Paul Banwell. Qual: RGN INP REFERENCES 1. Coleman S, Grover R, ‘The Anatomy of the Ageing Face: volume loss and changes in 3-dimensional topography’, Aesthetic Surgery Journal <https://academic.oup.com/asj/article/26/1_ Supplement/S4/223473> 2. Martin C, ‘The Filler Effect’, The New York Times <https://www.nytimes.com/2016/03/24/fashion/ dermatology-fillers-sagging-skin.html> 3. Hartley S, ‘The parts of the body you probably didn’t realise osteoporosis affect’, Netdoctor <https://www.netdoctor.co.uk/healthy-living/a26779/osteoporosis-affects-the-face-too/> 4. Juvéderm, Why Juvéderm It? <https://www.juvederm.co.uk/what-is-juvederm> 5. De Maio M, ‘MD Codes’ <https://www.mdmaio.com/md-codes/> 6. Dermal Fillers – The Cannula Technique (UK: DrMedispa.com) <https://drmedispa. com/2019/09/03/dermal-fillers-cannula-technique/> 7. Injection techniques (US: Medical Esthetics GmbH) <https://www.wo-med.com/en/dermalstyle/ aerzteinfothek/injektionstechniken/> 8. Fattahi T, ‘The Prejowl Sulcus: an important consideration in lower face rejuvenation’, Oral and Maxillofacial Surgery <https://www.joms.org/article/S0278-2391(06)02210-5/abstract> 9. Grzybinski S, Temin E, ‘Vascular Occlusion after Hyaluronic Acid Filler Injection’, CPC Emergency Medicine <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965121/> 10. Goodman GJ, Liew S, Callan P, Hart S, ‘Facial aesthetic injections in clinical practice: pretreatment and posttreatment consensus recommendations to minimise adverse outcomes’, Australas J Dermatol <https://www.ncbi.nlm.nih.gov/pubmed/32201935>

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Treating Hollow Temples with Filler Dr Ciara Abbott details the anatomical considerations of the ageing temple and shares techniques for successful treatment The temporal region is a frequently overlooked area in facial rejuvenation, yet its impact on the ageing face can be dramatic. Patients are often unaware of the negative impact of hollow temples on their appearance and due to the gradual ageing of this area, rarely request specific temple treatment. However, it is a key area that practitioners should actively assess and consider treating due to its wide range of positive outcomes, including improvement of deep periorbital lines, lifting of the lateral brow and rebalancing of the facial structure to create a more youthful appearance.

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tissue layers overlying the temple fossa. The four borders of the temporal region are recognised as: superiorly the temporal fusion line, inferiorly the superior border of the zygomatic arch, medially the lateral edge of the orbital rim and laterally the temporal hair line.6,7 The most important of these is the easily palpable temporal fusion line, which allows for reliable location of the ‘safe zone’. This is widely accepted to be 1cm superiorly along the temporal fusion line (caution should be taken if using the tail of the brow as the starting point due to medical and cosmetic alterations of the patient’s original brow), and 1cm inferior to this point (Figure 1).6 Not only is this safe zone most likely to be free of important vasculature (superficial, middle and deep temporal arteries, middle temporal vein) but also is the shallowest part of the temporal fossa to make contact with periosteum and allow for ease of injection, if choosing to administer product with a needle. Secondly, when considering temple anatomy, it is essential to understand the relationship of the tissue planes and their individual depth. This allows for appreciation of where product should be correctly placed for optimum results. Figure 2 highlights the multiple soft tissues layers originating from the cranium and their intimate relationship with one another. Although there is some discrepancy amongst anatomists as to the particular correlation these tissues, it is widely accepted that to treat the deep temple safely, and to obtain prime cosmetic outcomes, product needs to be placed ideally on the periosteum

Anatomy and the ageing temple In order to treat this important region successfully and without complication, it is essential to understand the anatomy of the temple and how the ageing process impacts the bony and soft tissue dimensions. Facial ageing is a complex process of bone deposition and resorption, redistribution of facial fat pads and declining skin elasticity.1 Dynamic bony changes result in significant bone atrophy in some areas supporting the temple, such as the inferolateral aspects of the orbital rim and maxilla, which contrasts with bone deposition and expansion in other surrounding structures, such as the zygomatic arch and supraorbital rim.2 In addition to skeletal changes, there is subcutaneous volume loss through the depletion of fat, reduction of elastin and collagen and loss of the temporal fascia, combined with an excess of orbital and temporal skin.3,4 The result is an apparent hollowing of the temporal fossa and what has been described as the ‘peanut-shaped face’ associated with ageing.5 It is best to approach the anatomy of the temple in two ways; the first being to understand the surface anatomical landmarks to demarcate the region itself, which ensures safe injection and helps avoid vascular complication and, secondly, to appreciate the complex soft

Patients are often unaware of the negative impact of hollow temples on their appearance and due to the gradual ageing of this area, rarely request specific temple treatment

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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1c

Within my own practice I regularly use HA dermal fillers to treat the temple, for several Temporal reasons. Firstly, HA fillers are thought to be Supratrochlear fusion line artery more stable and less likely to migrate in this Superficial area than alternative fillers mentioned above.10 temporal artery Supraorbital In addition, they provide immediate cosmetic artery results, and therefore allow the practitioner to actively assess the appropriate level of rejuvenation required and, thus, prevent overcorrection of this subtle area. Furthermore, their reversibility makes for a sensible choice in Suggested this complex anatomical region. safe zone When choosing which HA filler to use, one should consider the thickness of the dermis of the temporal skin, which, along with periorbital skin, Middle is known to reduce in thickness with ageing. It is temporal vein therefore important to consider filler viscosity to prevent visible skin complications but, in practice, if treating the temporal defect by deep periosteal injection, this should be of less clinical concern. In my experience, due to the large volume loss often seen in this area, a highly crosslinked, viscous product with a high G prime, is likely to produce better ‘lift’ and will provide potential longevity of treatment for the patient. Figure 1: Suggested safe injection zone for the temple lies between the superolateral bony orbital Volume of product is another consideration as, margin, approximately 1cm inferior to the temporal fusion line and over one finger breadth above the superior border of the zygoma in order to avoid the middle temporal vein.6 in order to achieve visible results, large volumes of HA filler may be required. From experience, in and inferior to the temporalis muscle. However, the temporalis muscle the majority of cases an average of 0.5-1ml of HA filler in each temple is often significantly adhered to the periosteum. As a result, product is required to rejuvenate this region, which may be undertaken in a deposition here is actually likely to be intramuscular but practitioners sessional approach, and it is essential to have this discussion with your should still ensure it is inferior to the deep temporal fascia.8 Within patient prior to treatment. the fascial layers runs significant arterial supply and therefore, again, comprehension of the soft tissue relationship to the periosteum will Treatment technique prevent vascular complications. Temple rejuvenation has been previously approached with both cannula and needle, and the differences in technique and outcomes Treatment approaches have been extensively discussed between aesthetic professionals.11 As appreciation for rejuvenating the temple has increased, so too has It is generally accepted that use of cannula in this region needs to be the evolution of product choice. Various treatments are utilised in this with a blunt tip and inserted superficially i.e. interfascial or subdermal; area, ranging from autologous fat transfer, to polylactic-L-acid (PLLA) the benefit being reduced vascular trauma and potentially less filler and the more commonly-used hyaluronic acid (HA) fillers. product requirements.12 However, I find that contour irregularities are a potential complication with superficial placement. More commonly is the use of needle injection, down to periosteum using a bolus technique.6,12,13 By being down to bone, one can be more confident that they are unlikely to be within a vessel, due to the vasculature in this region running within the soft tissue layers, for example, in the temporalis muscle and above. Herein we discuss my approach to use of needle injection for temple rejuvenation. It is essential with every individual patient to accurately mark the anatomical landmarks prior to treating the temple region. Once the location of the ‘safe zone’ has been identified, using the 1cm superior and inferior rule, the practitioner needs to palpate the ‘safe zone’ again to ensure there is no palpable pulse. This can be quite subtle and easy to miss; therefore, I would advise to feel for this with an ungloved finger. Once the clinician can be assured there is no arterial pulse felt, it is important to next look closely at the skin within the ‘safe zone’ to ensure there is no prominent venous supply. A surgical light can highlight this adequately, or asking the patient to lean forward and perform the Valsalva manoeuvre can emphasise any hidden venous 1c m

m

The end result should ensure an acceptable subtle concavity, particularly in females, to prevent masculinisation that occurs with a convexity or overcorrecting of the temple

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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supply which can subsequently be avoided. After ensuring there are no vessels at the site of injection, clean the skin and adopt appropriate aseptic technique. Then, using a 27 gauge needle, with entry perpendicular (90 degrees) to skin, I insert the needle deep to bone, cautiously ‘touching’ the periosteum to avoid trauma to the thin temple bone. This is followed by aspiration to ensure no return of blood in the needle hub.

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Bone

Temporalis muscle

Deep temporal artery

Middle temporal artery Temporalis muscle facia

Pericranium

Superficial temporal artery and vein Loose areolar tissue

If right handed, hold the syringe in the right hand, aspirate with the left and then immediately place the Tempoparietal fascia index and third finger of the left hand straight onto the Subcutaneous tissue patient’s hair line and apply light pressure to this area during the injection. This prevents posterior spread of product. Injection here needs to be extremely slow with Skin even pressure. During this slow delivery of product, the injector should be able to visualise the gradual lift of the temporal hollow, which not only confirms the correct position and placement of the product, but also Figure 2: The temporoparietal fascia flap9 allows for the injector to continually assess the amount of product required whilst injecting. Of course, if left handed, adopt the opposite approach. In my experience, careful mapping of anatomy, precise marking of It is important to bear in mind potential asymmetry, with the left and vasculature and the ‘safe zone’, and treating the temple with needle right temple potentially requiring different amounts of product due down to periosteum, with aspiration and slow injection, is the safest to uneven volume loss, and also to appreciate the need for underand most reliable way of treating this complex area. Counselling your treating the area. The end result should ensure an acceptable subtle individual patients about potential risks and side effects versus their concavity, particularly in females, to prevent masculinisation that possible aesthetic improvement is key to a successful outcome when occurs with a convexity or overcorrecting of the temple. treating the temple with HA filler.

Side effects and complications As with all dermal filler procedures, treating the temple can result in common side effects such as bruising, due to the thinness of the temple skin and/or swelling. In my experience, this can be counteracted by gentle compression of the injected area. Furthermore, patients can often describe the area as being tender some hours after the procedure, so general aftercare advice and post-treatment analgesia is beneficial. In addition, overcorrection of temple deficit by excessive product injection will result in an unwanted cosmetic outcome, so it is therefore best to always under treat and consider treatments in several sessions to avoid this. Serious complications have been documented when treating the temples with filler, and therefore anatomical understanding is key. The most significant of these are vascular complications, namely retinal occlusion resulting in iatrogenic blindness, when filler is injected inadvertently into the ocular circulation.14 To avoid these potentially catastrophic complications, I would recommend that the practitioner should adhere to the following: • After marking anatomical landmarks and the ‘safe zone’ adhere to deep bolus injection of the temple • Ensure needle is down to periosteum and aspirate to ensure no inadvertent vascular injection has occurred • Slow injection of small volumes of reversible HA filler

Dr Ciara Abbott is the medical director and co-owner of Barstable Medical Clinic in Essex and has worked in the aesthetic industry for the past nine years. Her clinic was shortlisted for Best Clinic South England at the 2017 Aesthetics Awards and she is an associate member of the British College of Aesthetic Medicine. Qual: MBBS, BSc, MRCS(Eng), MRCGP

REFERENCES 1. Coleman S, Grover R, ‘The anatomy of the ageing face; volume loss and changes in 3-dimensional topography’, Aesthetic Surgery Journal 2006; 26: S4-9. 2. Mendelson, Bryan and Wong, Chin-Ho, ‘Changes in the facial skeleton with aging: implications and clinical applications for facial rejuvenation’, Aesthetic Plastic Surgery 36 (2012) pp.753-760. 3. Jaishere Sharad, Maya Vedamurthy, ‘Aesthetic Dermatology; Current perspectives’, Jaypee Medical Publishers, 2019, p.178. 4. Kaur, Manavpreet et al. ‘Analysis of facial soft tissue with aging and their effects on facial morphology; A forensic perspective’, Egyptian Journal of Forensic Sciences 5 2015 p.45-56. 5. Fitzgerald R; Carqueville J; Yang PT., ‘An approach to structural facial rejuvenation with fillers in women’, International Journal of Women’s Dermatology. 2018, 13; 5(1) p52- 67. 6. Carruthers, J; Humphrey, S; Beleznay, K; Carruthers, A, ‘Suggested injection for soft tissue fillers in the temple’, Dermatologic Surgery. 2017 - Volume 43 - Issue 5 - p 756-757. 7. Issa, Maria; Tamura, Bhertha., ‘Botulinum toxins, fillers and related substances’, Clinical Approaches and Procedures In Cosmetic Dermatology. Springer International Publishing. Volume 4. (2019) p1-17. 8. Dr Tapan Patel, ‘Dermal Filler Treatment Temple Orbital’, E-Mastr https://e-mastr.com/lessons/dermalfiller-treatment-temple-orbital/ 9. Collier H, ‘Temple Restoration’, PMFA Journal, October/November 2015. Vol 3 No 1. 10. Sherman, Richard N, ‘Avoiding dermal filler complications’, Clinics in Dermatology. 2009. 27(3). 11. Onorati, H. ‘Best Practices for temple rejuvenation’, Dermatology Times. 2013. 12. Cotofana S, Gaete A., ‘The six different injection techniques for the temple relevant for soft tissue filler augmentation procedures – Clinical anatomy and danger zones’, Journal Of Cosmetic Dermatology, 2020. 13. Breithaupt AD, Jones DH, Braz A, Narins R, Weinkle S, ‘Anatomical basis for safe and effective volumization of the temple’, Dermatol Surg. 2015 Dec;41 Suppl 1:S278-83. 14. Funt, D and Pavicic, T, ‘Dermal fillers in aesthetics: an overview of adverse effects and treatment approaches’, Clinical, cosmetic and investigative dermatology, 6 (2013) pp.295-316.

Conclusion Treatment of hollow temples is often an under-appreciated part of facial rejuvenation, both by patients who overlook this subtle area of ageing, and sometimes by practitioners who may feel the potential side effect risks outweigh treatment benefit.

