December 2020: The Evolution Issue

Light Therapy

Hyaluronidase

Ageing

Dr Natasha Verma discusses the effect of exercise on facial ageing

Spotlight On: Uvence A look into the future of regenerative medicine in aesthetics

Aesthetics Awards: Finalists Announced We are delighted to announce the 2020 Finalists!

Aesthetics Around the World

Practitioners from across the globe share their speciality insights 46 Future Spotlight: Robot-Assisted Injection

Aesthetics explores the use of robots for botulinum toxin injections 48 Case Study: Facial Palsy and Botulinum Toxin

Nurse prescriber Anna Kremerov details treatment of Bell’s palsy 51 Treating Lipoedema

Dr Aamer Khan outlines the treatment options for patients with lipoedema

A round-up and summary of useful clinical papers

Special Feature: Utilising Ultrasound Page 19

Clinical Contributors

Dr Ahmed El Houssieny is a trained anaesthetist. He is an honorary lecturer at the University of Chester and an education provider on cosmetic procedures.

Dr El Houssieny is an associate member of the British College of Aesthetic Medicine.

Dr Natasha Verma is the CEO and medical director of Skin NV. She graduated from the University of Newcastle upon Tyne with a Bachelor of Dental Surgery qualification. Dr Verma has a background in oral and maxillo facial surgery.

Anna Kremerov is an advanced nurse practitioner and a registered prescriber. She has a Master of Science in Advanced Clinical Practice. Kremerov is the founder and clinical director of Anna Medical Aesthetics based in Swindon, Wiltshire.

Nurse prescriber Julie Scott gives guidance on clinic growth

Becoming an Aesthetic Trainer

Dr Vikram Swaminathan and Dr Paul Charlson explain how you can become an aesthetic trainer

Alan S. Adams advises on taking your clinic from good to great

In the Life Of: Dr Kate Goldie

Dr Kate Goldie discusses how she’s adapted to her new working routine 69 The Last Word: Training in Aesthetics

Dr Helen McIver debates the effectiveness of one-day training

Dr Aamer Khan graduated from The University of Birmingham in 1986 and has knowledge in areas including human psychology, psychiatry, surgery and dermatology. Dr Khan is the co-founder of the multiaward-winning clinic Harley Street Skin. NEXT MONTH

Chloé Gronow Editor & Content Manager @chloe_aestheticseditor

Well, what a year it’s been! Despite the challenges faced by everyone working in aesthetics this year, the specialty has continued to evolve at a rapid pace. We’ve had no shortage of product launches, company updates and training developments to cover in our news pages, while practitioners have thrived in the challenges COVID-19 has brought, with so many enthusiastically getting in touch to share what they’ve learnt in educational articles throughout the journal.

This collaborative spirit is what we love most about medical aesthetics and why we can’t wait to celebrate everyone’s hard work each year at the Aesthetics Awards! So to end 2020 on a high, we’re delighted to reveal the finalists on p.36 Congratulations to everyone who took part – as always, we had so many fantastic entries and there’ll be some very deserving winners at the ceremony on March 13!

Clinical Advisory Board

Now, on to this issue, all about evolution. We have some fantastic pieces that really demonstrate the high level of innovation in aesthetics – from ultrasound technology to better prevent complications (p.19), to the future of robot-assisted injections (p.46)!

We also chat to practitioners from other countries to learn more about aesthetics abroad on p.31, while delving into the rise of social media influencers requesting hyaluronic acid filler removal on p.16. Two practitioners detail the pros and cons of this, reflecting on the use of hyaluronidase in their own clinics and trends they’ve noticed.

We’d love to know whether you’ve experienced any similar trends, as well as the innovation you’re most excited to see released in the next few years, so do let us know by tagging us on Instagram @aestheticsjournaluk.

Wishing everyone a Merry Christmas and a Happy New Year from all of us here at Aesthetics – we hope to see you all in person at last in 2021!

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

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.

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

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

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.

PORTFOLIO

Alison Willis Director

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

ADVERTISING

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.

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

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

Courtney Baldwin • Event Manager T: 0203 196 4300 | M: 07818 118 741 courtney.baldwin@easyfairs.com

Judith Nowell • Business Development Manager T: 0203 196 4352 | M: 07494 179535 judith@aestheticsjournal.com Chloe Carville • Sales Executive T: 0203 196 4367 | chloe.carville@aestheticsjournal.com

MARKETING

Aleiya Lonsdale

Head of Marketing

T: 0203 196 4375 | aleiya.lonsdale@easyfairs.com

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DESIGN

Peter Johnson • Senior Designer T: 0203 196 4359 | peter@aestheticsjournal.com

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

Email editorial@aestheticsjournal.com

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

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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© Copyright 2020 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

Mr Dalvi Humzah, Clinical Lead

WE WANT TO HEAR FROM YOU!

Talk #Aesthetics

Follow us on Twitter @aestheticsgroup and Instagram @aestheticsjournaluk

#Training

Dr Tahera Bhojani-Lynch @officialdrtahera

Today’s Virtual Appraisal Training. Invaluable education in difficult times from the ever supportive British College of Aesthetic Medicine #bcam2020

#Virtual Miss Sherina Balaratnam @sthetics_clinic

Really enjoyed virtually presenting yesterday to medical and healthcare professionals across Russia and Ukraine on behalf of iS Clinical. Thank you to iS Clinical for the opportunity to share my experience with your audience.

Filler

Merz celebrates milestone for 10 million Radiesse syringes

Global pharmaceutical company Merz Aesthetics has sold 10 million syringes of Radiesse worldwide.

The product is a calcium hydroxylapatite injectable filler, which has been sold by the company for 20 years.

Katie Vaughan, UK and Ireland brand manager, said, “We are thrilled to mark this milestone for Radiesse. As we are looking ahead, we are really excited for what the future holds over the next few years.” Dutch aesthetic practitioner, and Merz Aesthetics key opinion leader Dr Jani van Loghem, commented, “Radiesse is my number one go-to product because of its versatility. Radiesse works for contouring, lifting, ligaments and volumising. It is a biostimulatory product going beyond a hyaluronic acid – the collagen gives the patient the final result.”

#Techniques

Swiss Care Clinic @swisscareclinic

Throwback to a fantastic training day last week with our GMC and GDC registered doctors. Always learning new and improved procedures and techniques to give you, our clients the best treatments. Thank you @drvix.manning @blairsinclairpharma @silhouette_soft

#Presenting Jackie Partridge @missjackiepartridge

Fun times presenting on the first UK GAIN (Galderma Aesthetic Injector Network) webinar this evening! #gain #galdermauk #galderma #restylane

NeoStrata launches four new products

#Melasma

@shinobay

Ready to discuss the heartbreak of melasma and hyperpigmentation with Dr Behrooz Kasraee. Thank you @cyspera @cysteamine_by_scientis for this enlightening opportunity.

Skincare company NeoStrata is introducing four new products to its portfolio following a recent company rebrand. According to the company, the new Clarify Exfoliating Mask is designed for oily skin, formulated with 8% NeoGlucosamine which aims to minimise the appearance of pores, improve skin complexion and clarity, and even out the appearance of post-blemish discolouration. The new Glycolic Microdermabrasion Polish contains 10% glycolic acid, combined with alumina crystals. NeoStrata states that the dual physical and chemical action removes surface skin cells to help clarify and clear impurities from pores. The Overnight Anti-Pollution Treatment is formulated using polyhydroxy acids, lilac plant cell extracts, in an amino acid hydration formula. NeoStrata explains that the new Enlighten Brightening Eye Cream blends together antioxidants, peptides and algae extract to target visible dark circles under the eyes. The mixture of gluconolactone plus bionic acid aims to target the skin’s natural hydrating matrix to cushion and brighten the appearance of dark, under-eye skin.

Skincare

Awards Finalists announced!

Vital Statistics

In a sample of 1,086 British women, 47% said they did not regularly check their breasts for any lumps or changes to their appearance (Breast Cancer Now, 2020)

New sponsors have also been announced for the prestigious ceremony, which will take place on March 13. Laser manufacturer Cynosure is supporting the Award for Best Clinic Midlands and Wales. Fiona Comport, marketing and communications manager for Cynosure, commented, “Cynosure are delighted to sponsor this Award and are thrilled to be part of a category in line with their values – commitment to excellence, high level of patient care and the quality of results. Congratulations to all Finalists and good luck!”

Brand new patient magazine

Beyond Beauty, brought to you by the Aesthetics team, is sponsoring the Award for Professional Initiative of the Year. Chloé Gronow, editor and content manager, commented, “Our new magazine Beyond Beauty is all about educating consumers to make informed choices when undergoing aesthetic procedures, while building their trust in safe practitioners and spreading a positive message about the specialty as a whole. This perfectly aligns with the Professional Initiative category, which celebrates the organisations that work so hard to enhance education and safe practice through their campaigns. We’re delighted to work alongside them and will profile the winner in an upcoming Beyond Beauty issue! Best of luck to all the Finalists!”

CCR will sponsor the Award for Best Independent Training Provider and the Aesthetics Conference and Exhibition (ACE) will be sponsoring the Award for Manufacturer of the Year. Events manager for ACE and CCR, Courtney Baldwin, said, “The CCR Award for Best Independent Training Provider is so critical as all Finalists play a key role in shaping the future of our industry, developing talent, supporting regulation, and striving for excellence in our specialty.” She added, “Each year at ACE, manufacturers lead the way in providing CPD-accredited, clinical education that is eagerly anticipated and loved by all delegates. We are excited to sponsor the ACE Award for Manufacturer of the Year to show our appreciation to UK manufacturers.” Voting is now open for the Aesthetics Awards categories and you can purchase tickets to the glamorous event by emailing contact@aestheticsjournal.com.

In a survey of 8,000 female participants, 53% of adults and 58% of people aged under 18 reported that the coronavirus lockdown restrictions made them feel ‘worse’ or ‘much worse’ about their appearance (Women and Equalities Committee, 2020)

66% of BAAPS members are continuing to offer video consultations after lockdown (BAAPS, 2020)

59% of 2,000 US women said their top concern when trying a new skincare product is whether it will actually do more harm than good and make their acne worse (OnePoll, 2020)

63% of 325 respondents reported having stopped or avoided treatment for rosacea because of the cost of medications (National Rosacea Society, 2020)

In a survey of 2,000 women, more than a third were asked by their employers to wear more makeup or do something to their hair for video calls, while 27% were asked to dress more provocatively (Slater and Gordon, 2020)

Finalists for the Aesthetics Awards have been revealed, turn to page 36 to find out the clinics, companies and products recognised this year!