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mild to moderate tissue sagginess.1 In this case, the patient’s jawline area was graded as mild sagginess. I always offer a cooling-off period prior to treatment to help patients make an informed decision. This is particularly important in the case of a thread lift as it requires compliance with aftercare guidance, including avoidance of makeup for 24 hours after the procedure, limitation of activities such as facial exercise and high impact Nurse prescriber Yuliya Culley describes treating sports for two to four weeks, a softer diet a younger patient to improve jawline definition for the first week, and avoidance of dental treatments for up to four weeks afterwards.3 Patient presentation I made sure all aspects were covered during the initial consultation A 39-year-old female Caucasian patient presented to Novello Skin to ensure the patient could make relevant arrangements and be fully clinic with concerns about her jawline definition. She requested a prepared for the procedure, as well as leaving herself enough time reduction in skin laxity and jowling, noting that she used to have a to recover afterwards. I have found that when patients are provided much more defined jawline, but this had been affected by age and with aftercare instructions and are well prepared for the downtime fluctuations in her weight. Even though she had been maintaining a following the procedure, they are not surprised or concerned about healthy lifestyle, with regular exercise and a good skincare routine, she mild side effects.2 believed that her jawline created an impression of extra weight. The patient felt that the contours of her face were important in helping her Treatment project a youthful appearance and maintaining her self-confidence. The patient was asked to arrive without makeup on the day to The patient had undergone a number of previous treatments at our minimise the risk of infection. She also was advised to avoid drinking clinic and, as a result, we knew that her medical history indicated no alcohol and taking omega-3 fatty acids and vitamin E preparations for underlying conditions. Previously we had put a gradual treatment plan two to three days prior to the procedure, in order to minimise the risk in place according to her anatomical features, starting with a mid-face of bruising.5 Traditionally, non-steroidal anti-inflammatory drugs such as treatment using Juvéderm Voluma and chin treatment with Juvéderm Ibuprofen are avoided prior and post some aesthetic procedures and Volux. Although these had a positive outcome, the patient felt that dermatology surgery, however the evidence of increased bleeding more lift to her jawline was required to achieve a better result for her in relation to their use is subjective.6 The procedure does require a whole face. We looked at several options for the jawline treatment longer treatment time than fillers or botulinum toxin injections. My such as jaw contouring with dermal filler, radiofrequency skin advice to patients is to allow two hours in the clinic for skin preparation, tightening and thread lift. We eventually decided that a non-surgical careful marking-up of the areas to be treated, as well as application of thread lift would be beneficial for achieving a desirable instant local anaesthesia to make the procedure more comfortable. outcome and long-lasting results, which would improve gradually Skin preparation with antiseptic, an aseptic protocol, meticulous due to collagen stimulation over time. The decision to opt for a marking of treated areas and technique is vital for successful Silhouette Soft procedure for the jawline was influenced by several outcomes and reduction of possible side effects such as excessive factors such as the product’s high safety profile, collagen type 1 swelling, bruising, thread protrusion due to incorrect placement, facial stimulation, as well as previous well-presented case studies for mild asymmetry and infection.2 The environment is also an important factor 1-3 to moderate skin laxity. to consider, including ensuring the treatment room is equipped with The Patients’ Selection guide 4 for the Silhouette Soft procedure was good lighting, a comfortable temperature, procedure consumables, used to establish suitability of the procedure for this patient. In and assistance is available. Before the procedure, the medical order to achieve satisfactory results, the indication for treatment is history of the patient was reviewed again, including a treatment plan recap and a photographic assessment. After initial skin cleansing with Clinisept+, the skin was marked with a Silhouette Soft ruler (Figure 1) and an iodine solution was applied on the tip of the wooden cotton swab. I prefer this marking technique to the water-soluble marker for infection control reasons, providing patients do not exit have allergies to iodine. For this patient, one entry point exit for the insertion of the threads was marked at a 1.5cm point inferiorly to the mandibular angle on both sides. entry The exit points were marked in the submental region point and sternocleidomastoid muscle area on both sides. entry point exit Xylocaine was used for the local anaesthesia with 0.2exit 0.3ml (using a 30 gauge needle attached to the syringe with anaesthetic) at the entry and exit points of the sutures. Eight-coned sutures/6cm – the smallest sutures in Silhouette Soft family (12 and 16 cones are available) – Figure 1: Entry and exit points of sutures

Case Study: Treating the Female Jawline with Threads

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Right side before

Left side before

Right side after

Left side after

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observed in clinic for 30 minutes after the procedure, with vital signs checked such as blood pressure, temperature, respiration rate and SaO2 levels. Additionally, an aftercare pack was provided, which included Cebelia L.C.E balm that aims to assist in bruising and swelling reduction, and Luxeface lifting mask for mechanical support of the treated areas, hydration and anti-inflammatory activity. The patient was reviewed one week post-treatment to ensure a satisfactory healing process was taking place, which it was, and four weeks later to observe the results once the inflammation fully settled.

Summary

Figure 2: Patient before and immediately after one treatment using Silhouette Soft threads

were chosen for this procedure, based on my clinical judgment to approach the patient with petite facial features in this way to ensure full submersion of cones into the subcutaneous tissue. The entry point hole was made with a 18 gauge needle and was used for both needles, attached by the manufacturer at each end of the suture, which were inserted under a 90° angle, placed in opposite directions to each other to achieve the tissue traction, firm soft tissue anchoring and consequent lift.7 The inner needle was moved subcutaneously from the entry point anteriorly to the exit point in the submental region; the opposite needle was advanced subcutaneously posteriorly towards the exit in the sternocleidomastoid muscle area.7 The overall insertion of the sutures on both sides took around 20 minutes. An important step in this particular thread lift technique for the jawline and neck area is to locate superficial vessels due to a higher rate of ecchymosis post-procedure in these areas.7 The correct traction and pulling technique of the cones is important to avoid protrusion and breakage of the threads.2 The manual compression and moulding of the anterior part of the cones first and suspension thread (posterior) end afterwards was performed. To avoid possible asymmetry, I compared lifting effect on both side of the patient’s face/neck in an upright position, before cutting off the suture ends. Additionally, this approach helps to avoid potential post-procedure suture extrusion that could lead to skin irregularities and irritation.2 After careful examination of the entry and exit points to ensure that the threads were submerged in the subcutaneous tissue, Chloramphenicol ointment was applied topically, with the purpose of prophylaxis of potential procedure site infection at the suture entry and exit points. Chloramphenicol ointment topical application on surgical wounds outside of ophthalmic surgery was chosen by 69% of plastic surgeons with wound infection prophylaxis and indicated a 40% lower infection rate.8 However, there are limitations in methodologies, with only a small number of randomised controlled studies for surgical wounds in other medical fields.8,9 Therefore, there is not statistically sufficient data on infection reduction in surgical wound with application in aesthetics, hence further research on the application of chloramphenicol in the aesthetic medical field is advised. Overall, the patient found the procedure much more comfortable than expected, but did experience a feeling of skin tightening, swelling and soreness in the treated areas. All these side effects were expected and covered during the initial consultation.

Aftercare As part of the patient’s aftercare, a light-emitting diode (LED) therapy session was incorporated straight after treatment to stimulate healing and minimise potential swelling and inflammation.10,11 The patient was

The patient was satisfied with the outcome of her Silhouette Soft thread lift procedure for jawline contouring, noting in her feedback that the immediate, noticeable jawline lift was observed after one treatment. As many patients prefer to undergo less invasive procedures rather than surgical solutions with longer downtime, the thread lift techniques provides us with a way to meet this growing demand.12 However, the Silhouette Soft procedure is an advanced technique requiring knowledge and skills to achieve positive results and minimise side effects. According to the Care Quality Commission (CQC), in England any procedures that incorporate insertion of instruments or equipment into the body, including thread lift, must be CQC registered by law.13 There is still unclarity regarding clinical standards by CQC around suture lift procedures to date. Currently, in the UK only medical practitioners who have been trained by Sinclair Pharma can perform Silhouette Soft lift, which is described as an in-office procedure, demanding aseptic technique and high training level.14 Yuliya Culley is a registered general nurse, an independent nurse prescriber, as well as the founder of the Novello Skin clinic. She has experience in emergency, cardiology and dermatology nursing. Culley currently trains other medical practitioners through 4T Medical. Qual: BSc, MSc RGN, INP REFERENCES 1. Nester, M. (2019). Facial lift and patient satisfaction following treatment with absorbable suspension sutures: 12-month data from a prospective, masked controlled clinical study. Clinical and Aesthetic Dermatology.12 (3), pp. 18-26. 2. Guduk, S., S. and Karaka, N. (2018). Safety and complications of absorbable threads made of poly-Llactic acid and poly lactide/glycolide: Experience with 148 consecutive patients. Journal of Cosmetic Dermatology. 17(6), pp.1189-1193, <https://www.ncbi.nlm.nih.gov/pubmed/29607627> 3. Guida,S., Persechino, F., Rubino, G., Pellacani, G., Farnetani, F. and Urtis, G.G. (2018). Improving mandibular contour: A pilot study for indication of PPLA traction thread use. Journal of Cosmetic and Laser Therapy. 20(7-8), pp.465-469, <https://www.ncbi.nlm.nih.gov/pubmed/29461124> 4. Sinclair Pharma (2016). Silhouette Soft patients’ selection. Easel print. <https://portal.sinclairpharma. com/portal/silhouette-soft/physicians/marketing-physician/patient-selection-easel> 5. Mousa, S. (2010). Antithrombotic effect of naturally derived products on coagulation and platelet function. Anticoagulants, Antiplatelets and thrombolytics. 2nd ed. pp. 229-240. 6. Nelson, S., Nelson, T., Mortimer, N. and Salmon. P (2019). Can I take my normal pain killer doctor? Therapeutic management of pain following dermatological procedures. Australian Journal of Dermatology. 60 (1), pp. 19-22. < https://onlinelibrary.wiley.com/doi/pdf/10.1111/ajd.12879> 7. Khiabanloo, S.R., Jebreili, R., Aalipour, E., Saljoughi, N., Shahidi, A. (2018). Outcomes in thread lift for face and neck: A study performed with Silhouette Soft and Promo Happy Lift double needle, innovative and classic techniques. Journal of Cosmetic Dermatology. 18, pp. 84-93.<https:// onlinelibrary.wiley.com/doi/epdf/10.1111/jocd.12745> 8. Shen, A., Haddad, E., Hunter-Smith, D. and Rozen, W. (2018). Efficacy and adverse effects of topical chloramphenicol ointment use for surgical wounds: a systemic review. ANZ Journal of Surgery. 88 (12), pp.1243-1246. 9. Heal, C., Buettner, P., Cruickshank, R., Graham, D., Browning, S., Pendergast, J., Drobetz, H., Gluer, R. and Lisec, C. (2009). Does single application of topical chloramphenicol to high risk suture wounds reduce incidence of wound infection after minor surgery? Prospective randomised placebo controlled double blind trial. BMJ. 338 (7688), pp. a2812-2818., < https://www.bmj.com/content/ bmj/338/bmj.a2812.full.pdf> 10. Pitassi, L. (2018). Light-Emitting Diode for Acne, Scars and Photodamaged Skin. Lasers, lights and other technologies. pp.73-87. 11. Jagdeo, J., Austin, A., Mamalis, A., Wong, C., Daniel, D. and Siegel, D. (2018). Light-Emitting Diodes in dermatology: A systematic review of randomised Controlled trials. Lasers in surgery and medicine. 50 (6), pp. 613-628. 12. Youssef, C. (2020). The art of threads. The comprehensive review. Prime Journal.10 (2), pp. 33-40. 13. Care Quality Commission (2018) Choosing cosmetic surgery. <https://www.cqc.org.uk/help-advice/ help-choosing-care-services/choosing-cosmetic-surgery> 14. Sinclair Pharma Limited (2020) Silhouette Soft: Step by Step Procedure. <https://silhouette-soft.com/ the-procedure/>

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eyelid contains the insertion of the levator palpebrae superioris muscle, which forms the upper eyelid skin crease (Figure 1).3 The intricate eyelid structure results in complex periocular changes over time. One of the first signs is the presence of excess skin, termed dermatochalasis. With ageing, the skin becomes loose and inelastic as collagen production declines and this is accelerated by UV exposure. Excess skin can be so severe that it can start to obstruct vision in the superior visual field. If the orbital septum and ligaments weaken, the support of fat and muscle is reduced.4,5 In the upper eyelid, there are two fat pads which commonly prolapse forward, namely medial and central posterior with respect to the orbital septum. In the lower lid, there are three fat pads, medial, central and lateral (Figure 2). As facial tissues descend and weaken there is an associated cheek ptosis which deepens the nasojugal fold, called the tear trough deformity. The levator aponeurosis can stretch resulting in ptosis of the upper eyelid. The smooth muscle retractors in the lower lid can also weaken, resulting in an entropion or ectropion. These age-related changes underpin the concerns of many patients seeking rejuvenation of the periocular area.4,5

Assessing the Eye Before Blepharoplasty

Periocular evaluation Assessment starts with a thorough history focusing on medical, ophthalmic and aesthetic aspects. A mirror is very useful at this stage. It is important to understand the patientâ&#x20AC;&#x2122;s concerns and manage their expectations realistically. I always offer surgical patients an optional complementary second consultation to discuss any outstanding issues. I also send a detailed medical report and information on aftercare. Practitioners should review the brow position; a ruler can be used to look for brow asymmetry and any brow ptosis should be noted and addressed prior to surgical or non-surgical blepharoplasty.6 Brow position does not change in patients who undergo upper eyelid blepharoplasty for simple dermatochalasis.7 A retrospective study by Goldberg et al. found the mean preoperative brow position to be approximately 17.5mm above the pupil, with the eye in primary position.7 For your assessment, the upper eyelid position should be inspected and any asymmetry, excess skin or fat pad prolapse should be noted. The measurements start with the palpebral aperture, which is the distance between the upper and lower eyelid; it usually measures 10mm.8 Next, to aid the diagnosis of a ptosis, the distance between the

Consultant oculoplastic surgeon Miss Elizabeth Hawkes discusses the ageing of the eye area and indications for surgical and non-surgical blepharoplasty Blepharoplasty is one of the most commonly performed cosmetic operations.1 The eyes are an important aesthetic facial feature and eyelid skin is one of the first areas of the face to show signs of ageing.2 By understanding the anatomy and associated facial changes over time, non-surgical and surgical treatment options can be considered. This article describes the ageing process around the eye and how to examine this area in the context of blepharoplasty, and the different blepharoplasty methods.

Ageing process in the periocular region The eyelid is made up of several layers. From superficial to deep; the skin, subcutaneous tissue, orbicularis oculi muscle, orbital septum and tarsal plates, smooth muscle and the conjunctiva. The upper Skin Superior orbital rim

Retro-orbicularis-oculifat pad

Central (pre-aponeurotic fat pad)

Orbicularis oculi muscle

Upper eyelid, central pre-aponeurotic fat pad

Upper eyelid medial fat pad

Orbital septum Lacrimal gland

Levator muscle aponeurosis

Superior rectus

MuĚ&#x2C6;llerâ&#x20AC;&#x2122;s muscle Conjunctiva Tarsal plate (with meibomian gland)

Figure 1: Diagram of the cross section of an upper eyelid3

Lower eyelid Medial fat pad

Inferior oblique muscle

Lower eyelid central fat pad

Figure 2: Diagram of fat pads around eye

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020

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Palpebral aperture

Figure 3: The MRD1 is the distance between upper eyelid margin and central corneal light reflex

Figure 5: Palpebral aperture measurement

pupillary light reflex and the upper eyelid should be measured, which is called the marginal reflex distance one (MRD1), depicted in Figure 3 and described in Figure 4.8 If a ptotic eyelid is ignored during blepharoplasty assessment the patient will likely be disappointed with the outcome because the upper eyelid will still be low. The upper eyelid skin crease should also be assessed. It is thought to be formed by the insertion of levator muscle fibres and is approximately 8-10mm in women and 7-8mm in men.8 The lower lid should be observed for skin quality, excess skin and fat pad prolapse. The presence of horizontal laxity can be assessed by pulling the lid laterally in both directions, which will measure the strength of the medial and lateral canthal tendons. Other measurements are usually taken at this point such as the presence of inferior scleral show, the distance between the inferior corneal limbus and lower eyelid and the distance from the pupil to the lower eyelid â&#x20AC;&#x201C; also known as MRD2 (Figure 4).

Non-surgical blepharoplasty Non-surgical blepharoplasty is an umbrella term which compromises various treatment options to target excess periocular skin. Resurfacing treatments The most basic options are periocular chemical peels and microneedling.10 Chemical peels can be used to treat fine lines and dark circles or used in combination with a transconjunctival blepharoplasty.11 One must be careful with the chemical concentration as the skin thickness may be as little as 0.2mm in this area.12 Products that can be titrated to produce superficial to moderate-depth peels can include glycolic acid and trichloroacetic acid.13 Practitioners may also use laser resurfacing treatments such carbon dioxide (CO2) and Er:YAG lasers with good results in the appropriate patient, however it is not able to address fat prolapse or volume loss.14 The CO2 ablative fractionated laser vaporises the epidermis and reticular dermis through thermal

Figure 6: Upper eyelid skin crease position

energy, thus causing deep tissue tightening.15 The Er:YAG laser tightens more superficial skin by vaporising the epidermis and superficial dermis. The healing and recovery times are shorter compared to the CO2 laser, and the risk of complications is lower.16 Radiofrequency lasers are different as they are non-ablative and cause deep tissue heating. They bypass the skin and induce collagen shrinkage and skin tightening.17 Ophthalmologists also use laser resurfacing treatments in combination with surgical blepharoplasty to treat dermatochalasis. Plasma Plasma technology is a non-surgical option that can be used for fine lines and mild dermatochalasis in the periocular region. Plasma, unlike laser, does not rely on skin chromophores to produce thermal energy. The plasma beam works by ionising the gases contained in air using thermal energy to create a voltaic arc.18 The tip of the device is applied to the skin at a distance of 2mm, thus air becomes a conductor. The thermal damage on the skin surface, directly produced from the plasma, causes tightening of the epidermis and superficial dermis.18,19 Platelet-rich plasma A series of platelet-rich plasma (PRP) injections can be used to treat dark circles and fine lines.20 This is thought to act on fibroblast stimulation and potentially, collagen production. As a result, it has become an increasingly popular option, especially with its low side effect profile.21 The exact treatment protocol is yet to be defined.

Dermal filler Patients with mild to moderate periorbital volume loss without severe orbital fat prolapse may be good candidates for tear trough hyaluronic acid filler. Patients with more severe orbital fat prolapse and excess of the lower eyelid skin are often better treated with surgical blepharoplasty.22 The advantages of HA filler are that the treatment is reversible and non-permanent. Patients with malar bags or â&#x20AC;&#x2DC;festoonsâ&#x20AC;&#x2122; are a Description Normal contraindication to tear trough filler due to Distance between the upper and 8-11cm the hydrophilic nature of dermal filler. lower eyelid margin

Eyelid measurement Palpebral aperture Upper marginal reflex distance 1

Distance between upper eyelid margin and central pupillary reflex

4-5mm

Upper eyelid excursion (levator function)

Measures elevation of eyelid, function of levator muscle

13-16mm

Upper eyelid skin crease position

With eye in downgaze, distance between upper eyelid margin and skin crease

8-10mm

Marginal reflex distance 2

Distance between central pupillary reflex and lower eyelid margin

4-5mm

Complications The main limitation with non-surgical blepharoplasty is that the ageing process is dynamic; one option may give good results, but over time will cease to work. This can have financial implications for the patient. It is essential to manage expectations about what can realistically be achieved. Specific complications on the various techniques have been described in detail elsewhere in the literature.

Figure 4: Eyelid measurement summary9

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Surgical blepharoplasty The non-surgical options described above will only address skin quality, which may be enough for some patients reluctant to undergo surgery. The underlying periocular ageing processes such as volume loss and fat prolapse are best addressed through upper eyelid or lower eyelid surgery, using various techniques. Upper eyelid blepharoplasty involves an incision into the desired position of the upper eyelid skin crease, with the most common method via a ‘skin pinch’ technique to measure how much excess skin should be excised (Figure 7). After skin removal, a small strip of orbicularis oculi muscle is removed. The medial fat pad is then resected via a small opening in the orbital septum. The skin is closed with or without skin crease forming sutures.23 The lower-eyelid blepharoplasty technique is variable depending on the anatomical changes. A trans-conjunctival fat resection or repositioning is appropriate for fat prolapse alone and is typically reserved for younger patients with minimal excess skin. If there is excess skin it can be combined with laser resurfacing. The transcutaneous blepharoplasty approach will address excess skin, lid laxity and fat prolapse, and is usually reserved for older patients.23

Figure 7: Skin pinch technique for upper eyelid blepharoplasty

Complications There is a low complication rate for blepharoplasty.24 The consent process includes discussion of risk of infection, bruising, transient dry eye, asymmetry and residual upper or lower eyelid skin. More severe complications include lagophthalmos and ectropion due to excess skin removal. The most devastating is loss of vision due to orbital haemorrhage. This may occur during fat excision due to deep orbital vessel rupture.

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon at the Cadogan Clinic in Chelsea, London. She specialises in blepharoplasty surgery and facial aesthetics. Miss Hawkes also leads the emergency eye care service for the Royal Berkshire NHS Foundation Trust. Qual: MBBS, BSc (Hons), FRCOphth REFERENCES 1. Cosmetic surgery national data bank statistics. Aesthet Surg J 2015;35 Suppl 2:1-24. 2. Bernardini FP, Gennai A, Izzo L et al. Superficial enhanced fluid fat injection (SEFFI) to correct volume defects and skin aging of the face and periocular region. J Aesthet Surg. 2015;35(5):504–515. 3. Snell RS, Lemp MA. Clinical Anatomy of the Eye, Second edition. 4. Camp MC, Wong WW, Filip Z, et al. A quantitative analysis of periorbital aging with three-dimensional surface imaging. J Plast Reconstr Aesthet Surg. 2011;64:148-154. 5. Nkengne A, Bertin C, Stamatas GN, et al. Influence of facial skin attributes on the perceived age of Caucasian women. J Eur Acad Dermatol Venereol. 2008;22:982-991. 6. Sinha KR, Al Shaker S, Yeganeh A, Moreno T, Rootman DB. The Relationship Between Eyebrow and Eyelid Position in Patients With Ptosis, Dermatochalasis and Controls. Ophthalmic Plast Reconstr Surg. 2019;35(1):85-90. 7. Nakra T, Modjtahedi S, Vrcek I, Mancini R, Saulny S, Goldberg RA. The effect of upper eyelid blepharoplasty on eyelid and brow position. Orbit. 2016;35(6):324-327. 8. Collin JRO. A Manual of Systematic Eyelid Surgery. Third Edition. 9. Denniston AO, Murray P. Oxford handbook of ophthalmology, Fourth edition. 10. Fabbrocini G, De Padova MP, Tosti A. Chemical peels: What’s new and what isn’t new but still works well. Facial plastic surgery: FPS 2009;25:5:329-336. 11. Clark E, Scerri L. Superficial and medium-depth chemical peels. Clinics in Dermatology 2008;26:2:209-218. 12. Ha RY, Nojima K, Adams WP Jr, Brown SA. Analysis of facial skin thickness: defining the relative thickness index. Plast Reconstr Surg. 2005;115(6):1769-1773. 13. Dailey RA, et al. Histopathologic changes of the eyelid skin following trichloroacetic acid chemical peel. Ophthalmic Plastic & Reconstructive Surgery 1998;14:1:9-12. 14. Blanco G, Clavero A, Soparkar CN, Patrinely JR. Periocular laser complications. Semin Plast Surg. 2007;21(1):74–79. 15. Bae-Harboe Y-SC, Geronemus RG (2014) Eyelid tightening by CO2 fractional laser, alternative to blepharoplasty. Dermatol Surg Off Publ Am Soc Dermatol Surg Al 40(Suppl 12):S137–S141. 16. Fitzpatrick RE, Rostan EF, Marchell N (2000) Collagen tight- ening induced by carbon dioxide laser versus erbium: YAG laser. Lasers Surg Med 27:395–403. 17. Preissig J, Hamilton K, Markus R. Current Laser Resurfacing Technologies: A Review that Delves Beneath the Surface. Semin Plast Surg. 2012;26(3):109–116. 18. Giroux PA, Hersant B, SidAhmed-Mezi M, Pizza C, La Padula S, Meningaud JP. The Outcomes Assessment of the Plasma Blade Technology in Upper Blepharoplasties: A Prospective Study on a Series of 25 Patients. Aesthetic Plast Surg. 2019;43(4):948–955. 19. Cantisani, C, Amori, P, Vitiello, G, et al. Nonsurgical blepharoplasty. Dermatologic Therapy. 2019; 32:e13119. 20. Aust M, Pototschnig H, Jamchi S, Busch KH. Platelet-rich Plasma for Skin Rejuvenation and Treatment of Actinic Elastosis in the Lower Eyelid Area. Cureus. 2018;10(7):e2999. Published 2018 Jul 18. 21. The in vitro effect of different PRP concentrations on osteoblasts and fibroblasts. Graziani F, Ivanovski S, Cei S, Ducci F, Tonetti M, Gabriele M. Clin Oral Implants Res. 2006;17:212–219. 22. Jiang J, Wang X, Chen R, Xia X, Sun S, Hu K. Tear trough deformity: different types of anatomy and treatment options. Postepy Dermatol Alergol. 2016;33(4):303-308. 23. Kossler AL, Peng GL, Yoo DB, Azizzadeh B, Massry GG. Current Trends in Upper and Lower Eyelid Blepharoplasty Among American Society of Ophthalmic Plastic and Reconstructive Surgery Members. Ophthalmic Plast Reconstr Surg. 2018;34(1):37-42. 24. lghoul M. Blepharoplasty: Anatomy, Planning, Techniques, and Safety. Aesthet Surg J. 2019;39(1):10-28.

Conclusion A fundamental understanding of eye anatomy is essential to manage the physical signs of ageing around the periocular area. This article has described non-surgical blepharoplasty options suitable for aesthetic practitioners. The decision to offer surgical or non-surgical blepharoplasty will be led by patient choice, the physician’s knowledge of the relevant anatomy and their relevant skill-set.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Introducing Carboxytherapy Dr Olha Vorodykhina provides an introductory overview to the use of carboxytherapy in aesthetic medicine Carbon dioxide (CO2) therapy, also known as carboxytherapy, refers to the intradermal and subcutaneous administration of medical CO2 for therapeutic purposes.1,2,3 Carboxytherapy has been used in aesthetic medicine for approximately 20 years for multiple cosmetic indications, such as improving skin quality and treating cellulite, and can be a good treatment to add to your current aesthetic portfolio.1

Understanding CO2 CO2 is an acid oxide that consists of one carbon atom and two oxygen atoms. It is a colourless odourless, inert, noninflammable, water soluble and sterile gas and is considered non-toxic and nonhazardous, except in high concentrations.1 CO2 is heavier than air and, in poorlyventilated spaces, it can reach potentially harmful concentrations (8-15%). To prevent this risk, it is important to use CO2 in wellventilated rooms and to have a log book that demonstrates maintenance and service of the equipment.1

Areas of treatment

Indications

Therapeutic effect of CO2 The first effect following CO2 injection is a strong vasodilation of the vessels; therefore increasing oxygenation in the treated area. It also improves regenerative activities and stimulates the formation of new capillaries – also known as angiogenesis. As a result, it increases circulation and stimulates localised metabolic activity of the tissues, which is known as the Bohr effect.1,4 About 1% of absorbed CO2 converts into carbonic acid CO2+H20=H2CO3; further reacting to leave bicarbonate dissolved in the blood plasma H+HCO3. These reactions cause the pH of the blood to decrease and release oxygen to the tissues.1 As well as this, the trauma caused to the dermis by injection stimulates the body’s own healing process and promotes new collagen synthesis.1,5

Administering CO2 For aesthetic indications, CO2 is injected intradermally and subcutaneously by medical professionals. It involves the use of a device or machine that is connected to Injection depth and needle gauge

Number of sessions

a cylinder of medical CO2. The equipment provides the practitioner with the ability to determine, regulate and monitor the following settings: gas temperature, infusion time, gas flow, volume or dose of gas to be infused, pressure and the volume of gas administrated.6 Only medical CO2 (99.5% v/v min), which has been sourced from a medical supplier and has been quality checked to ensure successful results and maintain patient safety, should be used.6 I obtain mine from BOC group.6 Some companies offer carboxytherapy guns that may come with preloaded cartridges of CO2 and can be used,4 however practitioners must ensure that the gas they use is medical grade by purchasing through a medical supplier. Carboxytherapy can be administered in multiple areas on the face and body in the same session and, from the patient perspective, this is a natural treatment with minimal down time. I tell patients that it’s a treatment that simply gives the body a ‘boost signal’ to switch on its rejuvenating and regenerating activities.

Using CO2 therapy in medical aesthetics In the cosmetic field, carboxytherapy has multiple indications as a stand-alone treatment to treat conditions like cellulite and localised adiposity, stretch marks, skin laxity, skin irregularities, loose skin, dark under-eye circles and eye bags, and scar tissues.4,7,8 Carboxytherapy can also be combined with liposuction surgery as a pre- and postoperative treatment.1,4 Gaps between sessions

Amount of gas to be administrated

Periorbital

Rhytids, dark circles, mild fatty prolapse, skin laxity

Subdermal 32G needle. Needle inclination: 20 degrees

5-10

1 session every 1-2 weeks

5-10cc per eye lid

Jaw and submental areas

Skin laxity, submental fat

Subdermal 30G needle into the fat compartment. Needle inclination: 45 degrees

5-10

1 session every 2 weeks

30cc total

Stretch marks

Stretch marks

Intradermal 30G needle Needle inclination: 30 degrees

10

Weekly

• Approx 15-30cc per sector • Total: 100-200cc

Localised adiposity body

Abdomen, thighs, upper arm

Subcutaneous 30G needle into the fat compartment. Needle inclination: 45 degrees

15-20

1-2 sessions per week

• Approx 50-80cc per sector • Total: 200cc-900cc

Cellulite

Thighs and abdomen

Subdermal 30G needle. Needle inclination: 30 degree

15-20

1-2 sessions per week

• Approx 30-80cc per sector • Total: 200-900cc

Table 1: Treatment protocols for carboxytherapy according to plastic surgeon Professor Cesare Brandi.1

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Figure 1: Patient treated to the upper, lower and mid-cheek using 4ml of hyaluronic acid filler and 1ml in the temporal fossa. Three months later the patient had five sessions of CO2 therapy around the lower periorbital area.