Treatment results

AlumierMD opens competition

Skincare brand AlumierMD has launched a new before and after competition for practitioners to showcase their best patient results. The company explains that the owner of the clinic that produces the winning entry will get £1,000 allocation for their clinic, and the practitioner that produces the winning entry will win one years’ supply of AlumierMD Skincare. Successful entries will be shortlisted and the before and after judging panel will select a winner from the finalists to be announced in May 2021. The judging panel includes Aesthetics deputy editor Shannon Kilgariff, alongside consultant dermatologist Dr Helen Robertshaw, AlumierMD global medical director Dr Francine Gerstein, dermatologist Dr Hope Mitchell and beauty author Jane Hiscock. Dr Mitchell commented, “As a board-certified dermatologist and lover of skin health and the AlumierMD line, I am excited to be joining Alumier’s before and after campaign as a panellist and expert judge. I love what this line is doing for my skin and the results of Alumier’s safe and corrective formulas on my patients’ skin.” The competition is open to all UK AlumeirMD stockists, and their therapists and practitioners can enter by emailing beforeandafter@alumierlabs.com

Skincare

PCA Skin releases at-home peel kit

Skincare company PCA Skin has released a Micro Peel At-Home Kit, benefiting patients who are unable to attend in-clinic treatments. According to the company, the kit features the Enzymatic Treatment product, which is formulated with enzymes and alpha hydroxy acids, as well as the Facial Wash, Hydrating Toner, Detoxifying Mask, Rejuvenating Serum, ReBalance and Daily Defense Broad Spectrum SPF 50+ products. It also comes with a treatment brush to help with product application. Lizzie Shaw, brand manager at PCA Skin UK, commented, “We are truly delighted to introduce the Micro Peel At-Home Kit for our consumers. Throughout 2020, we have seen a significant demand from our professional customers for something that could help them to deliver their expert care to the homes of their patients. This gives them the tools to do so effectively and safely. The Micro Peel At-Home Kit is also an excellent first-time treatment for those looking for professional-grade, visible results at home.”

BTL launches EMsculpt Neo

Device manufacturer BTL Aesthetics has launched the EMsculpt Neo body contouring device, combining radiofrequency heating and high-intensity focused electromagnetic (HIFEM) waves. According to the company, the results of seven new clinical studies with a combined cohort of 167 patients indicate that the device has an average of 30% fat reduction and 25% increase in muscle mass. BTL explains that unlike the original EMsculpt which utilises HIFEM, the new EMsulpt Neo combines radiofrequency with HIFEM, which the company states allows for patients with a higher BMI of up to 35 to be treated. Eddie Campbell-Adams, sales and marketing director for BTL UK, commented, “Patients want fast and efficient treatments with zero downtime and great results. EMsculpt Neo ensures that expectations are exceeded, due to its ability to maximise burning fat and building muscle in the same treatment. This is a result of us combining the technologies of trusted radiofrequency heating to burn fat and established high-intensity focused electromagnetic waves, which is proven to both build muscle and burn fat. We look forward to delivering the first systems in the UK in the coming weeks.”

Training

Wigmore Medical partners with DHAT

Distribution company Wigmore Medical has partnered with training provider Dalvi Humzah Aesthetic Training (DHAT) to incorporate a new curriculum into its current training offering. Wigmore Medical explains that the curriculum has been developed for medical practitioners entering the aesthetics field for the first time and that the course modules will be completed using a mix of both distanced and on-site learning. Modules on the new curriculum include: an introduction to aesthetics, an introduction to practice management, an introduction to anatomy, an introduction to light, an introduction to toxins, an introduction to dermal fillers, and management of complications. Danny Large, training and events consultant for Wigmore Medical, said, “This is a very exciting time for training with Wigmore Medical. With this new partnership with DHAT we feel we can not only improve the training but take on a whole new, modern way of educating delegates as well adding a whole host of new educational opportunities.”

Body sculpting

Hyaluronic acid Croma Pharma introduces new face mask

Medical aesthetic product manufacturer Croma Pharma has launched a new liquid skin mask called Pure HA. According to the company the product is formulated using 1.8% hyaluronic acid and is designed to provide the skin with hydration. Nina McMurray, country manager, commented, “Pure HA is produced in a sterile and highly professional glass container, and can be used to enhance in-clinic aesthetic procedures, targeting skin quality and enhanced hydration. This can be built into a number of in clinic procedures, allowing the clinicians to offer a pharmaceutical approach to a post-treatment skincare protocol at home. The patient can take away the three remaining HA face masks as part of their ongoing posttreatment protocol. We are pleased to be able to launch this popular product into the UK market.” Croma Pharma confirms that the product is suitable for all skin types.

Dermatology

Data indicates vitamin B3 may help prevent skin cancer

Research presented at the 29th European Academy of Dermatology and Venereology (EADV) Congress has indicated that a form of vitamin B3 may have the ability to protect skin cells from the effects of ultraviolet (UV) exposure. Researchers in Italy isolated cells (human primary keratinocytes) from the skin of patients with non-melanoma skin cancers which were treated with three different concentrations of nicotinamide (NAM), a form of vitamin B3, for 18, 24, and 48 hours, and then exposed to UVB. Results indicated that pre-treatment with 25µM of NAM 24 hours before UV irradiation protected the skin cells from the effects of UV-induced oxidative stress, including DNA damage. NAM was also shown to enhance DNA repair, decrease antioxidant expression and reduce iNOS protein expression. Lara Camillo, a research student from the Dermatological Unit of AOU Maggiore della Carità, commented, “Our study indicates that increasing the consumption of vitamin B3, which is readily available in the daily diet, will protect the skin from some of the effects of UV exposure. However, the protective effect of vitamin B3 is short-acting, so it should be consumed no later than 24 to 48 hours before sun exposure.”

BAAPS president launches surgery-focused podcast

The president of the British Association of Aesthetic Plastic Surgeons (BAAPS), Miss Mary O’Brien, has launched a surgery-focused podcast called Knife to Life. Miss O’Brien explains that the podcast will feature talks with key figures in plastic surgery and will talk about their life, career and the future of plastic surgery. Guests on the podcast include Ms Ruth Waters, president elect of the British Association of Plastic, Reconstructive and Aesthetic Surgeons and professor of plastic surgery Mr Ash Mosahebi. On her decision to start the podcast, Miss O’Brien commented, “My initial intention is to use the podcast as a tool to communicate, collaborate and keep up morale amongst the plastic surgery community during this difficult period. I have found it inspirational listening to colleagues that I respect and wanted to share those conversations with a wider audience. It’s an authentic account of what life as a plastic surgeon is really like and the different paths that can be pursued within this amazing career.”

BACN UPDATES

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

EXCELLENCE

2020 has been a difficult year for everybody, but throughout December, the BACN will be championing its nurse members and looking back to highlight the successes. The BACN will be using the hashtag #BACNExcellence via all social media channels to shine a light on some hidden heroes. Members are encouraged to take part!

COMPLICATIONS SURVEY

The BACN recently sent a survey out to all members focused on their characteristics. This has really helped when looking at the services on offer for 2021. Full results can be found in the December BACN newsletter. BACN members will be aware that there is a huge issue around complications management, particularly with regard to procedures carried out by non-medically trained practitioners. The BACN is also aware that for many new aesthetic nurse practitioners, managing complications is challenging. In order to refocus the support the association provides regarding complications, members are encouraged to take part in the new survey to gain more insight. The results will provide data to input into a number of major developments linked to regulation and the many media enquiries the BACN receives on this subject. All responses will be treated confidentially and no individual response will be identified and used. All members should have received the survey through the BACN communication channels. For more information contact Gareth Lewis at glewis@bacn.org.uk

BACN AGM

Every year, the BACN holds an Annual General Meeting that members are encouraged to participate in. All BACN members have been provided notice of this meeting by email – BACN Accounts and information relative to the meeting can be found in the BACN Member’s Area. The AGM will be held at a physical location in London on January 11th, but members will be asked to participate digitally via Zoom. If members have yet to receive the information, they are asked to contact Sarah Greenan at sgreenan@bacn.org.uk

This column is written and supported by the BACN

12 & 13 MARCH 2021 / LONDON

SAVE THE DATE

Onwards and upwards! We’re looking ahead to the biggest weekend in the Aesthetics calendar!

For the first time ever, the Aesthetics Awards will take place on the same dates as the Aesthetics Conference and Exhibition (ACE) – making the 12 & 13 March 2021 the biggest weekend in the aesthetics calendar! The prestigious Aesthetics Awards will take place on 13 March 2021 right after day two of ACE. The glamourous awards ceremony will celebrate the fantastic achievements of clinics, products, companies, and individuals working across the speciality. Exciting new categories and the Awards’ fabulous new location at Royal Lancaster Hotel will offer a refreshing and invigorating evening for both regular attendees and those new to the speciality.

“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 glamourous ballroom will be the perfect setting to bring the aesthetics specialty together for a fabulous evening of celebration, entertainment, and reunion. The Aesthetics team looks forward to seeing you all there!”

Alison

Willis, director of Aesthetics and CCR

LEARN FROM KOLS AT ACE

Aesthetic manufacturer and headline sponsor Teoxane will host two full days of free clinical education at ACE on 12 & 13 March 2021. Teoxane’s two-day symposia will be fully CPD-accredited and provide high-quality education and best practice from leading Teoxane trainers and injectors. Allergan, Galderma, HA-Derma, and more will also feature unrivalled education from their KOLs, and the Business Track will cover everything you need to know about establishing a successful practice.

ACE and the Aesthetics Awards will be the next time we all come together to meet and learn in person, and we can’t wait! FIND OUT MORE

aestheticsconference.com

Skin Study supports microdose toxin efficacy

A new study published in Plastic and Reconstructive Surgery has suggested that intradermal botulinum toxin injection, or microbotulinum, is a safe and effective method to treat skin flaws.