To see improvement, around five to 10 sessions are required, depending on the indication.1 Results are not permanent and patients are advised to undergo repeat treatment in six monthsâ&#x20AC;&#x2122; time. Some of the most common aesthetic indications are explored in more detail below, while others are mentioned in Table 1.1 Carboxytherapy can be used to improve the signs of ageing. A small blind crosssectional pilot animal-based study involving 10 rats found collagen turnover increased in animals following carbon dioxide injection into the subcutaneous cellular tissue and intradermally in comparison with the controls.9 Another larger study observed improvement in skin in animals injected with CO2. It involved 56 rats and suggested that subcutaneous injection of CO2 and atmospheric air decreased the amount of Substance P and pro-Calcitonin GeneRelated Peptide (15 kDa) neuropeptides in rat skin.10 Carboxytherapy can also improve the appearance of the periorbital area, such as dark circles, skin laxity and reduce mild fat pad prolapse.1 It can do this by reducing localised adiposity, stimulating lymphatic

drainage and circulation and oxygenation of the area.1 One study involved 90 patients with moderate to severe periorbital wrinkles and/ or dark circles who underwent subcutaneous injections of CO2 once a week for seven weeks. Two months after the treatment, patients reported a reduction of facial fine lines and wrinkles, as well as a decrease in periorbital hyperpigmentation. Some side effects were observed, but they were transient and did not require discontinuation of treatment.11 In my experience, treatment will not be effective for hereditary or sun damagerelated pigmentation, so these patients should have alternative treatments. Successful treatment of eye bags with CO2 alone is rare and I believe the treatment is more effective when combined with other therapies such as dermal fillers (Figure 2). If combining with fillers in the same area, I will always treat the patient with CO2 first to prevent migration of the injected filler. CO2 may also improve the appearance of cellulite and reduce localised fat deposits such as submental compartments, upper

Carboxytherapy can be administered in multiple areas on the face and body in the same session and, from the patient perspective, this is a natural treatment with minimal down time

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arm, abdomen and tights.1,4 I have found that the advantage of this treatment is that it is not only reduces fat compartments, but also tightens and rejuvenates skin at the same time. A study by Brandi et al. treated 48 female patients aged 24-51 for localised adipose accumulations, located on the thighs, knees, and/or abdomen.2 Study participants received six sessions of CO2 therapy, two sessions per week. Microscopic results of skin tissues demonstrated a thicker dermis appearance with collagenous fibres and a reduction in cellulite was observed.2 In a clinical audit of an aesthetic practice involving 101 women who underwent CO2 therapy for localised adiposities on the abdomen, it was found that there was a significant reduction in upper, mid, and lower abdomen circumference.12 In the 57 women who underwent thigh therapy, thigh circumference was significantly reduced, respectively, in the right versus left thigh. The authors concluded that results of the audit confirm that carboxytherapy is safe and effective.12 Carboxytherapy for cellulite and fat has its limitations; when treating larger areas like the abdomen or thighs I find that it needs to be combined with physical activities and dietary advice. Surgical methods can give better and longer-lasting results in larger areas. It is important to know that this treatment is only effective in small localised fat compartments.

Treatment tips In my experience of performing carboxytherapy for the past five years, for optimum results, treatment should be combined with a good at-home medical grade skincare routine two to four weeks before in-clinic treatments. The skin must be disinfected and I will usually apply topical anaesthetic for 20-30 minutes to minimise discomfort. For skin rejuvenation, I will use a 30 gauge needle and inject at a 20 degree angle. Intradermal injections will help to improve skin quality, and subdermal injections will help to achieve a lifting effect, as well as reducing any unwanted fat adiposity. My full-face rejuvenation involves 12 strategic injections points; three intradermal injections in the forehead, one intradermal injection into the upper and lower lid, and subdermal and intradermal injection into the zygomatic eminence, nasolabial fold, parotid area, oral commissure, under the angle of mandible, jowls and apex of the chin.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Figure 2: Patient received 10 sessions of CO2 in the abdominal area to treat 14-year-old stretch marks. Sessions were preformed weekly, with the after image taken three weeks following the completion of the last session.

When treating eye bags, I insert the needle to a subdermal depth and immediate inflation of the eyelid can be observed. Whilst treating, the patient will experience some warm sensation and very mild pressure when gas is delivered. Following treatment, I apply a skin recovery mask with HA, which has a soothing effect for the patient. CO2 can be effectively combined with other treatments such as PRP, dermaroller, fractional needling, dermal fillers and mesotherapy to address ageing concerns. It should be noted that in more advanced cases where severe sagginess is observed, treatment will not be effective. For treatment of fat pads, injection should be subcutaneous. I use a 30 gauge needle inserted at a 45 degree angle. I find that topical anaesthetic is not required.

Contraindications Relative contraindication need to be taken into consideration when the patient takes anticoagulants, has anaemia, receives therapies with carbonic anhydrase inhibitors or has needle phobia. Absolute contraindications apply if the patient is pregnant or breastfeeding, has acute infection in the treated area, diagnosed with severe heart failure, has acute kidney failure, suffers from neoplasia, acute thrombosis or angina pectoris.1,4 Before

Side effects There is a risk of bruising and mild discomfort in the treated site that can last up to a week post treatment. Mild swelling can last up to 24 hours post treatment and bruising typically will be resolved within seven to 10 days. In the study mentioned above by Brandi et al. very mild side effects were reported, such as crackling under the skin, which resolved within two hours, mild haematomas and mild pain in the treated areas that lasted for a few days post treatment.2 The use of higher concentrations are not recommended as patients may report headaches, and, in more severe cases, vomiting and nausea. There should not be any toxicity if practitioners deliver the correct the amount of gas, as advised by recommended protocols per treated area (Table 1).1 For eye bag treatments, mild puffiness of the eyelids can remain up to 24-48 hours’ post treatment, although I find that in most cases this is just two hours. Note that there is a high risk of post-injection bruising around the periorbital area.

Conclusion Carboxytherapy can be an excellent addition to an aesthetic clinic. In my experience, it has a high safety profile with minimal downtime. This therapy is very appealing

to the category of patients who are looking for more natural therapies and it can be used as a combination treatment with other treatment approaches. As with other treatments, consultation skills need to be applied and patient expectations need to manged correctly. Practitioners should seek appropriate training before introducing into their practice. Dr Olha Vorodyukhina is a dental surgeon with a special interest in facial aesthetics. She is the clinical lead of Cosmetic Courses in the Midlands and a regular speaker at aesthetics conferences. Dr Vorodyukhina has numerous published articles and is a member of Save Face and the British Dental Association. She has also appeared on Channel 4 and spoken on BBC radio. Qual: BDS REFERENCES 1. Cesare Brandi, Carboxytherapy. Practical Manual with Clinical Indications and Protocols, 2019, pp.27-99. 2. Brandi C, et al., Carbon Dioxide Therapy in the Treatment of Localized Adiposities: Clinical Study and Histopathological Correlations, Aesthetic Plast Surg, May-Jun 2001;25(3):170-4. 3. Amuso, D, ‘Combined benefits: The use of Carbon Dioxide and Oxygen in aesthetics’, Aesthetics journal, November 2014. <https://aestheticsjournal.com/feature/combined-benefits-theuse-of-carbon-dioxide-and-oxygen-in-aesthetics-1> 4. Zelenková H, Carboxytherapy Non-Invasive Method in Dermatology and Some Other Branches of Medicine, ACTA SCIENTIFIC MEDICAL SCIENCES, Volume 3 Issue 5 May 2019. <https://www.actascientific.com/ASMS/pdf/ASMS-03-0265.pdf> 5. Durães EFR, et al., The effect of carbo dioxide therapy on composite graft survival, Acta Cir Bras 2013, 28, 589-593. 6. Medical carbon dioxide. Essential safety information. BOC: Living healthcare. 2014. <https://www.boconline.co.uk/en/ images/medical_carbon_dioxide_tcm410-56027.pdf> 7. Zenker S, Carbon Dioxide injections in aesthetic medicine, Prime journal, Volume 2 issue 1 2012 <https://medikapoland. pl/themes/default-bootstrap/img/assets/pdf/Carboxytherapy_ MEDIKA_in_aesthetic_medicine.pdf> 8. Nina Koutná, ‘Carboxy therapy in aesthetic medicine’, Aesthetic Medicine Art and Techniques, 2012, p547-576. 9. Ferriera JC Haddad A, Tavares SA Increase in collagen turnover induced by intradermal injection of carbon dioxide in rats , J Drugs Dermatol 2008 7(3) 201-6. 10. Erica Calcagno Raymundo et al., Effects of subcutaneous carbon dioxide on Calcitonin gene related peptide and substance P secretion in rat skin, Acta cirurgica brasileira / Sociedade Brasileira para Desenvolvimento Pesquisa em Cirurgia 29(4):224-30 11. Fioramonti Paolo et al., Periorbital area rejuvenation using carbon dioxide therapy, Journal of Cosmetic Dermatology Volume 11, Issue 3, 2012. 12. Georgia SK Lee, Carbon Dioxide Therapy in the Treatment of Cellulite: An Audit of Clinical Practice, Aesthetic Plast Surg. 2010 Apr; 34(2): 239–243.

After

Figure 3: Treatment of submental fat deposits (double chin treatment). Patient had five sessions of CO2 to reduce localised fat atrophy in the submental area. Each session was performed two weeks apart. The after picture was taken four weeks following the completion of the last session.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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Dr Tracey Hopwood | Ashford, Kent Clinic "Tinkable Aesthetic Clinic has enabled me to expand the range of treatments I have available, I have been on many training courses and attended a wide range of conferences. I had my own aesthetics clinic before the Tinkable license but since taking on the license my practice has grown massively. I feel totally supported. I have experts driving my business and I truly feel I am a part of the Tinkable family."

Sally Fox | Jewellery Quarter, Birmingham Clinic "Being a licensee for such a reputable and quality driven clinic has kickstarted my entrepreneurial career in facial aesthetics. The support you are given from marketing to business resources is second to none, I can run my own company while focussing on my patients knowing that Tinkable look after the rest! This is without a doubt the best business decision I have ever made. "

Dr Alan Long | General practitioner "Aesthetics is a fast evolving industry that is always trying to find the most effective and safest way of delivering treatment outcomes for patients. Since working with Tinkable, there has been a wide range of opportunities. These include training in facial aesthetics, links and seminars available from well known aesthetic product manufacturers and a well organised online booking system with integrated treatment record keeping. I highly recommend them if you are looking for a license opportunity!"

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A summary of the latest clinical studies Title: Non-surgical Facial Reshaping Using MD Codes Authors: Bertossi D, et al. Published: Journal of Cosmetic Dermatology, July 2020 Keywords: MD Codes, Vycross; Botulinum Toxin Type A, Dermal Filler, Hyaluronic Acid Abstract: Both age-related and congenital volume deficiencies may be addressed through the injection of hyaluronic acid (HA) fillers. Deep injection provides structural support, more superficial fat-tissue injection mediates contouring, and superficial intradermal use of HA filler and/or onabotulinumtoxinA may be used for refinement. To evaluate the clinical efficacy, patient satisfaction, and safety of the MD Codes approach as a proposed standardized methodology for full-face rejuvenation. This was a retrospective, single-center study of 250 consecutive adult patients undergoing full-face rejuvenation with HA fillers (Vycross) and onabotulinumtoxinA based on the MD Codes approach. The mean age was 39.4 ± 11.6 years and 80.4% were female. All patients were treated with HA filler in the midface; 89.6% were also treated in the upper face, and 63.2% in the lower face. The mean number of syringes used was 14 ± 4 (range 4-25), with more syringes typically required in older versus younger patients. All patients received onabotulinumtoxinA treatment. Mean FACE-Q Appearance-Related Psychosocial Distress score decreased from 54.3 ± 9.3 pre-treatment to 36.1 ± 8.9 at 3 months post-treatment (p<0.05). The most common complications were bruising (35.2%), transient soft-tissue edema (14.0%), and prolonged periorbital edema (3.6%). Full-face rejuvenation based on the MD Codes approach provides significant aesthetic improvements, with no major safety issues observed. Title: Hyaluronic Acid Injections to Correct Lips Deformity Following Surgical Removal of Permanent Implant Authors: Rauso R, et al. Published: Journal of Craniofacial Surgery, July 2020 Keywords: Lip filler, Dermal filler, Hyaluronic Acid Abstract: One of the most attractive areas of the face are the lips, they are crucial for emotion and communication, both during animation and at rest. Throughout the years, several techniques to obtain permanent lip enhancement have been introduced, such as the use of nonresorbable fillers. The main problem related to permanent fillers is that undesirable results could not always be repaired; although lip sequelae can be addressed surgically, some surgeons will not perform this type of procedure due to its complexity and the lack of guidelines. In this paper, the authors present a case of a labial incompetence developed after lips implant removal performed elsewhere; after clinical examination the patient was planned for surgery, although during preoperative instrumental examination (chest X-ray) a solitary pulmonary nodule was noted; further investigation performed with needle biopsy revealed a lung cancer. For this reason, the surgical procedure planned for lip restoration was not performed; however, the patient asked for a minimally invasive procedure, thus to improve, although temporarily, her lips appearance. For the aforementioned reasons, the patient was treated just with hyaluronic acid injections achieving a pleasant result, solving also the labial incompetence at rest. To the best of the author’s

knowledge, this paper represents the first one describing the use of hyaluronic acid injections to restore lip competence following surgical removal of permanent implant. Title: Assessment of Laser Assisted Delivery Versus Intralesional Injection of Botulinum Toxin A in Treatment of Hypertrophic Scars and Keloids Authors: Sabry Hassan H, et al. Published: Dermatologic Therapy, July 2020 Keywords: Botox; CO2 Laser; Keloids; Scars Abstract: Keloids and hypertrophic scars could impair the psychological, physical, and cosmetic aspects of the patient’s quality of life. Unfortunately, there is no curative treatment available till now. This study aimed to evaluate the efficacy and safety of intralesional vs topical botulinum toxin A combined with Fractional CO2 laser in the treatment of hypertrophic scars and keloids. Twenty patients with Keloids and hypertrophic scars were enrolled in the study. Each scar was divided into two halves, one subjected to intralesional injection of botulinum toxin type A once a month for four months and the other was subjected to four sessions of CO2 laser therapy at one month interval followed by topical application of botulinum toxin A. Significant improvement was noted in Vancouver Scar Scale in hypertrophic scars in laser group than intralesional botulinum toxin A. In keloid cases, the improvement was significantly higher with intralesional botulinum toxin A. Clinical improvement showed significant negative correlation with scar duration and size. Botulinum toxin A is a promising treatment for hypertrophic scars and keloids. The use of fractional CO2 laser as a mode of delivery enhanced the efficacy of botulinum toxin in hypertrophic scars. Title: Why We Should Be Avoiding Periorificial Mimetic Muscles When Injecting Tissue Fillers Authors: Al-Niaimi, Firas, et al. Published: Journal of Cosmetic Dermatology, June 2020 Keywords: Dermal filler, complications, muscles, hyaluronic acid Abstract: Tissue fillers are generally safe and well tolerated by patients. However, complications do occur, and may be very severe, such as intravascular injection (with occasional residual tissue loss, visual and neurological sequelae) and late nodularity and swelling. Methods to lessen the likelihood of complications have been the subject of much recent literature. Depth of injection has been identified as a key safety consideration. The role of injection of facial filler into the muscular layer of the face is explored in this article. Literature was explored using available search facilities to study the role of injections in or around this layer in the production of significant adverse reactions. A body of literature seems to suggest that injection into mimetic musculature of the face especially the musculature in the periorbital and perioral regions is prone to adverse reactions. Injection of agents into the perioral and periorbital mimetic muscular layer may produce, product clumping, displacement, tendency to late nodularity and swelling. It also risks intravascular injection as compared to injection of other layers of the face. Injection into the mimetic muscles especially the sphincteric muscles should be avoided to minimize the risk of complications.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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particular, it was reported that 59% of single parents, 63% of young people aged 25-34, and 62% of women described having been anxious/worried compared to the overall adult population.6 The following groups were identified to be more at risk of having higher issues compared to the general population:

Overcoming Anxiety Following COVID-19 Psychologist Kimberly Cairns considers the impact and influence of stress related to the global pandemic on the aesthetic workplace At the beginning of the pandemic the World Health Organization documented that the coronavirus global health crisis is generating stress at an unprecedented level.1 So as restrictions ease and the aesthetics specialty looks to re-open, it is important to consider how this could affect you, your staff and your patients.