The authors of the study were from the Rigeneralab Centre for Regenerative Medicine and Pegaso University. A total of 62 patients – 54 women and eight men – participated in the study and the assessment was focused on skin texture, skin microroughness, and pore diameter before and 90 days after the microbotulinum injection.

To treat the face, a 125-US (Speywood units) vial of Azzalure was reconstituted with 1.25ml saline solution. Then, 0.5ml was drawn into a 1ml syringe and a further 0.5ml of lidocaine (0.5%), or saline if the patient reported allergy to lidocaine, was added to the syringe to make it a 1ml volume. Approximately 150 injections were then delivered into the superficial dermis using 32 gauge needles over the entire area, from the forehead to the cheek and down to the jawline.

The authors state in their conclusion that, “The results of this pilot study suggest that intradermal botulinum toxin injection, or so-called microbotulinum, is a safe and effective method to treat skin flaws affecting texture and microroughness and to reduce enlarged pore size.” They added, “Because of the high satisfaction rate among both physicians and patients, further studies are indeed mandatory to determine the optimal number of units needed for a longer and lasting effect with this particular novel dilution.”

WOW Facial introduces new SPF

Skincare brand WOW Facial Ltd has launched the Synergy 6 NX-Gen SPF 50 to its new Intradermology skin health range. The company explains that the Synergy 6 NX-Gen SPF 50 uses liposomal technology to prevent the absorption of the chemical filters by the skin and a 3D physical filter to guard the skin against environmental pollutants such as heavy metals, smoke and air particles.

It also features broad spectrum photoprotection of gossypium herbaceum, a natural Arabian cotton which aims to provide protection against blue light, and a blend of antioxidant, growth factors and acetyl hexapeptide-49 to improve cellular health, barrier function and increase hydration, according to the company.

Based on research conducted by WOW Facial, Synergy 6 NX-Gen SPF 50 minimises the damage caused by infrared heat, increases skin firmness by 11.9%, elasticity by 4.8%, and reduces the appearance of wrinkles by 20%. WOW Facial confirms the Synergy 6 NX-Gen SPF 50 is suitable for all skin conditions and skin types.

Suncare

Complications

ACE Group expands globally

The Aesthetic Complications Expert (ACE) Group has rebranded as ACE Group World and is now offering its services internationally.

Currently consisting of more than 4,000 members of doctors, dentists and registered nurses in the UK, ACE Group World will offer help and support, guidelines, an emergency helpline, educational modules and conferences to practitioners in countries around the world. Countries currently included in ACE Group World are Australia, Canada, Ireland, South Africa, the UK, and the US. Each will have its own website and forum and the criteria for joining the ACE Group will vary depending on individual legislation.

Dr Martyn King, aesthetic practitioner and co-founder of the ACE Group, commented, “We created ACE Group World due to international demand after offering education and support on complications in the UK since 2011. Our mission is to improve regulation in the medical aesthetic sector, to raise standards in clinical practice, and to improve patient safety.” The ACE Group website has been updated and rebranded, and new social media platforms and a new emergency helpline number have been launched. According to Dr King, practitioners should reregister with the new website, and they will be refunded for the remaining months of their previous membership.

Sinclair Pharma launches podcast

Pharmaceutical company Sinclair Pharma has launched its own podcast called Authentic Aesthetic. The company explains that each bi-monthly episode will focus on a unique topic and feature a different speaker. Upcoming episodes include: My First Times in Aesthetics with aesthetic practitioner Dr Kuldeep Minocha, How Safe are Aesthetic Treatments? with clinic owner Ffyona McKeating, Lifting or Not Lifting with aesthetic practitioner Dr Leah Totton, Non-surgical Rhinoplasty? with consultant surgeons Mr Charles East and Miss Lydia Badia, Are We Doomed to Get Duckface? with aesthetic practitioner Dr MJ Rowland-Warmann, How Minimal Are Minimally Invasive Treatments? with Dr Ali Ghanem, All Things Collagen with surgeon Mrs Sabrina Shah Desai, and Is Filler Always the Best Solution? with aesthetic practitioner Dr Nina Bal. Jo Neal, Sinclair Pharma brand manager, said, “We are committed to helping connect our professional community with existing and potential patients. We have developed a number of new ways to encourage a dialogue with patients and are also launching consumer-facing website, Aesthetic Insider, and can’t wait to share more news about this venture early in 2021.”

Health and safety

Lynton launches infection prevention qualification

Laser manufacturer Lynton has launched a VTCT Level 2 Award in Infection Prevention. According to the company, the virtual half-day course is a knowledgebased qualification aimed at aesthetic practitioners who need to understand the COVID-19 infection prevention methods required in the working environment in order to maintain high levels of health and safety. The assessment will be hosted by Lynton’s trainer and assessor Kirsty Turnbull. Lynton’s clinical director, Dr Sam Hills, commented, “Lynton is delighted to offer this important qualification in conjunction with VTCT. We know there is little evidence of COVID-transmission in our industry when appropriate infection control procedures are in place and gaining this qualification will help clinic owners reassure their customers that they are being treated in a COVID-safe environment and demonstrate to them that the safety of their patients is paramount.”

News in Brief

Novo Nordisk to host weight loss webinars this month

On December 3 and 10, pharmaceutical company Novo Nordisk will host webinars on how to incorporate weight loss services into clinics. The first webinar will be hosted by aesthetic practitioner Dr Kam Lally and Sarah Le Brocq, head of Obesity UK, covering the best ways to talk to your patients about weight. The second webinar will be presented by aesthetic practitioner Miss Mayoni Gooneratne on how to integrate holisticfocused weight loss into your clinic. Novo Nordisk explains that the aim of the webinars are to help practitioners understand how they can be a key person in a patient’s journey against becoming overweight.

VIVACY hires new sales representative Aesthetics product manufacturer VIVACY UK has appointed Rachael Hall as its new sales representative for Scotland. Hall previously worked as brand manager for skincare brand Elemis. Terina Denny, sales manager for VIVACY UK, commented, “We are delighted Rachael is joining our team. She comes with a wealth of knowledge and experience and is a welcomed addition to VIVACY UK.” Country director Camille Nadal added, “I am thrilled to welcome our new colleague and I have every confidence that Rachael will embody perfectly our set of values at VIVACY.”

New certificate in hair science

The College of Trichological Science and Practice is launching its Certificate in Hair and Scalp Science for Trichology in January 2021. The course content will cover an introduction to trichology practice, anatomy and physiology for trichology, nutritional health in trichology, an introduction to disorders and diseases of the hair and scalp, and cosmetic science and chemistry in trichology. Director Iain Sallis commented, “This marks an unprecedented change in trichological education and is ideal for aestheticians to understand more about hair loss problems they treat on a regular basis.”

FVCE launches virtual consultations Online marketplace FVCE has launched digital consultations in order to help practitioners keep their businesses going throughout COVID-19. According to FVCE, practitioners will not be limited by a specific skincare brand. The company explains that all payments will be processed through the platform. Dr Hussain Cheema, co-founder and director, commented, “During this pandemic, we have had to think outside of the box and see how we can support practitioners run their businesses whilst helping consumers achieve their skin goals, minimising face-to-face time.”

LABthetics introduces Christmas gift sets

UK owned skincare manufacturer LABthetics has launched its new Christmas gift sets. The sets available include a three-step vitamin A retinol gift box, an antioxidant duo gift box, a mini facial kit and a luxury facial box.

According to the company, the facial kit contains a cleanser, toner, enzyme mask, hyaluronic serum and a vitamin A moisturiser. The luxury facial box contains a full-sized version of each. LABthetics founder Emma Caine commented, “The gift boxes smartly feature the monotone brand colours of LABthetics finished with a luxury branded ribbon. Our gender-neutral packaging will appeal to the male skincare market this Christmas. As the public are becoming more aware of the benefits of active and vitamin-based ingredients, we at LABthetics are thrilled to introduce our products in a beautifully wrapped Christmas box.”

Devices

US laser company established in the UK

US aesthetic laser manufacturer Sciton has launched direct operations in the UK and Ireland. Sciton was established in 1997 and offers aesthetic and medical devices for women’s health, fractional and full-coverage skin resurfacing and skin revitalisation, phototherapy, vascular and pigmentation lesions, scar reduction, acne, body contouring, and hair reduction.

David Percival, vice president and general manager for Sciton International, commented, “The UK is an important market for Sciton’s global growth strategy and we look forward to introducing our innovative aesthetic technologies with an outstanding customer experience to match.”

New eye and periocular cleanser launches

New aesthetic company FaceRestoration Ltd and manufacturer Clinical Health Technologies Ltd have partnered to release Purifeyes, a pH balanced eye and periocular antimicrobial and antiinflammatory cleanser.

FaceRestoration Ltd explains that the cleanser uses hypochlorous technology to provide protection against transmissible respiratory contamination, organisms responsible for inflammation, styes or chalazia, dry eyes, and post-intervention infections. Practitioners can use it before and after, as well as during, their injectable treatments around they eye.

Miss Rachna Murthy, co-founder of FaceRestoration Ltd and consultant oculoplastic and aesthetic surgeon, commented, “The idea for Purifeyes came from the recognition of an unmet need. As an oculoplastic and aesthetic surgeon, with an interest in complications management, I was acutely aware of the limitations of current antimicrobial cleansers. They stain, sting or are toxic to the eye and skin. I have witnessed alcohol-related corneal burns and suffered from chlorhexidine allergy. Collaborating with the leading maker of a high purity hypochlorous, which our body naturally produces to fend off bacteria and viruses, we have formulated an eye safe antimicrobial. Purifeyes meets this unmet need and I believe will revolutionise periocular care and treatments.”

Training Surge in training course searches

According to new data collected by insurance company PolicyBee there has been a surge in online searches for aesthetic training courses over the last 12 months. According to the research, August 2020 recorded the highest number of searches this year at 10,960, which showed a 64% increase from August 2019. The results of the data also indicated a 115% increase between April and August of this year.

The company believes that the increasing numbers of searches for aesthetics training goes hand-in-hand with the expansion of the non-surgical cosmetic procedure sector in the UK and the phenomenon of ‘lockdown face’ due to increased video calls. Jim Savin, managing director of Cosmetic Courses, agrees that demand for aesthetic training has increased over the last 12 months. He said, “At Cosmetic Courses we have had a huge demand for our service with total revenue growing by 20% from October 2019 for courses. We encourage all delegates to continue their learning to not only offer new treatments but ensure they are treating to a high standard.”

Mesotherapy

DermaFocus to host 1-to-1 training

Distribution company DermaFocus is offering free one-to-one video training for their clients throughout December. According to the company, the sessions will feature an introduction to the Pistor Eliance mesogun and Bioformula meso sterile solutions, as well as discussing a range of mesotherapy treatments and protocols, reviewing product selection and equipment recommendations, and opportunities for questions to be answered.

DermaFocus managing director Kamran Bermana commented, “At DermaFocus, we put a huge emphasis on training and supporting our clients so they achieve results with the highest level of standards. Given that we are once more in a national lockdown, we decided to utilise this time to a great effect and run free one-to-one video training for Pistor Eliance mesotherapy injector and Bioformula’s meso sterile solutions.”

Supporting Charities Through COVID-19

It’s been a tough year for charities. Katrin Kandel, voluntary CEO of Facing the Word, explains, “With the COVID-19 pandemic taking over 2020, most charitable donations have rightly gone to supporting the NHS and those in need. But unfortunately there are so many causes missing out that still desperately need your support.” For Facing the World, plans for international fellowships have been put on hold until normal travel resumes. Kandal says, “While we are sad not to

be welcoming our Vietnamese colleagues on their fellowship visits to the UK, US and Canada, we are extremely proud that clinics and life-changing surgeries are continuing safely and with great success in Vietnam for our patients in greatest need.” Yet donations are still needed to fund these operations and continue to train new doctors in the skills needed to treat facial differences, which effect thousands of children in the country every day. That’s why, this Christmas, we’re asking you to make a £10 donation to Facing the World. Tag @aestheticsjournaluk and @ftw_charity on Instagram when you’re done so we can reshare and spread the message!

We’re all hoping for a better 2021, so why not help these children achieve it?

Donate today to fund scholarships for medics in Vietnam.

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

THEIR LOOK

*Juvéderm® offers a range of

We believe the most natural-looking, long lasting results are achieved by enhancing your client’s features, not changing them. That’s why this year we’ll be launching a striking new campaign to educate your clients about our Juvéderm® Vycross® range. In fact, our versatile range of fillers includes five tailored products, each designed to benefit a specific area of the face at the optimum dermal level. Which means you can offer your clients a more bespoke and tailored treatment to suit their needs.

So, to help achieve good results for your clients and your business, choose Juvéderm®.

To

It’s dangerous because, as we know, there is a lot that can go wrong between the needle and the product that can’t be reversed.”

Dr Shotter also worries that it will encourage patients to seek unnecessary hyaluronidase procedures. She explains, “Influencers are called influencers for a reason, so what concerns me is that dissolving is just becoming another trend for people. Young women in particular are impressionable, and if they become aware of hyaluronidase injections through Instagram or YouTube it might encourage them to follow suit, without really knowing what it is or what it does.”

Dr Shotter has noticed that over the last two to three years patients are saying to her in their initial consultations, ‘Well if I don’t like it, I can just get it removed’. She says, “Correcting minor aesthetic issues isn’t the purpose of hyaluronidase! The main uses should be for emergencies like a vascular occlusion or allergic reaction. If celebrities are documenting this sort of thing, they need to make it clear that it isn’t an easy solution, because right now the public aren’t educated enough.”

News Special: Is Hyaluronidase

“I’ve made so many mistakes when it comes to filler in my face, but slowly I’m starting to reverse it all,” says Love Island star Molly-Mae Hague. The comment comes from her recent YouTube video, in which she discusses the decision to get her lip fillers dissolved. This comes only a few months after having the same done to her cheeks and chin. At the end of the video, she concludes that getting rid of her filler was, “The best decision I have made in a long time.” This isn’t an isolated event and Molly-Mae is the most recent in a long line of influencers having their aesthetic procedures and surgery reversed, following people such as Kylie Jenner, Megan Mckenna and Olivia Attwood. It’s being dubbed by the media as ‘the explant movement’ or the ‘lip switch’.1,2

Although publicly discussing the decision to have fillers dissolved can have positive outcomes, does it trivialise hyaluronidase as being a quick and easy solution? Aesthetics speaks to aesthetic practitioners Dr Tijion Esho and Dr Sophie Shotter to find out their take on the movement.

Negative impacts

Recent survey results from Save Face indicated that 59% of 61,000 respondents see cosmetic procedures as comparable to getting a manicure or a haircut. Although this can be seen as a positive for the normalisation of aesthetics, it indicates that many people are unaware of the risks involved with procedures.3

With the constant promotion of filler dissolution in the media and by influencers, Dr Esho is concerned that hyaluronidase injections are also becoming viewed as low risk. He says, “The risk that comes from influencers talking about the dissolving process is that often they trivialise it. If they don’t go into full detail about the process and all its risks it can reinforce the opinion that you can quickly get a bit of filler and then easily get it removed if you don’t like it.

While Dr Esho acknowledges that it in some circumstances it can be okay to dissolve fillers for cosmetic reasons, he emphasises that it should only occur if patients have been fully informed of all the risks involved, such as allergic reactions and anaphylactic shock. He comments, “Patients don’t often understand that they’re more likely to have a reaction to hyaluronidase than actually to the filler itself! I once had a patient who had filler injected and dissolved six times by previous injectors. When I asked her whether she had ever been made aware of the dangers, she said no. It’s worrying, and patients should never be under the illusion that it’s a quick fix.” Dr Esho believes that practitioners should view hyaluronidase as a last resort. “When I’m using it on a patient it’s either for emergencies or if they are suffering from a psychological impact,” he says, adding, “If a patient isn’t delighted with the aesthetic outcome, but it’s not bothering them in any way, we shouldn’t rush to take the money and do the procedure. We have to put patient safety first.”

Positive awareness?

While the way the content is often presented by influencers may be a cause of concern, Dr Esho recognises that there are positives to celebrities talking about their filler journeys. “I do praise influencers that are being open about it,” he says, adding, “Previously, celebrities would come to me and get

fillers dissolved or removed, but it would remain a secret. The problem with this is that it stops their fans from being aware of the complications or the dangers of getting too much filler. So, I think that as long as people promote it in the right way, such as always including a medical opinion to explain the reality behind the procedure, it can be a good way to educate people.”

Dr Shotter also acknowledges that there can be benefits, stating, “It’s good when women who portray themselves as an unattainable standard of beauty are honest and hold their hands up about the work they’ve had done, as well as admitting when they’ve gone too far. Promoting a more natural look or making people aware of the downsides to cosmetic procedures is a good thing, but only when it’s done right.”

Despite these positives, it should be noted that practitioners should never be advertising hyaluronidase as a reversing agent as it’s a prescription-only medicine and would go against ASA guidelines.4

The future of hyularonidase

Dr Shotter believes that practitioners will see a rise in patient requests for dissolving filler, but warns them from easily agreeing to treatment. She says, “Practitioners should have a balanced discussion about what the options are, and always implement a couple of weeks’ cooling-off period, unless of course it’s a medical emergency. Waiting for filler to naturally break down is the best choice for most people, and you need to inform them of the risks involved with dissolving.” Dr Shotter adds that if practitioners do choose to go ahead with the treatment, you should ensure you manage patient expectations. “Hyaluronidase often needs to be injected more than once and we can’t guarantee how much will actually be dissolved each time. Patients need to know that after one session they aren’t automatically going to be fixed or happy with their look, which is what they expect after watching influencer vlogs,” she concludes.

REFERENCES

1. Jess Lester, Blunder the Knife, 2020 <https://www.thesun.co.uk/fabulous/13083775/stunningstars-cosmetic-surgery-reversed-lip-fillers/>

2. Zoe Cripps, What Molly Mae and Kylie Jenner look like without lip fillers, 2020, <https://www. ok.co.uk/lifestyle/beauty/what-molly-mae-hague-kylie-22988370>

3. Save Face, What we learned from the UK’s biggest poll about lip filler, 2020, <https://www. saveface.co.uk/what-we-learned-from-the-uks-biggest-poll-about-lip-fillers/>

4. ASA, 2020, Stick to the Script, <https://www.asa.org.uk/news/stick-to-the-scriptprescription-only-medicines-and-the-code.html>

“Our goal is for Beyond Beauty to take pride of place in every clinic waiting room and be the go-to information source for consumers. This special magazine is designed to inform patients of what to expect from treatments and encourage them to become loyal, returning visitors to aesthetic clinics. No frills, no fluff – the content will be purely educational, written in language that patients will understand and trust.”

“If celebrities are documenting filler removal, they need to make it clear that it isn’t an easy solution, because right now the public aren’t educated enough”

Dr Sophie Shotter

BRINGING THE WORLD OF AESTHETIC MEDICINE TO YOU

The Eye Area: A Strong Urge For Aesthetic Rejuvenation

Dr Angelica Kavouni is one of the UK’s most well-known, respected and requested female plastic surgeons, with more than 10 years of cosmetic private practice experience.1 Specialising in surgical procedures and aesthetic rejuvenating treatments, Dr Kavouni explains why Thermage FLX® has become a vital addition to her clinic. “Eye rejuvenation is something that is frequently requested by my patients. Whether it’s reducing dark circles or fine lines and wrinkles, the ageing eye is a common concern for both men and women,” says Dr Kavouni. With face masks now compulsory, there is more focus than ever on the eye area. “There is an increased focus on the eyes specifically to combat dark circles and puffiness,” she says, adding, “The emphasis has moved away from the mouth and the eyes have taken on a new importance. Patients are no longer looking at their face as

one, they’re compartmentalising their eyes and noticing infinite detail the things that they would like to change.”

This is mainly due to the fact that the glabella and crow’s feet lines are some of the most visible lines of expression that contribute to the aged appearance of the face2 and are particularly accentuated by the severe stress associated with the pandemic.