Anxiety through lockdown One emotion that has become conventional in COVID-19 dialogue is anxiety. Anxiety is defined as a particular worry about the future and includes what may or may not happen. This fear for the future is a natural reaction to our environments or circumstances and is to be expected at this time of uncertainty. However, experiencing prolonged restlessness, uneasiness or dread can be signals of a developing anxiety condition.2 If this apprehension becomes constant, overwhelming or disproportionate then it may start to cause disruption to daily life. Intense, negative or limiting beliefs that affect your ability to focus, rest, eat, or live your life

as fully as you want to, can all be signs of an anxiety disorder.3 Unhealthy patterns of behaviour may form with any level of anxiety. The UK Mental Health Foundation charity (MHF) has conducted a UK-wide, long-term study of more than 4,000 adult exploring how the pandemic is affecting people’s mental health.4 Comparing results from mid-March (before lockdown) and currently up to July 9, five waves of data have been collected which are helping us identify the complex and divergence of stressors that the aesthetics community may face.5 The MHF states that the extent of coping well is improving amongst the population as a whole. Reports of anxiety have fallen from 62% to 53%, the proportion of people having panicked has gone down from 22% to 13%, and the proportion of people reporting financial concerns as a result of the pandemic has decreased from 42% in mid-March to 29% at the end of May.6 It appears certain groups of people are at greater risk of experiencing poor and, in some cases, deteriorating mental health. In

• Single parents: higher risk of anxiety, feeling more lonely, more hopeless, not coping well and higher proportion of reporting financial concerns compared to the general population. • Individuals with children: higher proportion of parents with young children aged 5-16 reported greater financial difficulties than the general population, which can induce anxiety. • Young people: those aged 18-24 are more at risk of feeling lonely and more hopeless. Adults aged 25-34 also reported to feel more hopeless and also reported greater financial difficulties than the general population. • Those with health conditions: a higher proportion of people with long-term health conditions said they were not coping well compared to the population overall. A pertinent factor to the mental health crisis which is persistent and likely to increase is specifically financial inequality and the devastating link to mental health outcomes.7-10 The black, Asian and minority ethnic (BAME) community (a term covering a wide ranging group of people with diverse needs, given that different ethnic groups have different experiences of mental health problems which reflect their culture and context) have been widely reported to be suffering disproportionately, along with having an increased risk of COVID-19.6-8 This has further implications to those communities that face societal and individual challenges which can affect their access to healthcare.12,13

What does this mean for clinics? Identifying those at higher risk of being affected by anxiety and other disturbances due to COVID-19 allows the potential to respond in the most appropriate way and construct useful adjustments in the clinic. When doing this, consider your entire aesthetic community; the workforce and the patients, including their usual support systems, to acknowledge those discrete co-morbidities and unintended factors that will inflate the ‘emotional load’ as individuals

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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reintegrate back to the clinic and/or seek cosmetic treatments. Fear and anxiety may well be the most common emotional responses most of us will feel ahead of, and during, the easing of lockdown restrictions. Acknowledging this as a reasonable expectation of our emotional response system is an important first step of self and ‘other’ compassion. We must accept that the pandemic has dramatically changed the aesthetic landscape as we return to something we haven’t been doing for a while or had in a while, and in new circumstances. Each person re-entering the clinic or ending any period of isolation, whether they have been exposed to COVID-19 or not, is going to feel different about it. This might present in the clinic as a diverse and complex assortment of emotions including tiredness, irritability, decreased concentration excitement, fear of own health, fear of another’s health, financial fears, loneliness, boredom, anger, guilt, sadness, relief, complicated and interrupted grief.2,14 All of which may be embedded in the experiences associated with a deterioration of a pre-existing health condition (including mental health), weight gain, increased smoking and alcohol use, the increased prevalence of repetitive behaviours (for example, handwashing and exercise), which is a significant feature to the comorbidity of Obsessive Compulsive Disorder in relation to Body Dysmorphic Disorder.2 Patient considerations For our patients, lockdown may have been relatively quiet, isolated, reflective and educated, or equally frantic, disturbed and unfulfilled. Coming back into the clinic for the first time, just driving through the traffic or using public transport, might lead to an overwhelmed presentation when they arrive. Coupled with the fact that due to restrictions we have undergone immense variations to

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our usual routine, which include deviations to our diet, exercise and, generally, our movement overall. There is a growing body of research suggesting that we are relating to our appearance differently, and that something has changed in our bodies and potentially our body image through lockdown.15 We must be vigilant to this change as it presents in our clinics. It is likely to become evident in the way in which patients seek or talk about their perceived appearance concerns at booking, consultation, treatment and follow up, and we must give time to allow the patient to explore these changes throughout their patient journey should the need arise. It is imperative that we consider the patient narrative and reframe with a non-judgemental narrative. For demonstration I will use an example patient concern and alternative practitioner responses for you to reflect on and consider which response is more appropriate and why: Patient: ‘I’ve been sat doing nothing for months, I’ve put on weight, feel awful and I need to sort it all out’ Practitioner response A: I know, so many of us feel like that too, we have this device that would do it for you. Practitioner response B: It sounds like this time has reduced your activity significantly and left you with unwanted weight gain. It is important that we do not unintentionally inflate, collude, or become unknowingly predatory to exploit vulnerabilities that patients may bring to us as lockdown eases. Whilst the long-term impact of coronavirus and the way in which we relate to our appearance is unknown, we need to use the data available with suitable caution to protect the at-risk groups amongst us to becoming more vulnerable. The influential Bioethics Nuffield Report demonstrates the contextual ethical complexities of the aesthetics

Fear and anxiety may well be the most common emotions most of us will feel ahead of the ease of lockdown restrictions

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specialty which we should all be familiar with to safeguard and improve liabilities.16 Critical ethical considerations have also been highlighted in the Brunton rapid review, commissioned as part of the Keogh report in 2013, that addressed the specific question ‘What factors are associated with requesting and undergoing cosmetic interventions?’.17 It was concluded with a strong association (amongst other characteristics including dieting, smoking, alcohol use, higher stress, medicated sleep and nervous conditions) that those seeking aesthetics had suffered interpartner violence, more commonly known as domestic abuse.17Although this publication was in the absence of COVID-19, the Met Police reported that domestic violence arrests have increased to nearly 10% above that in same period last year,18,19 which motivated the UK Government to launch its own dedicated advice for those in abusive situations during COVID-19.20 We must therefore carefully manage the psychological risk and benefit from accessing aesthetic treatments, especially when attempting to relieve or pursue an emotional target underpinned within the motivation for treatment, as we have to accept the potential rise of inter-partner violence that will be present, perhaps silently in our own clinics. Team considerations: promoting positive mental health Providing safe personal care for others requires a compassionate approach. We know the complexities noted above suggest it may take longer for some to adjust to necessary workplace changes. It is imperative that staff feel they are adequately supported with both physical and psychological personal protective equipment (PPE), prior to having patient contact. If the practitioner is lacking insight to their own needs, this will disturb the patient experience and will have negative consequences to your business as a whole. Look out for warning signs: if a practitioner’s usual ability to relate to others is diminishing, providing additional support is a must. Looking out for lateness, absenteeism and presenteeism. Taking time to reintegrate is key, go at the right pace for your business and your team. Avoidance is anxiety’s best friend, meaning that building our exposure to tolerate emotional discomfort will provide a resilient antidote to anxiety.21 This is important to the safe use of PPE, specifically face masks that can mimic the physical sensations (shallow breathing, shortness of breath, headache dizziness, increased heart rate, nausea or dry mouth)

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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The more prepared aesthetic practitioners are, the less concerned they will be of a panic attack and replicate or exacerbate and anxious presentation.3 You may wish to commit experimental time to the use of PPE in training days, or even offer home-care packages for staff. Encouraging employees to engage in a scripted or guided relaxation/ meditation or breathing exercise to separate, diffuse or combat any possible negative consequences with the use of PPE could also help. There are a number of free resources available, with a summary accessible via The Free Mindfulness Project.22 Clinics making space for experiential time and reintegration will be adopting a growth mindset, where accountability prospers, and blame diminishes. Now is a great time to make subtle changes to your practices to allow your values to penetrate deeper into the culture and experience of work to improve for all.23 Vulnerabilities have many faces, and it can be extremely challenging to demonstrate leadership in uncertainty. Encouraging safe, trusted and approachable spaces to talk is crucial. Just one recommendation is having dedicated ‘worry time’.24 This can counteract the effects of a toxic culture or unhelpful COVID-19 conversation in the workplace, which can be destabilising to both the practitioner and the patient. This may seem counterintuitive, however making an allowance for this at work and signposting staff to this designated time promotes opportunities for mental curiosity and flexibility. Emotional regulation and healthy strategies of coping can then become built into a cohesive and collective attitude at work which will provide a corporate construct for a demonstrable impact working against the COVID-19 mental health consequence. You may also consider appointing a mental health champion(s) in your workplace. This can be done through a reputable external training provider and has great contributes to your expanded CPD profiles and workplace opportunity. The DBK experience is a leading provider of prosocial transformational corporate workshops that can certify your employees as confident mental health first aiders.25

KLNIK wellness also offers an inclusive (specialist integrated approach to aesthetics) authentic model of corporate wellness based on the 5 Rings of Wellness; an accessible effective concept curated alongside Rebecca Adlington OBE.26 Hosting regular mental health days or wellness days with or without a professional will bring about healthy collective coping systems to strengthen your practitioners. This is also an opportunity for you to demonstrate your corporate values. Planning selfcare is particularly important within the healthcare sectors. Wellbeing days can include a plethora of activities. Just one example is sharing hobbies; taking a field trip for a long country walk or bike ride, sharing a streamed yoga session, baking, or practising origami are just a few example. This can have a minimal financial overhead and encourages the opportunity to explore coping behaviours and conversation together. Delegating activity choices throughout your team deepens active coping further and adds an opportunity for autonomous leadership. With dependable and authentic commitment, such wellbeing opportunities provide an abundant employee wellbeing service that embrace understanding and diversity. Team considerations: role adjustments Protocols that include self-monitoring are challenging. Furthermore, virus monitoring in others will be demanding. Cultivating a culture of adaptation and growth will support the confidence with protocol adherence, and pressures of health screening as an additional job role. For practitioners and clinic owners alike, reconnecting with your values of working are essential steps to uphold your own moral code of how you run your clinic. Promoting inclusive COVID-secure reporting will give a more realistic and useful picture of how effective your COVID-19 controls are, which can be discussed at weekly staff meetings. Having weekly designated staff time can also inspire adaptation and positive change. This can create a platform to deliberately celebrate small wins (and big

wins), while inspiring practitioners to keep a note of what they are achieving in a shared group forum gives another opportunity to notice and reward behaviours in others, and an occasion to improve confidence. Reconnecting and adjusting in this way can lead to improved job satisfaction, confidence and quality of life.23 With the incorporation of a daily mindful workplace task, this can enhance the notion further. Purposefully signal a clear boundary at the start or end of the working day or shift or break time. Introducing a physical activity in break and lunches or simply putting on/off your name badge, face shield, mask or apron, even your ‘work shoes’ or handwashing beyond the superficial, mundane or resented ‘things to do’ can help transition yourself from a professional or personal space healthily. Start by allowing yourself to be curious with the physical sensations of this task, knowing and thanking yourself that in doing this you are acting in accordance to your values and supporting the things that are important to you. Extending this gratitude to your colleagues and your patients too, as for each new procedural or compliant task they undertake, they too are looking after you, and your loved ones, enhancing the experience of connection to your values. The more prepared aesthetic practitioners are, the less concerned they will be.

Summary With our return to the workplace it is essential to acknowledge that everyone reacts to stress differently; this is not a reflection of strength nor courage, but complex individual characteristics. We must not accept that we have all been in ‘the same boat’ – we have each been fighting the storm of the sea within our own individual boat, and continue to sail a very distinctive sea. Kimberly Cairns is a psychologist working to strengthen psychological awareness and understandings to empower consumers of the aesthetic industry. She aims to provide education and research within a committed ethical ethos as a Personal Wellness Trainer and Practice Manager at the award-winning aesthetic practice KLNIK in Wilmslow.

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2. Write (and post) the job spec with the perfect candidate in mind

Hiring a Clinic Coordinator Nurse prescriber Julie Scott shares her experience and tips for recruiting a new team member After nearly 17 years in business, I was long overdue in hiring a clinic coordinator. I was drowning in admin, having to turn away new enquiries, and working until 10 o’clock at night when I decided it was time to expand the team. But how could I add the task of finding the perfect person to complement my business, which had been my baby for longer than my actual baby – my daughter is now 14 – to my already overfull schedule? At that point, my amazing aesthetician and I comprised the entire team. Beyond two other visiting practitioners, we didn’t have anyone else on the team and certainly not in an admin role. It was therefore time to hire a clinic coordinator. After a trial using a recruitment company – I have learnt that these don’t always work well for everyone – I decided to recruit my new hire on my own. After three months I eventually found the right person, so I’d have no hesitation in recommending someone in a similar situation to do the same. There is no one-size-fits-all perfect hire; after all, your perfect team starts with YOU and what works for some might not work for others. But if you are interested in learning how I made the right choice without compromising, here’s how I did it.

1. Explicitly define the job role There are hundreds, if not thousands, of sample ‘clinic manager’ or ‘clinic coordinator’ job specifications out there. In my opinion, you shouldn’t look at any of them, at least, not straight away. It’s important to think of what you specifically need to complement your role in your business. I took out a big piece of paper, wrote ‘Wonder Person’ in the centre, and then everything that needed to be done in the clinic around that. From there, I sorted those tasks into categories: • Tasks only I could do (injecting patients) • Tasks that I’m not well-versed in doing but which needed to be done (social media, for example) • Things that I could do but needed to delegate to make better use of my time and maximise potential (such as booking appointments) From the latter two categories I formed the crux of my future clinic coordinator’s job description. Only following this exercise and honing in on your company’s specific needs would I recommend that you look at other job postings, just to ensure you have not missed something.