Dr Kavouni emphasises, “The eyes are often an area that can show signs of ageing as the skin is typically thinner, more delicate and susceptible to structural changes around it, such as flattening of the midface fat pad, which can have a direct impact on its appearance. There are many modalities which we can use to improve various aspects of skin ageing, such as fillers or topicals for tear trough correction as well as of course, Thermage FLX® radiofrequency for the improvement of fine lines and wrinkles

and to tighten lax skin.” Thermage FLX® offers an effective standalone treatment but it can also be used as a combination therapy for maximum results, Dr Kavouni explains. “Combining advanced medical skin care technology with cosmetic products performed as part of a sophisticated medical skin rejuvenation programme will boost the results by treating the multiple layers of the skin,”3 says Dr Kavouni.

What is Thermage FLX®

Thermage FLX® is different to anything else available in the marketplace at the moment because it’s the only non-invasive radiofrequency treatment of its kind that requires a single treatment as opposed to a full course.4 Thermage FLX® is noninvasive so there is no surgery or injections. The procedure offers significant clinical improvement5 with few potential side effects and little downtime,6 so patients can quickly return to their normal routine. In addition, Thermage FLX® has demonstrated a good safety profile.5 The treatment can be used on all skin types and tones and can be done all year round. Thermage FLX® uses radiofrequency technology to heat the deeper, collagen-rich layers of the skin to offer a deep rejuvenation of tissues. Thermage FLX® works across the entire face, including the forehead, eyelids, jawline and the submental area, as well as on the arms, buttocks, abdomen and flanks and thighs. It can be used at different ages, in men and women.

REFERENCES

1. www.ionkavounilondon.com

2. Mendelson B.C, O’Brien J.X. (2016) The Aging Face. In: Scuderi N., Toth B. (eds) International Textbook of Aesthetic Surgery. Springer, Berlin, Heidelberg. pp 855-865.

3. Fabi S, et al. Combined aesthetic interventions for prevention of facial ageing, and restoration and beautification of face and body. Clin Cosmet Investig Dermatol. 2017 Oct 30;10:423-429.

4. R. Fitzpatrick et al. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med. 2003;33(4):232-42.

Thermage FLX® offers new features

25% faster treatments compared to the previous Thermage CPT® version*: the new Total Tip 4.0 provides greater surface area coverage than the Total Tip 3.0.

AccuREP™ Technology: automatic calibration allows for optimised energy delivery to provide consistent output.*

Patient comfort: mechanical advancements provide vibration elements to assist with patient comfort.7

Single handpiece: consistent treatment from head to toe without the need to interchange any handpieces.

Touchscreen navigation: updated interface brings a modern look and functionality.

5. E. Finzi, A. Spangler. Multipass vector (mpave) technique with nonablative radiofrequency to treat facial and neck laxity. Dermatol Surg. 2005 Aug;31(8 Pt 1):916-22.

6. M. Fritz and al. Radiofrequency treatment for middle and lower face laxity. Arch Facial Plast Surg. Nov-Dec 2004;6(6):370-3.

7. Solta Medical, 2009. Report on Gazelle Clinical Study 09-100GA-T ‘Validation of the Thermage 3.0 cm2 STC and DC Frame Tips, Comfort Software and Vibration Handpiece on the Face and Thighs’ (#09-019ER). Bothell.

*Data on file

Leading cosmetic surgeon Dr Angelica Kavouni explains why radiofrequency is a vital tool when treating the eye area

Photos courtesy of Mary Lupo, MD. Before and after photos result from Thermage FLX®

Before After

Utilising Ultrasound in Aesthetics

Ultrasound-assisted injections and complication prevention

Ultrasound has been a topic commonly discussed at international congresses and described in the literature for more than 12 years.1-8 Yet, despite its clear potential in enhancing dermal filler safety, it still hasn’t become a mainstream tool in aesthetic practice. Here, we explore the benefits and limitations of ultrasound and where its future lies in clinical practice.

Using ultrasound in practice

A simple literature search reveals dozens of papers on ultrasound and dermal fillers;3 many highlight its potential as a noninvasive tool for reducing dermal filler complications,4 monitoring the behaviour of filler implants,4,5 detecting dermal filler sites, quantity, and the nature of the filler injected,2 as well as identifying and managing dermal filler complications.6,7,8 So with rising reports of complications, why hasn’t ultrasound become a common tool in every aesthetic practice?

Phlebologist Dr Leonie Schelke and dermatologist Dr Peter Velthuis practice in the Netherlands and are co-founders of one of the world’s few aesthetic ultrasound training providers – Cutaneous. They have been using ultrasound to aid in complication management and guide

their injectable treatments for the past 10 years. The pair suggest that the main reason ultrasound isn’t commonplace in many aesthetic clinics is because historically, device prices have been too high, costing around the same as a large laser. UK-based aesthetic practitioner Dr Alexander Parys, who previously worked in the NHS as a radiologist, believes that the newer, cheaper, hand-held alternatives have increased momentum for the use of ultrasound in aesthetics. While Dr Schelke, Dr Velthuis and Dr Parys all say these smaller devices can have a number of benefits for clinics, they also note that there are limitations and considerations for their use.

Due to his prior experience in clinical and interventional radiology, Dr Parys purchased a hand-held ultrasound device to assist in injecting platelet-rich plasma into the elbow of his patients to improve conditions such as tennis elbow. “I later expanded to the face as I realised it could be hugely beneficial for complication prevention, particularly vascular occlusion,” he says, explaining, “Although you may know your anatomy and employ safe injection techniques, with variations amongst individuals and higher risk areas, the danger is still there. I’ve found that ultrasound can be a useful tool to identify vessel location and depth and allow you to adapt your injection technique to make sure the filler is being deposited into the correct, lowerrisk location.” Dr Parys notes that although he finds it very useful, at the moment he only uses it for higher-risk areas and is not something he routinely does for every patient as he says it can be time-consuming and doesn’t replace good technique, anatomical knowledge, and complication recognition. Dr Velthuis and Dr Schelke on the other hand, use it routinely. “I use ultrasound to assist my dermal filler injections for every patient and, after a lot of practice, it now only takes me two to three minutes prior to injection. I think it’s a much safer method of injecting and although I still employ other complication prevention practices, if I don’t do my ultrasound examination I do feel a bit worried,” Dr Schelke says, adding, “I will check to see if there is any other filler already injected, try to identify the filler type and, importantly, assess whether there is variation in the vascular anatomy.”

Complication management

All practitioners note the large scope for complication management. In fact, Dr Schelke and Dr Velthuis first began using ultrasound purely to treat complications.

Hand-held ultrasound devices available

Ultrasound involves using different frequencies to view certain structures at various depths. When looking for a device, practitioners note that frequency and definition should be considered. There are a few different hand-held devices available on the market. Dr Parys uses the Butterfly iQ.9 He says, “It has a frequency range of 1-10MHz, which allows you to see 1-30cm into the skin. Once you purchase there is an ongoing subscription to use the app and images, which you can save through the cloud.”

Dr Schelke and Dr Velthuis have the Lumify device, which has varying frequencies and depth according to the transducer chosen.10 “I personally think this is the most convenient and affordable option and the app is fantastic,” Dr Velthuis notes. Other devices are also available such as the Sonoinject and Clarius.

A look at the use of ultrasound in medical aesthetics for improving dermal filler safety and assisting in complication management

Ultrasound can give practitioners a whole new appreciation for 3D anatomy

“When I began I was using it once every six weeks to help treat complications. Now, at our complication management centre, we have two full days every week with a waiting list of a couple of months and always use ultrasound,” notes Dr Schelke.

Ultrasound allows for very targeted hyaluronidase injections, Dr Velthuis and Dr Schelke explain, which can be of huge benefit to the patient. “Ultrasound allows you to see exactly where the problem is – such as an obstructed vessel – and this means that you can treat it very precisely and even see the restoration of the blood flow. Instead of injecting the area with 1500 units every hour for example, I would inject once or twice using only 70-100 units. This allows for your patient to require less hyaluronidase because you don’t have to guess where the issue is, and the patient can ultimately go home earlier and recover quicker,” Dr Schelke explains.

Dr Velthuis adds, “Many patients come to us after their practitioners have tried to resolve their complication and have already been injected with hyaluronidase, but just not in the precise location.”

Dr Parys highlights that the uses of ultrasound doesn’t just stop at occlusions. “You can identify an abscess, nodule,

oedema and various other types of complications, which can lead to quicker diagnosis. Identifying vascular occlusion is particularly helpful. You can potentially trace the blood supply to/from the area and the blood flow. Even if you had a patient with a clear bruise and you just wanted to doublecheck it wasn’t something more concerning, you can use ultrasound as an adjunct to check for adequate perfusion,” he explains.

Other uses in aesthetic settings

Ultrasound is also commonly used in clinical studies to monitor treatment outcomes and effectiveness. Dr Schelke says she is currently using it to explore how HA integrates into the tissue over time. However, she notes that this requires larger devices with higher frequencies. Dr Parys explains that he uses ultrasound for other procedures in his clinic, such as body contouring and fat-dissolving injections. “I have an EMsculpt machine – which aims to build muscle whilst simultaneously burning fat – and I like to use ultrasound to monitor the results on the abdomen,” he says. Dr Parys will scan the patient pre-treatment and measure the fat and muscle, then repeat after the end of the treatment plan.

He notes, “It’s nice to be able to explain patients’ improvement to them in a quantifiable way. I especially like using it with patients with diastasis recti after childbirth as I am able to tell them exactly how much they have improved. It doesn’t change safety or protocol but, from a patient point of view, it’s a really nice addition to their treatment. And, as a practitioner, it helps you scientifically validate that your treatments are working!” Dr Parys adds, “I also use it for fat dissolving assessment for gynaecomastia. It’s important to be 100% sure that it’s the fat, rather than glandular tissue, which is causing the issue and I know I can check this with ultrasound and safely treat.” He also likes to use ultrasound on patients who have previously had implants or metal work to ensure he avoids the area to prevent biofilms.

Enhancing anatomy knowledge through ultrasound

There is a vast array of educational opportunities when it comes to ultrasound, the practitioners note. Dr Velthuis explains that much like cadaver training, ultrasound can give practitioners a whole new appreciation for 3D anatomy. “Textbook anatomy is so different to real-life anatomy, and once you start using ultrasound a lot you are able to form a 3D image of the anatomy in your mind, which is extremely helpful for complication prevention and achieving optimum results. It really made me recognise the anatomy and what’s going on underneath the skin in real time, allowing you to know where you are injecting, exactly what plane you are in and how the filler is responding to this area. What’s amazing is often you are so sure you are in a particular plane, but then you check with ultrasound and realise you aren’t in the layer you thought!”

Dr Parys adds that he has also finds ultrasound extremely useful for continued

RHA

topical skin

learning. “Personally, I think training is where the real future lies rather than day-today practice. Depending on one’s medical background, the facial anatomy isn’t often something learnt in-depth and, like cadaver training, which can be hard to come by, ultrasound really helps you to visualise all the layers. You also grasp what an injection feels like and can associate it with what it looks like under the skin after looking at it through ultrasound.”

Dr Velthuis says it’s particularly good to understand how tissues react to dermal fillers through movement. He also notes that the apps provided with many handheld ultrasound devices allow for easy collaboration with others, explaining, “You could be in the mountains injecting someone and be able to show your ultrasound images in real-time to a colleague miles away! The potential for collaborative work is huge and it’s ideal for training, webinars and teaching virtually.”

to use the ultrasound and interpret the images for the particular areas you will treat,” Dr Schelke says, adding, “You have to invest time and money to do this.”

A lot of practice is also required, all practitioners note. “You need to practice a lot; it’s like driving a car. Once you have been trained it really does take a couple of weeks to get used to – scanning friends and family is a good approach before integrating it into practice,” Dr Velthuis emphasises.

Although all practitioners say that purchasing a hand-held device is ‘affordable’, they come in lower frequencies compared to larger machines so there are restrictions to the resolution and visible layers. Dr Parys adds that the probes currently available are a technical limitation. He says, “The image quality for the small hand-held devices are actually surprisingly good, but you don’t have the option of different probe sizes and that’s definitely missing at the moment. For larger areas it’s ok, but scanning the tear trough, for example, is very difficult at the moment and we would really benefit from different adapters.”

Alongside this, it can be difficult injecting and holding an ultrasound device at the same time. Dr Parys says, “I like to use it for assessing more challenging and high-risk areas like the forehead/glabella or temple, but personally I find it a bit impractical for day-to-day use for every single filler treatment.”

How will ultrasound progress in aesthetics?

Despite the positives of incorporating ultrasound into clinical practice, it’s still not commonly used in aesthetic clinics. However, Dr Schelke, Dr Velthuis and Dr Parys all believe there is future.

Dr Parys says, “For me personally, I think training is where ultrasound in aesthetics will really excel. It can make a real difference to one’s knowledge of the anatomy which will increase treatment outcomes and reduce complications. I don’t see it becoming mainstream until cheaper, more dedicated devices with better adapters come onto the market, as well as more dermal filler-specific training becomes available.”

Dr Schelke and Dr Velthuis do believe that the future of aesthetics will involve ultrasound. “I think it will become much more mainstream with further device developments featuring higher frequencies and better probes. We are also starting to see many company key opinion leaders train with us, so I think this could have a ripple effect and encourage more to seek training. You can see what you are doing in real time, so the safety and quality of treatments can improve,” says Dr Schelke says, highlighting, “Our patients also like the fact that we use ultrasound! We have patients come to us especially because we use it as they want an ultrasound-guided treatment due to enhanced safety, so that’s something that might influence the market.”

REFERENCES

1. Young SR & Bolton PA, Use of high-frequency ultrasound in the assessment of injectable dermal fillers, Skin Res Technol, 2008 Aug;14(3):320-3.

2. Gripped FR & Mattei M, The Utility of High-Frequency Ultrasound in Dermal Filler Evaluation, Annals of plastic surgery, February 2011, 67(5):469-73

3. Pubmed, ‘Ultrasound and Dermal Filler’ Nov 2020, <https:// pubmed.ncbi.nlm.nih.gov/?term=ultrasound%20and%20dermal%20filler&sort=pubdate&page=14>

4. Phumyoo T et al., Anatomical and Ultrasonography-Based Investigation to Localize the Arteries on the Central Forehead Region During the Glabellar Augmentation Procedure, Clin Anat, 2020 Apr;33(3):370-382. <https://pubmed.ncbi.nlm.nih. gov/31688989/>

Limitations

Despite its progression to become more user-friendly, affordable and available, ultrasound still has limitations, according to the practitioners interviewed. Of course, without appropriate training, you can’t simply purchase a device and start using it. “You really have to be trained in how

Dr Parys notes that as ultrasound is very operator dependent, things could be missed, giving practitioners a false sense of security when using it for injections. “Very fine vessels could be missed due to the resolution, and practitioners could also misinterpret the image, so it can’t be your only method of complication prevention and you can’t rely solely on this,” he emphasises.

5. Carvalho Rocha LP et al., Ultrasonography for long-term evaluation of hyaluronic acid filler in the face: A technical report of 180 days of follow-up, Imaging Sci Dent, 2020 Jun;50(2):175-180. <https://pubmed.ncbi.nlm.nih.gov/32601593/>

6. RK Mlosek, et al., High-frequency ultrasound-based differentiation between nodular dermal filler deposits and foreign body granulomas, Skin Res Technol, 2018 Aug;24(3):417-422. <https:// pubmed.ncbi.nlm.nih.gov/29363178/>

7. Schelke LW, Decates, TS & Velthuis PJ, Ultrasound to improve the safety of hyaluronic acid filler treatments, J Cosmet Dermatol. 2018 Dec;17(6):1019-1024. <https://pubmed.ncbi.nlm.nih. gov/30084182/>

8. de Freitas Lima, VG, et al., External vascular compression by hyaluronic acid filler documented with high-frequency ultrasound, J Cosmet Dermatol, 2019 Dec;18(6):1629-1631. <https://pubmed. ncbi.nlm.nih.gov/30838729/>

9. Butterfly 2020. <https://www.butterflynetwork.com/au/specs>

10. Philips Lumify 2020. <https://www.philips.co.uk/healthcare/sites/ lumify/transducers>

Figure 2: Images taken on ultrasound showing the anatomy of the lip. Images provided by Dr Leonie Schelke.

Figure 3: How hyaluronic acid appears on ultrasound. HA has been injected in the medial corner of the eye. Image provided by Dr Leonie Schelke.

Supralabial artery

Teeth

Subcutaneous tissue Orbicularis oris muscle

Modiolus

REASONS TO CHOOSE

Restylane

WORLD’S FIRST NON-ANIMAL HA FILLER WITH 40 MILLION TREATMENTS OVER 24 YEARS1

Restylane is the world’s first non-animal stabilised hyaluronic acid (HA) dermal filler.1 Restylane has been delivering results for 24 years with 40 million treatments completed across the world.1 Restylane sets the standard for dermal fillers, delivering results time after time.

RESTYLANE NASHATM: CLOSER TO NATURAL HA THAN ANY OTHER FILLER3

The hyaluronic acid (HA) in NASHATM gels (Restylane and Restylane Lyft) is closer in composition to the HA that occurs naturally in the body than any other fillers on the market today.3 Rather than adding more BDDE or other chemicals, Restylane’s NASHATM gels largely use the natural entanglement of HA. This means that the body is more likely to accept the HA and Restylane is considered to be generally well-tolerated.4,6 Restylane Lyft has the highest G’ on the market and has been shown to last 24 months with one retreatment.2,7 It’s used on the nose, chin, jawline and cheekbone - where projection is needed, without volume.

STRONG CLINICAL EVIDENCE: 60 TRIALS CITED IN 320 PAPERS5

The effectiveness and safety of Restylane has been evaluated in 60 clinical trials cited in 320 peer-reviewed clinical papers.5 That’s a lot of data and means every claim can be substantiated with incredibly strict and high standards. The world’s leading practitioners trust Restylane. You can too.

References

1. Data on file (MA-39680).

2. Data on file (MA-39364).

3. Kablik J et al. Dermatol Surg 2009;35(Suppl1):302–312.

4. Weiss RA et al. Dermatol Surg 2016;42:699–709.

5. Pubmed search for ‘Restylane’ Available at: www.ncbi.nlm.nih.gov/ pubmed/?term=restylane Accessed October 2020.

6. Narins RS et al. Dermatol Surg 2011;37:644–650.

7. Data on file (MA-43049)

Explaining Dermal Filler Characteristics

Injectable soft tissue fillers or dermal fillers have become an integral part of aesthetic medicine with around 60 products available in the UK.1 When, as practitioners, we choose a dermal filler, what guides our choice? We are likely to be making a judgement about the suitability of that filler for the procedure we have in mind. Yet, what are the fundamental properties of fillers that inform this judgement? Hyaluronic acid (HA) fillers are the most common filler type, being used in almost 80% of filler procedures in the US.2 However, they vary greatly from one another in terms of their physical properties due to the different technological processes used in their development.3

This article aims to explore some of the key properties of HA dermal fillers and asks how we take them into account to optimise our choice of filler for any given procedure or area of the face. The focus will be on the rheological properties of G-prime (elasticity) and G double prime (viscosity), as well as cohesivity and concentration of HA.

Fillers and forces

Dermal fillers injected into the face at any level or location are subject to different stresses throughout their lifespan. This starts with the extrusion force exerted to eject the filler through the needle or cannula during the injection process and extends through the moulding and massage, which places and integrates the filler.3,4 When in place, the filler is subject to stresses from adjacent tissues, as well as from facial expression and external forces, such as rubbing a cheek or physical exercise.4,5 The stresses in question are compression and stretch forces (applied perpendicular to the filler) and shear forces (applied along the surface of the filler or torsion) as shown in Figure 1 4

The array of fillers available to practitioners of aesthetic medicine all possess properties that respond to these forces in a way that enables them to be effective. However, levels of elasticity, viscosity and cohesivity, as well as other properties, vary greatly between different products. It is important that the practitioner chooses a filler with an appropriate profile to respond to the forces exerted upon it during injection and for the duration of its placement in any given facial area.

Elasticity and G-prime

The G-prime (or G’) is a rheological property of a dermal filler and, in my experience, is one that often forms a central part of any discussion around filler choice. The G-prime or G’, also called the ‘storage modulus’ or ‘elastic modulus’, measures elasticity or the extent to which a filler can recover its shape after deformation due to shear stress.4 Manufacturers measure the G-prime of dermal fillers under stress using a rheometer.6 Values in commercially available HA dermal fillers are dependent on each filler’s chemical structure and range from 10 to 1,000 pascals.7-9 This gives a wide choice for the practitioner looking for an appropriate product.