Imagine you are the perfect candidate to complete your team, with all the right motivations and skills. Now, what is going to attract you to this role? Throughout the job specification, you should advertise the value you will provide to them. It’s their job at the interview stage to convince you of the value they will provide to you, but we will get to that later. We had previously employed a business coach to help me grow my business and take it to the next level and they advised to start the job spec with leading questions to capture attention. Some examples include, “Do you want to work in an amazingly tranquil setting with a supportive team around you?”, or “Do you want to work for a clinic that WILL value you and reward you for your contribution?” We asked our new hire what attracted her to the role and she said it was these questions that ultimately convinced her to apply. Also consider where you want to post the advert. We had success with Indeed, but other platforms such as LinkedIn, Facebook and the Aesthetics Media jobs page, allow you to post vacancies and can be useful tools. How much you pay to post your job is up to you. Indeed’s free listing yielded us around 70 applications, LinkedIn’s paid option yielded us about four, and though we didn’t use Facebook or Aesthetics Media’s free options, we would be happy to try in the future. Another feature we liked about Indeed is that it allowed us to include questions in the application process that would pop up on our applicants’ screens as soon as they submitted their CV. By making the questions optional, it made it easy for us to pass on candidates that chose not to answer. We asked three short answer questions: • What encouraged you to apply for the role? • What are your expectations of the role? • What are your aspirations? At this point, we were really just looking for a level of engagement from the candidates. We wanted to see relevant, interesting answers instead of just textbook responses. There was not much that would rule them out initially beyond leaving the questions completely blank, showing no effort, or extremely poor spelling and grammar. Based on their answers, we could narrow our selection down to 12 candidates with which to proceed.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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3. Utilise the phone Because of the speed and ease at which we can type a quick message between appointments, email is tempting to use when beginning to whittle down your applications. Instead though, I would highly encourage you to pick up the phone. Gauging someone’s phone manner is important for most roles, but especially a clinic manager, coordinator or a front-of-house position. Instead of inviting them for an interview, a 30-minute phone call with each candidate will tell you whether you’re able to establish a rapport with them. With some, you’ll know within just five minutes if they’re not right for your team, meaning your time with that candidate can end there. I asked candidates at this stage questions such as, ‘What do you know about my business?’ and ‘Who do you think my typical patient is?’ After explaining the role and my needs, I asked, ‘Based on what you now know, and based on your skillset, how do you think you could help me and fit into this role?’ From the 12 phone interviews we did, which we easily scheduled between patients or at the end of my clinic day, I whittled our list down to just six candidates that I believed were suitable for the next stage. This saved hours I would have spent interviewing had I not first conducted this vital step.

4. An informal in-person meeting I recommend inviting your candidate in for a quick, informal meeting at the clinic before a proper interview. The main benefit of this is that you can figure out how well they would fit the role and the rest of your team without having to schedule masses of time to go through questions like salary requirements or flexible working hours (which generally don’t need to be discussed until later). I invited the candidate to the clinic, showed them around, and then sat down for an informal chat that took about 30 minutes. For other clinic owners, this may be quicker! I found that the more interested I was in a candidate, the longer the conversation lasted. Questions to ask yourself here: do they fit the role well? For example, do you want someone friendly and bubbly, or calm and stoic? Can you see yourself building a rapport and working long hours with them? Be careful of judging a book by its cover and remember you can’t exclude a candidate based on age, race, gender, orientation, religion, etc. Of the six candidates we invited to our clinic for an informal meeting, there were only three we wanted to take to the formal interview stage. I felt a natural affinity

I asked my candidates to take 20-30 minutes in another room and write a letter from my perspective pitching a marketing collaboration to a local business with these three candidates in regards to how they engaged and communicated with me; I was looking for someone that could work on the same page as me, sing from the same hymn sheet, adopt our ethos and message, and work in synergy with us. A lot of it was down to intuition and how I interacted with each person, as well as how I could perceive them interacting with my patients.

5. The formal interview Here’s a curveball – give candidates a test as soon as they walk in the door. I asked my candidates to take 20-30 minutes in another room and write a letter from my perspective pitching a marketing collaboration to a local business. It may seem mean, but it tested their ability to work well under pressure, their confidence with the written word, and whether they had an understanding of my business. And it doesn’t have to be writing a letter. Another practitioner may prefer to test candidates on their IT ability, creative flair or emergency response skills. Any test to learn more about a candidate’s skillset, along with their reaction to being asked to do an unexpected task, will help you in your decision-making process. After that, we sat down for the formal interview and went through more standard questions along with posing scenario-based questions. We asked questions such as, “Say you have a patient complaining to you about my services. How would you proceed?” and “If you had a patient collapse in the waiting room, what would you do?” Don’t be afraid to ask about tough scenarios. They come up in real life, so it’s best to bring them up in the interview stage to not only measure your candidate’s responses, but to also prepare them for what they might expect working for you. These interviews ranged from two hours to only 40 minutes – here I knew 10 minutes in that it wasn’t going to work out. Generally though, I suggest to

give your candidate time to shine; people may be nervous and need a little time to become comfortable.

6. Making the final decision After finishing the last formal interview, I took a few days to reflect before offering the job to my preferred candidate. However, not everyone will feel ready to make their decision quickly, and it’s important to get the decision right. If you’re not ready yet, other things to consider are bringing candidates back for a second formal interview, taking them out into a different setting to see another side of them, or bringing someone else into the interview to get a second opinion.

You know your business Personally, I was deciding between two candidates. Both were very strong with wide-ranging skillsets who had performed very well at their interviews. There was no clear winner, so I ultimately went with my gut, and sometimes that’s all it comes down to. After all, the person who knows my business best is me, no matter how much I value other people’s opinions. This is why I was happy to conduct the process myself from start to finish, even though it was ultimately a bit more time-intensive. By doing it this way, I felt in control the entire time, I kept 20% of my hire’s salary in my business rather than a recruiter’s pocket, and I have been very happy with my choice since. Julie Scott is a registered nurse and independent nurse prescriber with more than 20 years’ experience in the aesthetics industry. She now practises from her own Essex clinic, Facial Aesthetics. Scott is always happy to speak with fellow members of the aesthetics specialty about recruitment or any other aspects of running a clinic. Qual: RGN, NIP

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Understanding Telemedicine and its use in Aesthetics Practitioners explore the impact of COVID-19 and the use of telemedicine in the aesthetic specialty The start of this year marked unprecedented times; an infection that started on a smaller scale, but quickly spread all over the world. Pandemics have occurred before, and although we face many struggles, we aesthetic practitioners can adapt and be prepared for a new approach to clinical practice. Understanding the epidemiology of pandemics and our role as a medical health professional is an utmost necessity. Telemedicine is a blessing and with the advancements in technology and the current situation demanding it, is proving to be appealing, though it has its own caveats. It does seem to work not only as a standby modality but an important part of an aesthetic professional’s approach to the ‘new normal’ clinical practice in the near future, which we will explore in this article.

The aesthetic practice and business A survey by Hamilton Fraser with 1,360 respondents was undertaken between March 22-24 regarding the impact of COVID-19 on UK clinics. Results found that 72% didn’t have a contingency plan, while of the 28% who did have a plan, one of the primary options was returning to the NHS.1,2 Yet ensuring continuity of care and increasing the likelihood of returning and new aesthetic customers, with effective and timely communication as clinics reopen, is pivotal. Aesthetic practitioners across the globe must try to make the best use of technological advancements in communication today and get innovative to maintain employment and business. Aesthetic business relies a lot on loyalty and over time a bond of trust and a relationship is built with patients.3 In times of enforced closure, maintaining this relationship is vital, implying that we’re all in this together.4 Ensuring return business is not about doing one or two big things but ‘little things’. Many practitioners have benefitted from using social media (SM), email or other telemethods to post positive messages and updates, a personal courtesy message or video, advice on home skincare that could be performed or regular SPF application for example, whilst spending more time outside gardening, walking or exercising.

SM platforms such as Facebook and Instagram are changing the nature of how we communicate, collaborate, and market our business.5 Targeted SM campaigns can be beneficial in promoting products as well as enabling clinics to provide an insight for potential customers into what is available.6 However, SM doesn’t capture all current and potential patients; clinics need to have a host of communication methods in order to maintain current relationships and cultivate newer ones. The go-to medium for functionality and patient satisfaction in these times is telemedicine.

Telemedicine and its use in pandemics Telemedicine can be defined as the use of electronic communication and technology to provide healthcare to patients when distance or situations makes it impossible for an ‘in person’ meeting.7 This is delivered predominantly through existing user devices like mobile phones, tablets, computers and laptops. The main benefits of telemedicine are providing a way to address barriers that limit access to healthcare, while reducing the cost of care and saving time.8 Telemedicine serves as a means for practitioners to consult with patients, undertake an evaluation, diagnose and to provide a care plan remotely, which is especially pertinent during pandemics, with the benefit of reducing risk to both patients and practitioners.9,10 Especially in aesthetic practice, owing to its visual and non-emergency nature, this mode of clinical practice is very useful.11 Telemedicine allows professionals to share educational information with peers too. The use of telemedicine has been commonplace in various forms for 20 years and is standard medical practice in many parts of North America and Europe, with evidence supporting its cost effectiveness, clinical benefit, good patient satisfaction in concordance with in-person consultations.11 The World Health Organization (WHO) has also included telemedicine among essential services aimed at strengthening healthcare in times of pandemics, while supporting it as an alternative and/or supplement for clinical services.9

Teledermatology: various types, pros and cons

The Medical Defence Union advises consent for the remote consultation is ascertained, outlining limitations and potential security risks

Different types of telemedicine exist to support remote communication:10,12 • Live/real time options like use of telephone for consultations, radio to link up emergency medics to medical centres, video conferencing, certain websites, kiosks, mobile phone and wearable devices allows practitioners to see patients in real time during examination. • Non-real time include ‘store and forward’ methods which means that data may be stored in the device and sent across as per convenience. • Both real and non-real time through dedicated third-party platforms in the form of apps such as Mfine, DocsApp, JustDoc, Lybrate, MedHarbour, MonkMed and Practo. These allow patients to connect with doctors and provide both real and non-real time communication.

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Mode of communication Video

Examples Telemedicine facility kiosk, mobile applications or apps, video on chat platforms, Skype/Facetime/WhatsApp

Audio

Phone, Voice Over Internet Protocol (VOIP), also called IP telephony, mobile applications like WhatsApp, Skype

Text based

Specialised chat-based telemedicine smartphone apps, SMS, websites, messaging systems e.g. WhatsApp, Google Hangouts, FB Messenger

Asynchronous/ store and forward technique (where images/data are transferred from one system to another)

Email/fax/apps like WhatsApp/ iMessage

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Advantages

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Disadvantages

• • • • • • • •

Real-time interaction Patient identification is easy Closest to in person-consult with better rapport with patient Certain tasks/questions can be obtained on the spot Allows risk management plan Obvious signs on patient and inspection of patient can be done High level of satisfaction Helps in education

• • • • • •

Quick Easily reached Beneficial for emergency cases and follow-up Less infrastructure needed Privacy assured Real-time interaction

• • • • •

Quick Easily reached Beneficial for emergency cases Less infrastructure needed Can be real-time

• • • • • •

Easy to document No major infrastructure needed As per convenience of practitioner Least expensive No language or cultural barrier Beneficial if second opinion is needed

• • • • •

Highly dependent on good quality internet connection on both sides Hardware cost may be high Possibility of misuse/abuse of information therefore privacy is very important Potential for security risks Fair knowledge of computer use is needed for both parties

• • •

No visual inspection feasible Patient identification may be difficult Non-verbal signs are missed

• • •

Visual, physical and non-verbal signs are missed Hard to build affinity with the patient Potential for security risks

• • • • • •

No real-time interaction Depends on device capability and internet Patient identification is barely possible Visual, physical and non-verbal signs are missed Delay may occur if data not seen Potential for security risks

Figure 1: The four types of telemedicine describable today12,14

These platforms give the practitioner an organised and secure way to practise remotely, tracking the data of the patient and documenting all remote patient visits. Consent forms can be signed electronically with integrated billing where charges are transferred to the practitioner instantly. The practitioner is able to prescribe drugs using digital prescription services where options of even pre-set safe prescriptions may be transferred directly to pharmacies. Most of these platforms have medical device integration, allowing transfer of information using mobiles.13 Based on mode of communication, there are four types of telemedicine describable today (see Figure 1).12,14 Most studies and reviews have been optimistic about teledermatology practice.15 Results from a randomised controlled trial with a sample size of 392 participants showed that ‘store and forward methods’ did not result in longer wait times for patients when compared with face-to-face consultations.16 These methods offered comparable long-term clinical outcomes when compared with conventional clinic-based care.17 Another study included 17 teledermatologists across different settings that provided access to healthcare for underserved populations. Significant challenges were faced whilst trying to provide an efficient service; these included poor image quality, insufficient medical history taking, expensive software and miscommunication with providers, as well as lack of training on how to use technology.18 Concerns with telemedicine An important concern in telemedicine is privacy and confidentiality of patient information, security of data and lack of implementation models.19,20 The legal and ethical approach is to protect confidentiality and keep the personal data of patients private. The European Union General Data Protection Regulation (GDPR) restricts the transfer of personal data to the countries outside the EU. Many parts of the world also follow GDPR guidelines. Taking informed consent is much harder during remote practice, but it is necessary. The Medical Defence Union (UK) advises consent for the remote consultation is ascertained, outlining limitations and potential security

risks.21 Other challenges with telemedicine are ensuring safety from cyber-attacks, quick infrastructure scalability and internet bandwidth issues.9 There are several issues that can cause a difficulty with a virtual consultation, including: • Patients being late or missing the appointment • Poor internet connection • Disruptions from others • Poor lighting • Difficulty in picking up non-verbal communication A recently published article by Aesthetics provides helpful guidance on how to overcome some of the difficulties with telemedicine as described here.22

Getting back into business: being responsible, adaptations and precautions Getting back to work is something that makes practitioners across the globe more anxious than they were during the closure of clinics due to the pandemic. Many practitioners may question the future of their businesses and careful planning for re-opening and moving forward is crucial. Several aesthetic associations and organisations have published guidance on safely returning to practice, which can all be viewed via the Aesthetics website.23 Consulting and advising through online consultations need to be adopted to continue practice. This reduces the amount of unnecessary contact and encourages social distancing. Practitioners must remember their duty of care to patients even through such trying times.24 Experiencing and getting through a pandemic is both a scare and a learning opportunity. It takes a slow and steady path uphill to reach that ‘normal’ aesthetic practice that was in the pre-pandemic period. The ‘new normal’ needs patience and perseverance, it needs caution and adaptation. It is said that the stronger the storm one goes through, the brighter the rainbow at the end. In the case of aesthetics, patient needs and demands will rise, so will we as an industry with evolved, proficient and renewed energy.

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Note: this article was originally written as part of the authors’ PgDip/ MSc in Cosmetic Medicine with the University of South Wales, which they are all currently studying towards.