Generally speaking, G-prime is seen as a measure that gives an indication of where in the face the filler may be used.10 Higher G-prime fillers are better able to resist force and, as a result, are recommended in the literature and by manufacturers where deeper injections are needed or where volume needs to be added.8,10-13

Conversely, a lower G-prime means a more fluid filler that may be suitable for larger areas or where softness is required, such as the tear trough.10,11

However, the effects of G-prime are not independent from other filler properties. Cohesivity and viscosity each work in tandem with G-prime, as well as with one another, and this interaction must also be taken into consideration when choosing an appropriate HA filler.8,9,14 G-prime, G double prime (discussed next), and cohesivity work together in dermal fillers to produce the desired results but, due to differences in manufacturing, there are many different combinations to choose from, each with its own particular effects.

Borrell and colleagues, for example, found that lift was achieved in two smooth HA fillers with high cohesivity but lower G-prime.14 This was in contrast to a more granular filler, which achieved lift with a higher viscoelasticity and lower cohesivity.14 The practitioner must then consider what consistency of filler is most suited to the procedure. If a greater level of lift is required, a filler that combines high cohesivity with high G-prime has been shown to be effective.14 Thus, while G-prime is a central property to think about in the selection of an HA filler, it cannot be considered in isolation.

Viscosity and G double prime

Dr Ahmed El Houssieny takes a look at key physical properties of HA dermal fillers and explores the difference they make in practice Figure 1: Forces to which dermal fillers are subjected. Image recreated from Michaud (2018).5

Another key measure to consider is G double prime (or G”). Also referred to as the viscous modulus, G double prime measures viscosity. Viscosity is the quality of thickness of a filler or its ability to resist flow and G double prime measures the inability of a filler gel to regain its original shape after the removal of shear stress.4 Like G-prime, G double prime is measured using a rheometer to assess gel that is placed under stress by being moved at a range of different rates or oscillation frequencies.6,9 Viscosity is crucial at the point of filler injection. It is a fundamental

Gel viscosity Cohesive gel

Gel with low viscosity

Gel with high viscosity

Non-cohesive gel

Figure 2: Relation between cohesivity and viscosity in an HA dermal filler. Image recreated from Molliard et al. (2018).3

requirement that dermal filler can be extruded through a narrow needle or cannula. The more viscous a filler, the more difficult it is likely to be to inject.3,4 HA is a naturally viscous substance, but manufacturers use a range of technologies and formulations to ensure that it is of an appropriate viscosity for use.3

It has been suggested that viscosity is unimportant once a filler has been injected.4 However, others argue that viscosity plays a key role in integration of a filler gel into tissue.3,13 A low viscosity filler can spread, leading to a smoother integration with the skin tissues in treatment of superficial areas.15 Good integration is essential to achieving a natural effect.16 However, integration with tissues is not only the product of viscosity but also of a filler’s cohesivity. While, a low-viscosity filler may be desirable in terms of spread, a filler which combines low viscosity with a higher cohesivity allows spread without the gel losing its integrity. This also allows a filler to be moulded or massaged after injection to ensure correct placement and distribution within the tissues.3,17

Viscoelasticity

Elasticity and viscosity are interdependent properties of dermal fillers and can be combined into one measurement. The measure for viscoelasticity is G* or the complex modulus which combines G-prime and G double prime. Viscoelasticity is also referred to as ‘hardness’, although it should be noted that this term refers to the cross-linked structure rather than a quality of the gel itself.4 All fillers require both elasticity and viscosity so that they can respond to the different stresses to which they are subject.4,5 Consider how a

filler is required to flow out of the needle during injection in response to high shear stress (viscosity) and then to regain its shape once it has been injected and is exposed to low levels of shear stress (elasticity).4,5 Generally speaking, HA fillers are more elastic than viscous.18

Cohesivity

It is important to consider the cohesivity of a filler when choosing an appropriate product; both its function and how it interacts with other filler properties. Cohesivity is the capacity of a dermal filler not to dissociate because of the mutual affinity of its molecules. In other words, it enables the filler to remain intact. In the case of HA fillers, internal cohesive forces hold together the individual crosslinked HA units that comprise the gel.14

In the absence of a standardised measure, a range of testing modalities has been used to show the clinical value of this property in HA dermal fillers.14,19 The Gavard-Sundaram observation-based scale has demonstrated variation in cohesivity levels, ranging from those fillers that fragment in water upon contact to those that retain their integral shape after an extended period of time.17,19

It has been suggested that cohesivity may not be required in addition to G-prime for the performance of a filler.15 Drop-weight assessment was used to show an inverse correlation between G-prime and cohesivity in fillers with an HA concentration of 20mg/mL or higher.15

Fillers with higher G-prime showed lower cohesivity, while lower G-prime gels showed higher cohesivity.15 However, compression force testing (quantitative) and dye diffusion (qualitative) have shown that lift capacity can be achieved using HA fillers with high

Mid – balance between vertical projection and malleability4,5

High – tissue projection/expansion and volumisation4,5,19

cohesivity for the frontal region5

Low-to-moderate cohesivity for the superficial fatty compartment in the mid-face5

Mild-to-moderate marionette lines4

Deep fatty compartment in the mid-face5

Moderate-to-severe marionette lines4

Table 1: Suggested applications for facial dermal fillers according to key filler properties. (a) low-to-medium G-prime may be appropriate for some deeper lines; (b) combine with higher cohesivity to prevent disaggregation.

cohesivity and low G-prime, as discussed above.14 Cohesivity may contribute to lift capacity through tissue expansion, rather than through projection as G-prime does.19

Further, histology and immunohistochemistry have demonstrated the homogeneous integration and optimal spreading of cohesive fillers after intradermal injection compared with non-cohesive fillers.18 Cohesivity and viscosity work closely together (Figure 2), allowing spread into the tissues as required while ensuring that the gel does not fragment.3

Concentration of HA

HA occurs naturally in vertebrates where it plays a part in maintaining extracellular space and lubrication, particularly of joints.21 In its natural state, however, HA has poor viscoelasticity and is quickly degraded by hyaluronidase in the body.22 As such, it is chemically altered to achieve the characteristics required for it to function well as a dermal filler. Changing HA concentration can alter the viscosity, elasticity and cohesivity of HA fillers.4,15,22 A high concentration of HA also increases the resistance to a filler gel being degraded by naturally occurring hyaluronidase, thus increasing the durability of the filler.22 Concentrations of HA in commercially available fillers are within the range 5-24mg/ml. Higher levels can make the gel too viscous to administer.9,18,23 Dilution of the filler with saline or lidocaine is one response to this difficulty and may lead to good results, however practitioners should be aware that reducing the concentration of HA by diluting it decreases the G*, G’ and G”.9 This can not only make the gel softer, less elastic and less viscous, but may also reduce its duration.4,9

What does this mean in practice?

How do the properties outlined above guide the practitioner’s choice of dermal filler for their patients? One may start by considering the area to be injected. The properties of the chosen filler need to be appropriate for injection depth, skin thickness, the strength of the facial muscles in the area being injected and whether the skin is loose or tightly stretched.5 The filler needs to be able to resist deformation exerted upon it in any given facial area, whether through shear or compression forces from injection and throughout its lifespan.4,5 Crucially, being familiar with the properties of a dermal filler alone is not enough. Filler choice also needs to be based on the patient’s treatment goals, the quality of their patient’s skin and their facial musculature. These may vary greatly based on gender, age, ethnicity and personal preference.11 Broadly speaking, facial filler injections can be divided into two types: those into deep and bony areas of the face requiring higher levels of viscoelasticity or cohesivity, and those into softer more superficial tissue, requiring lower levels.18 However, there are nuances to take into account for both. A summary of key properties with example applications is given in Table 1

When treating dark circles around the eyes, for example, there is little compression from surrounding tissue and little shear stress in this part of the face.5 A low G-prime filler is appropriate: little lift or volume is required.5 Low cohesivity and low viscosity are also appropriate.5,24 Low-cohesivity filler is believed to spread evenly in the tissue and to reduce the risk of lump formation and of the bluish colouration (Tyndall effect) caused by too superficial a placement of HA filler.16 A smooth gel should ensure the filler is invisible once implanted.5

Similarly, for fine lines, a filler with lower cohesivity and low viscosity is suitable.3,4,5 However, the forces exerted in the individual patient’s face should be taken into account. In the perioral area, both compression and shear stresses are present and can vary in strength.5 Here, low-cohesivity may need to be combined with low-to-medium

viscoelasticity or G-prime 4 For deeper lines in the perioral area, a higher cohesivity may be needed.5 Filler used in this area needs to spread adequately and be malleable so that it can be fully integrated.5 Other areas require greater lift and volumisation: the temporal region, for example, with its thick skin and strong, large temporalis muscle. Shear stress is low in this area, but in order for deeply-injected filler to achieve lift and volume, HA fillers with high G-prime and a high cohesivity or high viscoelasticity are recommended.5,24 Similarly, where lift is required along with resistance to compression stress, such as in the chin, a high G-prime, high-cohesivity filler is appropriate.4,5 Injecting a low G-prime filler, or one with low cohesivity, in areas that require lift, volume and resistance to strong forces may not cause harm, but it will not achieve the desired projection.5 When considering levels of viscosity and cohesivity in a filler, it is worth remembering that lower viscosity is linked to ease of injection.3 However, the relationship between these properties also affects distribution and may affect your choice (see Figure 2). A filler with high viscosity and low cohesivity may disperse as microboluses in the dermis, in contrast with a low-viscosity, high-cohesivity filler which may distribute homogeneously.3,19 Intermediate viscosity and cohesivity have been shown to display an intermediate distribution pattern.19 On the other hand, medium to low cohesivity may be easier to mould on initial placement of the filler.4

Note that there may be more than one suitable filler option. A 2010 study, for example, found that lower volumes of a high G-prime dermal filler was found to be as effective in the treatment of nasolabial folds as a filler with a lower G-prime (firmness; 1,800 vs 660Pa) with fewer touchup treatments 25 Equally, if the same degree of lift may be achieved using a filler with high cohesivity and low G-prime or vice versa, for example, there may be other qualities, such as duration of effect, that are central to filler choice. While following the broad principles on suitable filler properties for a facial filler procedure, take detail into account and tailor the choice of filler to the individual case. It may be useful to record results in your patients that note filler properties so that you can build on your own experience.