Dr Julien Bachour has a degree in biology and chemistry from the University of Balamand, as well as qualifying as a Doctor of Medicine from the University of Balamand in Beirut, Lebanon. He completed his internship in internal medicine, and residency in dermatology at Saint George Hospital University Medical Center and trained in different countries during his residency, including in the UK. Qual: BSc, MD Dr Lubna Chaudhry is an aesthetic practitioner and GP currently working in My Care Clinic, Saudi Arabia. She completed her BSc and MBBS in Pakistan, before working in A&E in Saudi Arabia for three years. Dr Chaudhry has a MCPS in family medicine and a diploma from the American Academy of Aesthetic Medicine. She has practised aesthetics for six years. Qual: BSc, MBBS, MCPS, AAAM Dip Jude Dunican has worked fulltime in aesthetic medicine since 2015. She is a nurse prescriber and has her own private practice in Bromley after working on Harley Street for several years. Dunican is also the national trainer for Obagi Medical in the UK. She has a special interest in device-based therapies and has been treating patients of all skin types since 2009. She is a member of the British Association of Cosmetic Nurses. Qual: BSc (HONS), Pg. Dip, RGN, INP Dr Sindhu Rakshith is a consultant dermatologist and aesthetic practitioner from Bangalore, India with more than six years of clinical experience. After completing her MBBS degree from JSS Medical College, she pursed her special interest in dermatology to complete a Post Graduate Diploma in Dermatology, Venereology and Leprosy from Command Hospital. Qual: MBBS, DDVL

REFERENCES 1. Hamilton Fraser, What is the impact of COVID-19 on the aesthetics industry? (UK: Hamilton Fraser, 2020) <https://hamiltonfraser.co.uk/knowledge/covid-19-aesthetics-industry/> 2. Shannon Kilgariff, News Special: Expecting the Unexpected (UK: Aesthetics, 2020) <https:// aestheticsjournal.com/feature/news-special-expecting-the-unexpected> 3. Underdown, P, Maintaining Patient Loyalty, (UK: Aesthetics, 2015) <https://aestheticsjournal.com/ feature/maintaining-patient-loyalty> 4. Gronow, C, Managing a Clinic During the COVID-19 Pandemic, (UK: Aesthetics, 2020) <https:// aestheticsjournal.com/feature/news-special-managing-a-clinic-during-the-covid-19-pandemic> 5. Aral, S., Dellarocas, C. and Godes, D. ‘Introduction to the special issue—social media and business transformation: a framework for research’, Information Systems Research, 24(1) (2013), pp.3-13. 6. Suresh, V., Chitra, M. and Maran, K., ‘A study on factors determining social media on cosmetic product’, Journal of Pharmaceutical Sciences and Research, 8(1) (2016), p.1. 7. Bashshur R, ‘Telemedicine Evaluation’, Telemedicine and e-Health (2005) <https://www.researchgate. net/publication/7709250_Telemedicine_Evaluation> 8. Berman M, Fenaughty A., ‘Technology and managed care: patient benefits of telemedicine in a rural health care network’, Health Econ, 14(6) (2005), pp.559-573. 9. Imenokhoeva M, ‘Telehealth in the time of COVID 19’, Mobihealth news (2020) <https://www. mobihealthnews.com/news/europe/telehealth-time-covid-19> 10. Institute of Medicine (US) Committee on Regional Health Data Networks; Donaldson MS, Lohr KN, editors., ‘Health Data in the Information Age: Use, Disclosure, and Privacy’, Washington (DC): National Academies Press (US).4.Confidentiality and Privacy of Personal Data (1994). 11. Kaliyadan F, Ramsey ML, ‘Teledermatology’ StatPearls Publishing, (2020). 12. The Indian Medical Council, ‘Telemedicine Practice Guidelines: Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine, <https://www.mohfw.gov.in/pdf/ Telemedicine.pdf> 13. Siwicki B., ‘Comparing 11 top telehealth platforms’, (2017) <https://www.healthcareitnews.com/news/ comparing-11-top-telehealth-platforms-company-execs-tout-quality-safety-ehr-integrations>

Caroline Street is an aesthetic nurse prescriber and owner of Caroline Street Aesthetics and The Beauty Room in West Dorset. She has extensive experience in acute medicine, A&E, as well as working in a GP practice. Street has worked in aesthetics for 10 years and is a member of the British Association of Cosmetic Nurses. Qual: BSc, RGN, INP Rebecca Taylor is an aesthetic nurse prescriber and owner of Rebecca Taylor Aesthetics in Cambridgeshire. She is a trainer for Cosmetic Courses and has a keen interest in cosmetic dermatology, preventative medicine and ageing well. Taylor is a member of the British Association of Cosmetic Nurses. Qual: BSc (Hons), PG Dip, RGN Elaine Williams is an aesthetic nurse prescriber and founder of EOS Aesthetics in Ascot, Berkshire. She has worked in aesthetics for more than 10 years, practising in Liverpool and Harley Street, and is a member of the British Association of Cosmetic Nurses. Qual: RMN, INP, BSc (Hons) PG Cert, PG Dip, MSc Amanda Wilson is a nurse prescriber with a BSc (Hons) in adult nursing. She has worked in aesthetics for six years at a number of London clinics, including The Clinic by Dr Mayoni. Wilson is one of the lead trainers at Healthxchange Pharmacy. Qual: BSc (Hons), RN, INP Dr Alfred Yuen is a geriatrician with a special interest in dermatology, practising in Hong Kong as both a GP and a physician. Qual: MBBS (HK), MRCP, FHKAM, MSc (Epidemiology & Biostatistics, CUHK), DPD (Cardiff), DCH (Sydney), Dip Clin Derm (London)

14. Thomas, J. and Kumar, P., ‘The scope of teledermatology in India’, Indian dermatology online journal, 4(2), p.82. 15. Trettel, A., Eissing, L. and Augustin, M, ‘Telemedicine in dermatology: findings and experiences worldwide–a systematic literature review’, Journal of the European Academy of Dermatology and Venereology, 32(2) (2018), pp.215-224. 16. Whited JD, Warshaw EM, Kapur K, et al., ‘Clinical course outcomes for store and forward teledermatology versus conventional consultation: a randomized trial’, J Telemed Telecare. 19(4) (2013) :197-204. 17. Pak H, Triplett CA, Lindquist JH, Grambow SC, Whited JD., ‘Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care’, J Telemed Telecare. 3(1):26-30. 18. Armstrong, A.W., Kwong, M.W., Ledo, L., Nesbitt, T.S. and Shewry, S.L. ‘Practice models and challenges in teledermatology: a study of collective experiences from teledermatologists’, PloS one, (2011) 6(12). 19. Pros and Cons of Telehealth for Doctors (2018).< https://evisit.com/resources/pros-and-constelehealth-for-doctors/> 20. Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, & Brooks M., ‘Evaluating barriers to adopting telemedicine worldwide: A systematic review’, Journal of telemedicine and telecare, 24(1), 4–12. 21. MDU, Conducting remote consultations (UK, MDU, 2020) <https://www.themdu.com/guidance-andadvice/guides/conducting-remote-consultations> 22. Carver, H. Conducting a Successful Video Consultation (UK: Aesthetics, 2020) <https:// aestheticsjournal.com/feature/aesthetics-provides-advice-for-holding-patient-consultationsonline?authed.> 23. Gronow, C, News Special: Returning to Aesthetic Practice (UK: Aesthetics, 2020) <https:// aestheticsjournal.com/feature/news-special-returning-to-aesthetic-practice> 24. Chatterjee M,Kharkhar RD,Mittal A,Kiran S, ‘How COVID 19 will impact dermatology practise in the foreseeable future?’, Digital Dialogue ,Ajanta Pharma. <https://coact.live/ajanta/dermatology6/>

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Assessing Your Clinic using Service Design Business consultant Jack Garnham discusses the use of service design methodologies to identify improvements in aesthetic businesses The goal of any aesthetics business is to ensure that all your patients receive an excellent and safe experience, whilst your employees work efficiently and have a positive experience doing their job. However, issues often arise when businesses attempt to marry these ambitions whilst also trying to increase sales. For instance, methods designed to promote employee efficiency, such as adhering to strict schedules, may compromise patient safety. One way to overcome these difficulties is to employ service design thinking and methodologies, which aim to coherently structure the people, processes, and tools of the business as a means of optimising the quality of the interaction and experience between practitioners and their patients.1 As positive patient interactions and experiences are the foremost objective of a successful aesthetics business, service design is of significant relevance to key stakeholders operating in this sector. Therefore, the focus of this article is on how business owners, practitioners, and clinic managers can employ service design to ensure excellent patient and employee experiences, whilst also maximising your commercial return.

What is service design? Service design is an emerging field focused on designing well thought through user experiences and interactions by restructuring services and their associated systems, tools, and processes.1 Within an aesthetic business, the user is the patient, and their experiences and decisions when interacting with the clinic will be determined by service design. For instance, when a patient first arrives, the decisions they make will be influenced by a myriad of factors, including how they enter the building, who greets them, how they check-in, and where they wait. Meanwhile, staff are also making decisions, such as checking the patient in and communicating their arrival to other staff, who in turn may then guide the patient to a waiting area and offer them drinks and snacks. Each of these decisions is influenced by the service design, which ultimately determines the overall experience of both the patient and employee. Service design may be considered a diagnostic tool for aesthetic businesses to optimise patient and employee experiences by providing clarity on key business processes. This is a necessity in the aesthetics sector, which is underscored by numerous patient-practitioner touchpoints

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– including phone/face-to-face/email communications, booking systems, consultations, treatments and follow-up appointments – producing a myriad of patient journeys. Thus, service design provides an opportunity for businesses to look inwardly and determine what ‘treatment’ their business may need to improve the experiences they’re offering, thereby ensuring they attract and retain more customers. The purpose of this process is to explicitly establish the best practices for designing services that meet the needs of both patients and staff within the competencies/ capabilities of the business. Rather than being a simple abstract exercise, this activity encourages stakeholders to design an optimised service offering that ensures excellent user interaction, similar to how designers and architects plan and construct physical, tangible products, such as cars, houses, and clothes. It is also worth noting that service design may be applied to both improve an existing service offering or to create an entirely new service altogether, thus making it relevant to both established businesses and fledgling start-ups.

Applying service design to clinics The most common and practicable way that service design can be applied to an aesthetic business is by following the end-to-end patient journey, enabling all stakeholders to understand and improve both patient and employee experiences at each relevant touchpoint. This may be achieved through a combination of market research, patient interviews/questionnaires, mystery shopper activities, on-site observations, collaborative group workshops, and one-to-one staff interviews.2 By evaluating their patient journey, aesthetic businesses are endowed with a collaboratively produced and explicit step-by-step visualisation, such as a patient experience map, which communicates all the key touchpoints and associated processes to both internal and external stakeholders.3 Such patient experience maps use flow diagrams to communicate the framework governing key processes, including: Onboarding patients Booking management Patient payments Consultations/appointments/treatment Reviews and feedback Procurement and supply chain management • Hiring and onboarding new staff • • • • • •

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Process

1. Email Enquiry

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Patient Experience Map

Patient email

2. Phone/Walk-in Enquiry

Response

Patient call/walk-in

New Lead

New Lead

Pre-Screen

Pre-Screen

3. Pre-consultation

New Enquiry

New Lead

Pre-Screen

Booking

4. Booking Consultations

Online Booking Page

‘Leads’ Followed Up

Consultation Booked & Health Questionnaire sent

Confirmation & Reminders

5. Consultation

Entrance

Waiting Area

Consultation

Triage

Figure 1: An example of a patient experience map, which would continue past the consultation through to the treatment booking and reviews and post-treatment process

Aside from addressing these processes, this activity often uncovers and highlights further areas within the business that need addressing, including changes to internal and external communications, organisational structure, roles and responsibilities, and product management. The collective combination of aforementioned tasks (e.g. interviews, workshops, observations etc.) allow businesses, or their business consultant if they are working with one, to produce an optimised patient experience map (see Figure 1 as an example). If working with a business consultant on this, it’s important that it is done collaboratively; the key to a successful patient experience map is the ‘buy-in’ from all internal stakeholders, not only in terms of providing the consultant with full access to your clinic, but also in terms of feeling comfortable. Clinics will need to honestly and openly discuss which areas of their work they consider to be challenges and where they feel improvements are required. Once the optimised patient experience map has been produced, aesthetic businesses may then evaluate the proposed process improvements to produce a prioritised roadmap of actionable next steps. Going forward, businesses should view this patient experience map as a ‘living document’ that should be continuously reviewed to identify ways to improve their service offering. From my experience of evaluating aesthetic businesses using service design, I’ve found that patient communications have frequently been a common process that’s needed improvement. With one clinic, we produced

a list of 77 proposed improvements, covering all of the key processes outlined in the bullet points above; interestingly though, once we grouped these improvements into themes, we found that 42 of them concerned their patient communications, with the remainder relating to the adoption of new technology, adjustments in the booking management system and improved marketing, amongst others. Many of the improvements relating to patient communications concerned how effectively the patient customer relationship management (CRM) system was being used. Previously, the staff in the clinic had expressed concerns regarding the robustness of the CRM system to effectively send the appropriate patient communications at the right times. For instance, one of the proposed improvements was to ensure that the CRM system recorded those patients that requested a quote during a consultation to ensure that they were appropriately followed up within the desired time period. Other improvements concerned automating the CRM system to ensure that patients received the appropriate communications at agreed times and through the appropriate communication channels. For instance, providing consultation and treatment reminders via both text messages and emails, as well as ensuring that patients were called when appointments had to be cancelled, in case they hadn’t received or seen the text message or email. Collectively, these proposed improvements not only reduced the time and burden on staff who

were having to send emails manually, but also ensured that communications were standardised throughout the patient journey, thereby helping to manage and maintain patient expectations across the whole clinical experience.

A useful diagnostic tool Service design thinking is a useful diagnostic tool for evaluating the shape of an aesthetic business, providing an opportunity for honest reflection to help identify ways to improve the experiences of both patients and staff. Such projects can provide businesses with a visual patient experience map outlining the optimised processes concerning each touchpoint within the end-to-end patient journey. Jack Garnham completed a PhD in Healthcare and Biomedical Sciences at the University of Leeds and now works as a consultant with Rokker, a UK design-led business and management consultancy. He consults a wide range of businesses within the healthcare, technology, and media sectors on how they can employ service design thinking methodologies and tools to improve their service offering and enhance the customer experience. REFERENCES 1. Stickdom, M, This is Service Design Thinking: Basics – Tools – Cases (Amsterdam: BIS Publishers, 2011), p. 10. 2. Gleason B, Bohn J, ‘Using Small Step Service Design Thinking to Create and Implement Services that Improve Patient Care’, in Service Design and Service Thinking in Healthcare and Hospital Management, ed. by Mario A. Pfannstiel & Christoph Rasche (Cham: Springer, 2019), pp. 39-53 (p. 42). 3. Druckenmiller, G What Is the Patient Engagement Journey and Why Is It Important? (Evariant, 2019) <https://www.evariant.com/ blog/why-is-patient-engagement-journey-important?origin=faq_ patient-journey-mapping>

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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“I love helping other people feel happier about themselves” Aesthetic nurse prescriber and trainer Mel Recchia shares her journey from performing arts to aesthetics Growing up in Surrey, independent nurse prescriber Mel Recchia wasn’t always planning on heading into the aesthetics field. Until the age of 15 she attended ballet school, and had hopes of becoming an actress. She recalls, “From a young age my intention was always to go to drama school, but I got advised to do something else beforehand so that I had something to fall back on. I decided to go into beauty therapy, officially qualifying as a beauty therapist in 1981. I ended up working in that industry for 14 years, running my own salon and, after gaining a Certificate in Education, teaching in technical colleges. However, I was always fascinated by cosmetic surgery.” Because of this, Recchia trained to become a nurse at Stoke Mandeville Hospital in 1997. “After qualifying, I started working there in the burns and plastics unit,” she says. “I really enjoyed it, but it was a tough sector to be in as you had to be mindful of the psychological aspects of treating a patient as well. I moved to A&E and stayed there for around nine years.” One day Recchia worked with a trainee plastic surgeon in A&E, who told her about his plans to open a cosmetic surgery clinic. This made her think that she could utilise her beauty background, and offered to become his nurse. While she lost touch with the doctor, this was the basis for which she first considered entering the aesthetics speciality. In 2007, Recchia went on her first aesthetics training course at Cosmetic Courses, and is now a trainer for the company. “Training in aesthetics was much briefer back then so the specialty has come a long way,” she reflects, explaining, “I was shown how to do lip filler straight away, and that’s something we would never do in foundation training now because of the higher risk of potential complications in this area.” Following her initial training, Recchia made the decision to leave the NHS and work in aesthetics full time. Three years ago, she opened the Alchemy Skin Clinic in Aylesbury.

“In some regards, opening my clinic was easy because I was an experienced practitioner by then, but I found the business side of things difficult. You have to be very organised – I was so used to having a receptionist do everything for me. I don’t think people realise that there’s so much more to opening a clinic than just finding a room, making it look nice and then performing the injections – there are rules and safety protocols and planning permissions,” she adds. Alongside training and practising in her own clinic, Recchia works one day a week at The Private Clinic Northampton/ Buckinghamshire, as well as being a faculty member for Allergan and a board member of the British Association of Cosmetic Nurses (BACN). Recchia notes that her favourite thing about working in the aesthetic specialty is seeing how it can positively impact people’s lives. She says, “Aesthetics isn’t just all about giving people big lips and big cheeks. It’s about making people feel better about how they look – I love that. I love helping other people feel happier about themselves. I remember this one lady who came in, and her face was slightly flat and droopy so I just put a little bit of filler in her cheeks and it gave her a much brighter look. I remember her getting up off the bed and looking in the mirror with a tear in her eye because she was so pleased. I have so many patients that react in that way and it makes the job so rewarding.”

There are more challenging aspects to the job however, with high patient expectations often proving difficult, she says. “Lots of patients show you a photo and ask you to make them look exactly like the person in it – but that’s not realistic. I’ve learnt that it’s so important before a procedure to tell the patients exactly what you can or can’t do – it’s almost about lowering their expectations. That makes your life a little bit easier, because they won’t ring you up in a week’s time complaining about the procedure,” Recchia explains. She continues, “I think that practitioners need to learn the importance of saying no. I found that difficult at the beginning of my career because I wanted to keep patients happy by doing everything they wanted. But you soon realise that if the treatment isn’t right for that person, you will create a lot more problems by doing it.” Recchia is also a regular speaker at conferences, which she says have given her some of the best and most memorable moments of her career. “I do often say that I’m a failed actress, so I love just going on stage and doing talks, like at ACE or CCR,” she laughs, adding, “I like the recognition and being somebody who is looked up to for the knowledge that I have. Back when I started we didn’t really have anyone to ask for guidance, and we certainly didn’t have any journals offering advice so I’m always very happy to share my experience and insights with my colleagues and those joining our specialty!”

My favourite treatment to perform is… Botulinum toxin. I just love the science behind it and the results you can achieve on the face. Something people don’t know about me… I write astrology charts! I’ve been doing it for years. We used to have to do the calculations by hand, but luckily we now have software that does it for you. If I wasn’t in aesthetics I would… Go back to A&E! Or any kind of hospital work.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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that the condition itself should be treated first. According to the Clinical Practice Standards Authority,3 once BDD has been identified, referral to a psychological/ psychiatric professional is advised prior to commencing cosmetic treatment.

Those for treatment

The Last Word Dr Danielle Davy explores the arguments for and against practitioners performing treatment on patients showing evidence of body dysmorphic disorder Body dysmorphic disorder (BDD) is a condition commonly characterised by a person excessively and persistently worrying about perceived flaws in their appearance.1 According to Veale et al.,2 BDD is a very underdiagnosed condition, particularly within the cosmetic surgery industry. The Cosmetic Practice Standards Authority highlights that a clinician must assess and document any evidence of a patient’s body dysmorphia prior to providing treatment.3 It is commonly thought that patients suffering from BDD frequently have ‘unrealistic expectations’ of treatment outcome and are therefore more likely to be unhappy with results.4 Additionally, there have been reported cases of dissatisfied BDD patients attempting to sue surgeons whom they believe have worsened their perceived flaw following treatment.5 In such cases, patient capacity to provide ‘valid’ consent could be questioned.6 According to the Dental Defense Union (DDU), for informed consent to be deemed ‘valid’, the patient ‘must have capacity’, and consent should be ‘given voluntarily’.7 Whether BDD decreases one’s ability to make an ‘informed decision’ is debatable, however, it is something that is important for clinicians to assess on an individual patient basis.8

Those against treatment When researching BDD, I found much past literature which cited the condition as a contraindication to receiving aesthetic treatment.9 A study conducted by Bouman et al. found that approximately two thirds of dermatologic surgeons considered BDD a contraindication for cosmetic procedures.10 These clinicians argued that BDD is a patient’s issue with their own body image, and therefore cosmetic surgery/ procedures will not resolve the issues the patients have. It is believed instead

In contrast to this view, an increasing number of clinicians believe that the decision whether or not to treat a patient should be based on the severity of the patient’s BDD.11 It is suggested that patients with ‘severe BDD’ will likely show ‘impairment of functioning’.12 They are also more likely to be depressed and have more irrational behaviour.13 In contrast to this, those with ‘mild-to-moderate’ BDD have been found to have more ‘localised appearance concerns’ and ‘realistic expectations’ when it comes to treatment.14 While most studies agree that cosmetic procedures in the ‘severe’ category of patients should be contraindicated, it is felt by some that those with ‘mild-to-moderate BDD’, may actually benefit from cosmetic treatment.15 A study conducted by Felix et al. in 2014 found that out of 31 patients, 90% with mild-to-moderate BDD were pleased with their surgical procedure outcomes one-year post-op.15 Yet despite these clinical studies, there does not seem to be any clinical guidelines specifically advising practitioners whether or not to treat patients with differing severities of BDD. For this reason, the choice fundamentally lies with the practitioner.

How this influences practice These studies do help to reinforce the importance of identifying BDD during the consultation process, prior to any cosmetic procedures. The JCCP competency framework supports this notion, stating that as a practitioner, you ‘must assess the patient

While most studies agree that cosmetic procedures in the ‘severe’ category of patients should be contraindicated, it is felt by some that those with ‘mild-to-moderate BDD’, may actually benefit from cosmetic treatment

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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My experience As part of my Non-Surgical Facial Aesthetics Level 7 PGCert course at the University of Salford, I have treated many patients with botulinum toxin in the upper third of the face. During one of my clinical days, I treated a patient who showed several signs of BDD. When given a mirror and asked to look at herself, this patient remarked, ‘no, it makes me feel sick’. Additionally, when asked what she liked about her appearance, she answered, ‘nothing’. Despite these clinical observations, however, no further mental health assessment/questionnaire screening was undertaken as part of her consultation. When the patient returned for review after completing treatment, she seemed very pleased and no further top up was indicated. On reflection of this particular case, when the patient presented at her consultation appointment, other than the remarks mentioned above, she complained of localised upper face wrinkles (specifically dynamic wrinkles in her lateral canthus region and frontalis). I then performed a thorough clinical examination (alongside my clinical mentor), whereby we assessed her upper face dynamic wrinkles, the heaviness of her brows and eyelids and, from this, decided she would benefit from the treatment I could provide. Had the patient attended complaining of issues I physically could not see, I think this would have been a different clinical scenario. In hindsight, however, I think conducting a mental health assessment using a validated questionnaire would have been beneficial and may have helped establish a BDD diagnosis. Moving forward, this is something I will adopt. I plan to do so by printing off copies of the BDDQ and including this in my paperwork documents for patients to fill in prior to their consultation. This will not only to aid my treatment decision, but will also aim to protect myself from legal implications if a patient is not satisfied with the treatment outcome.

for psychological conditions and deliver appropriate treatment accordingly’.16 Joseph et al. states that generally, clinicians are not very good at screening for patients with BDD on their own, in comparison to when using a validated screening tool.14 According to Higgins and Wysong, the gold standard diagnosis tool for BDD is a 24-question structured clinical interview assessment; commonly used in a psychiatric setting for evaluation of DSM-IV psychiatric disorders.4 It is believed that this assessment can take multiple hours to complete, which is unrealistic when treating patients in a busy clinic. There are therefore two validated screening tools that exist, the BDD Questionnaire (BDDQ) and Dysmorphic Concern Questionnaire (DCQ).17 These screening tools, however, have been shortened and adapted from use in a psychiatric setting to a cosmetic one, and therefore seem to only provide a ‘potential BDD’ diagnosis rather than a definitive one.4 They also don’t help to assess the ‘severity’ of BDD cases. For this reason, it is advised that if you recognise BDD as a potential diagnosis in practice, you should always involve a multidisciplinary team, for help both in the diagnosis confirmation, but also the appropriateness for treatment.11,18 According to Kapsali et al., the Yale-Brown Obsessive-Compulsive Scale Modified for

Body Dysmorphic Disorder (BDD-YBOCS) is the most commonly used scale to measure BDD severity.19 Despite this, it is mainly used in research studies and in a psychiatric setting rather than in medical practice.19 I believe a clinical screening tool for BDD severity may be a useful aid for clinicians, allowing them to help assess patient suitability for cosmetic treatment. By utilising any of these BDD screening tools in practice, and referring appropriately if required, in theory this should help to optimise patient satisfaction rates of those undergoing treatments and also prevent legal implications that can occur when patients are dissatisfied post procedure.

Summary BDD is a prevalent but underdiagnosed mental health condition commonly found in patients within the cosmetic treatment environment.10 While BDD is considered by some as a contraindication for cosmetic treatment,10 others support evaluating BDD severity prior to making a decision.13 In order to assess the severity of BDD, I believe a new validated, preoperative clinical screening tool would be beneficial in practice.17 Additionally, providing a multidisciplinary approach to treatment is also important, working with a mental health team for patient referrals once the disorder is identified.3

Dr Danielle Davy qualified as a dentist from Leeds University in 2017 and has since worked in various aspects of NHS dentistry throughout the North West. Dr Davy has completed her Royal College of Surgeons’ MJDF Part 1 and also spent a year in a maxillo-facial department. She is currently undertaking the Non-Surgical Facial Aesthetics Level 7 PGCert course at the University of Salford. Qual: MChD/BChD of Dental Surgery, BSc Oral Science REFERENCES 1. Krebs, G., Cruz , F and Mataix-Cols, D. 2017. Recent advances in understanding and managing body dysmorphic disorder. Evidence Based Mental Health Journal. 20(3), pp 71-75. 2. Veale, D., Gledhill, L.J., Christodoulou, P and Hodsoll, J.2016. Body dysmorphic disorder in different settings: a systematic review and estimated weighted prevalence. Body Image Journal. 18, pp. 168–86 3. Cosmetic Practice Standards Authority. 2018. CPSA Clinical and Practice standards, Overarching Principles. London: Cosmetic Practice Standards Authority. 4. Higgins, S. and Wysong, A. 2018. Cosmetic Surgery and Body Dysmorphic Disorder – An Update. International Journal of Women’s Dermatology. 4(1), pp. 43–48. 5. Sweis, I.E., Spitz J., Barry D.R and Cohen, M. A review of body dysmorphic disorder in aesthetic surgery patients and the legal implications. Aesthetic Plastic Surgery Journal. 41(4), pp. 949–954. 6. General Dental Council. 2013. Standards for the Dental Team. London: General Dental Council. <https://www.gdc-uk.org/docs/ default-source/standards-for-the-dental-team/standards-printerfriendly-colour.pdf?sfvrsn=98cffb88_2> 7. Dental Defense Union. 2018. Guide to consent to dental treatment. London: Dental Defense Union. <https://www. theddu.com/guidance-and-advice/guides/quick-guide-toconsent> 8. James, M., Clark, P and Darcey, R. 2019. Body dysmorphic disorder and facial aesthetic treatments in dental practice. British Dental Journal. 227, pp. 929-933. 9. Lee K., Guy A., Dale, J and Wolke, D. 2017. Adolescent desire for cosmetic surgery: Associations with bullying and psychological functioning. Plastic and Reconstructive Surgery Journal. 139(5), pp.1109–1118. 10. Bouman T.K., Mulkens, S., Van Der Lei, B. 2017. Cosmetic professionals’ awareness of body dysmorphic disorder. Plastic and Reconstructive Surgery. 139(2), pp. 336–342. 11. De Brito M.J., Felix, G., Nahas F.X., Tavares H., Cordas T.A and Dini G.M. 2015. Body dysmorphic disorder should not be considered an exclusion criterion for cosmetic surgery. International Journal of surgical reconstruction. 68(2), pp 270-272. 12. Ziglinas P., Menger D.J and Georgalas, C. 2014. The body dysmorphic disorder patient: to perform Rhinoplasty or not? European archives of Oto-Rhino-Laryngology Journal. 271(9), pp.2355–2358 13. Bowyer, L., Krebs, G., Mataix-Cols, D., Veale, D. and Monzani, B. 2016. A critical review of cosmetic treatment outcomes in body dysmorphic disorder. Body Image Journal. 19, pp. 1–8. 14. Joseph, A.W., Ishii, L., Joseph, S.S., Smith, J.I., Su, P and Bater, K. 2016. Prevalence of body dysmorphic disorder and surgeon diagnostic accuracy in facial plastic and oculoplastic surgery clinics. JAMA Facial Plastic Surgery. 19(4), pp.269–274. 15. Felix G.A., de Brito M.J., Nahas F.X., Tavares, H., Cordas, T.A and Dini G.M. 2014. Patients with mild to moderate body dysmorphic disorder may benefit from Rhinoplasty. Journal of Plastic, Reconstructive and Aesthetic Surgery. 67(5), pp. 646–654 16. JCCP. 2018. Competency Framework for Cosmetic Surgery. London: Joint Council for Cosmetic Practitioners. 17. Dufresne, R.G., Phillips, K.A., Vittorio, C.C. and Wilkel, C.S. 2001. A Screening Questionnaire for Body Dysmorphic Disorder in a Cosmetic Dermatologic Surgery Practice. Dermatologic Surgery. 27(5), pp. 457-462. 18. American Psychiatric Association.1994. American Diagnostic and Statistical Manual of Mental Disorders (DSMIV). Arlington: American Psychiatric Association. 19. Kapsali, F., Nikolaou, P. and Papageorgiou, C. 2019. Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS): Greek Translation, Validation and Psychometric Properties. EC Pyschology and Pschiatry journal. 8(8), pp. 884-894.

Reproduced from Aesthetics | Volume 7/Issue 9 - August 2020


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AUGUST: THE INJECTABLES ISSUE  

Discover the latest updates in aesthetics, along with multiple articles on how to enhance your practice with injectable treatments

AUGUST: THE INJECTABLES ISSUE  

Discover the latest updates in aesthetics, along with multiple articles on how to enhance your practice with injectable treatments

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