Conclusion

The wide variation in property combinations in HA fillers has an impact on their suitability for a procedure and the results.18.19 Familiarity, then, with the key properties of available HA fillers supports the practitioner in making an appropriate choice. The selection of dermal filler with properties best tailored to the treatment in hand is central to achieving a natural-looking aesthetic outcome that has good duration and is inline with an individual patient’s requirements and expectations.

Dr Ahmed El Houssieny is a trained anaesthetist with a passion for aesthetics. He is an honorary lecturer at the University of Chester and an education provider on cosmetic procedures. Dr El Houssieny is registered with the General Medical Council, as well as being an associate member of the British College of Aesthetic Medicine.

Qual: MBBCH

READ THE REFERENCES AND RECEIVE YOUR CPD CERTIFICATE ONLINE AT AESTHETICSJOURNAL.COM/CPD

hydrafacial london

Let’s be frank, 2020 has not been a good year! It’s been a huge challenge for everyone, and the aesthetics industry has been no exception. It’s also been a year where good news has not come along very often. That’s why we are genuinely delighted to be able to tell you about something great.

From early December 2020 through to the end of January 2021(restrictions permitting) we’re bringing the glow back to the capital and opening the doors of our Flagship HydraFacial London Pop Up Experience Event.

Located at a fantastic venue in Marylebone, it will be a packed experience where we’ll showcase all the latest from HydraFacial, including our new Elite System, highlighting new products like Keravive and partnership boosters as well as protocols, training sessions - and generally having a great time!

Our audience will be wide and diverse, and we will be engaging with both business and the media - but most importantly we will be bringing the brand to the publicand potentially your future clients!

We will be expecting to see over 1000 consumers come through our doors and each of them has the potential to be your customer in the future. On the day each of them will receive a free HydraFacial Signature treatment and the team will be explaining the benefits of long-term courses to follow on.

If you’d like to know more about the event visit www.hydrafacial.co.uk/pop-up

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Understanding Exercise and Skin Ageing

Dr Natasha Verma discusses the effect of exercise on facial ageing

Ageing is commonly associated with structural deterioration of skin that compromises its barrier function, healing, and susceptibility to disease. Much like other lifestyle and environmental factors, exercise or physical activity can impact an individual’s appearance. As this article focuses on the impact of exercise on skin ageing, it is important to clearly define exercise. There is limited evidence on this topic, as supported by Saluja et al.1 Simioni et al. define physical activity as, ‘Any bodily movement produced by skeletal muscles that results in energy consumption’. They explain that exercise is a sub-category of physical activity and is characterised by being planned, structured, and consistent with the intention to improve or maintain one or more aspects of physical fitness.2

Evidence and discussion

Hjerrild et al. discuss the involvement of advanced glycation end-products (AGE) in the progressive and irreversible changes of the ageing process.3 According to Crane et al., many studies indicate that these changes are driven largely by impaired tissue mitochondrial metabolism.4 Saluja et al re-enforce this by explaining that ageing is an oxidative process, affecting receptor-initiated signalling, mitochondrial damage, protein oxidation, and telomere-based DNA damage responses.1

Glycation

AGEs are formed as a result of nonenzymatic reactions and they accumulate in molecules such as collagen, altering the structural components and resulting in tissue damage.1

Some AGEs are fluorescent, therefore glycation can be measured non-invasively using skin auto-fluorescence (SAF).3

Hjerrild et al. used SAF to investigate the effect of regular long-term exercise and diet on glycation. They used a sample of 194 Danish males between ages of 19-41 years, who trained at least twice a week for 10 years. Their results were compared to 34 sedentary Danish males who had not carried out regular exercise for 10 years. Their findings demonstrated that SAF increased with age (p<0.0001) and decreased with training years (p=0.041).3

Unexpectedly, it was determined that there was no difference in SAF between the athletes and controls, however, more training experience was independently associated with lower SAF, thus lower glycation. Following analysis, the researchers suggested that an active year contributed 18% less SAF than an inactive year, and that long-term exercise is required to impact SAF levels in skin.3

However, they did highlight limitations of their study. Even though current smokers were eliminated, 42 participants were ex-

smokers which would increase SAF values. The control group was entirely of the Danish population and skin pigmentation was not taken into consideration, both of which would affect the SAF results.3

Mitochondrial function

Crane et al. support findings by Simoni et al. that physical activity can bring about numerous health benefits, and discovered that endurance exercise attenuates agerelated changes to skin in humans and mice.2,4 A sample of sedentary elderly adults of 65-86 years of age went on a 12-week endurance exercise training programme and the results showed an increase in collagen content, a reduction in stratum corneum thickness and, unexpectedly, a reduction in stratum spinosum thickness, all of which were found to be significant results (p<0.05).4

This was a surprising outcome as a previous cross-sectional cohort study by the group, for which details were not provided, showed a contrasting effect of exercise on the stratum spinosum. As such, the researchers believe that a longer intervention may promote more extensive remodelling, restoring stratum spinosum thickness.4

Saluja et al. have addressed that there is very limited scientific research available on the effect of exercise on skin ageing. However, they discuss a study of sedentary individuals, who exercise for less than an hour per week and active individuals, who do a minimum of four hours of high-intensity aerobic exercise weekly.1 A biopsy taken from each volunteer’s sun-protected buttock skin supports Crane et al.’s findings that the active individuals had significantly thinner stratum corneum and increased reticular dermis collagen content when compared with the sedentary individuals.4 A thicker reticular dermis is beneficial as this increases the support, elasticity and flexibility of the skin whereas, a thinner stratum corneum can accentuate signs of ageing.

Both groups of researchers identified exercise-stimulated hormone IL-15 as a regulator of mitochondrial function in ageing skin.1,4 It was found that IL-15 and exercise treatment resulted in higher stratum spinosum thickness and dermal collagen content in 23-month old mice compared with PBStreated mice, which partially reversed the effects of ageing.4

They suggest that a reduction of IL-15, released from skeletal muscle and other tissues during sedentary living, is a causative factor that may be responsible for the accelerated degeneration of dermal

years

of transformation

fibroblasts, bringing about signs of skin ageing. They even suggest that low-dose IL-15 therapy may be considered a beneficial strategy to address skin ageing.4

Oxidative stress

Simioni et al. report that ageing and strenuous exercise increases oxidant production in muscle, and chronic exposure to high levels of reactive oxidative species (ROS) can become toxic, leading to impaired cellular function and macromolecule damage.2 However, within their literature review, they found that moderate exercise and an active lifestyle have been demonstrated to improve antioxidant defences and reduce lipid peroxidation levels. The exercise-induced ROS generation results in increased activity of enzymatic antioxidants, therefore an increased resistance to oxidative challenges.2

As per Simioni et al., the extent to which reactive species are helpful or harmful depends on the exercise duration, intensity, fitness status and diet of the individual. Therefore, excessive strenuous physical exercise is detrimental to untrained individuals, but progressive training allows for an adaptive response, enhanced function of the mitochondria and accumulation of smaller doses of ROS at a given intensity compared to the untrained individuals. The cells are able to detoxify a larger amount of ROS more easily, resulting in a rapid recovery of the oxidation, thus providing protection from oxidative damage.2

Saluja et al. discuss how oxidative stress affects different tissues that can bring about

clinical signs of ageing.1 They found that recent studies have demonstrated that ROS affect bone homeostasis such that bone formation by osteoblasts is reduced, whereas osteoclast differentiation, thus bone resorption, are enhanced. This can be further exacerbated by gravity-induced mechanicalloading exercise on other aspects of the skeletal system, however the skull does not experience the same forces.1 Facial bone structure is affected, resulting in the lack of craniofacial skeletal support to overlying soft tissue which can further accentuate the nasolabial folds and the inferior displacement of the malar fat pad in the mid-face, volume loss in the perioral region upon mandibular and alveolar resorption in the lower face, and widening of the orbital socket, leading to the formation of the tear trough in the upper third of the face.1

Saluja et al. also mention associations with accelerated fat ageing and oxidative stress in adipocytes, resulting in fat loss. Loss of fat and migration of fat pads in any part of the face can exacerbate the ageing appearance.1 The reduction of bony and fat support will naturally affect the taut nature of the skin. Oxidative stress, which brings about over-expression of matrix metalloproteinases, will promote the degradation of collagen and elastin in the dermis, resulting in loss of elasticity, and will be clinically noticeable as saggy skin and rhytids. Saluja et al., explain that all these tissue and skeletal changes as a combination will contribute to the ‘inverted triangle’ ageing face.1

Conclusion

There is a general consensus within the data that suggests that moderate exercise within an active lifestyle is recommended, rather than episodes of strenuous activity. This is an interesting find as there will be many individuals who will not realise the impact this action will have on their skin and, in their effort to lose weight, may be accelerating the ageing process. I do believe there is limited evidence on this topic and further research in to how other factors, such as sun protection, hormones, gender, and type of physical activity may affect signs of ageing when exercising. I will be considering this evidence and incorporating it within the holistic care plans that I offer to my patients, in my attempt to promote physical conditioning, general wellbeing and healthier skin.

Dr Natasha Verma is the CEO and medical director of Skin NV. She graduated from the University of Newcastle upon Tyne with a Bachelor of Dental Surgery qualification. Dr Verma has a background in oral and maxillofacial surgery and teaches undergraduate dental students in King’s College, London.

Dr Verma has experience with numerous non-surgical procedures in several clinics in London. She is currently completing an MSc in Aesthetic Medicine at Queen Mary University of London.

Qual: BDS, MFDS, RCS (Eng), MJDF

REFERENCES

1. Saluja S.S and Fabi S.G, ‘A Holistic Approach to Antiaging as an Adjunct to Antiaging Procedures: A Review of the Literature’, Dermatol Surg, 43 (2017), p.475-84.

2. Simioni C, Zauli G, Martelli A.M, Vitale M, Sacchetti G, Gonelli A and Neri L.M, ‘Oxidative stress: role of physical exercise and antioxidant nutraceuticals in adulthood and aging’, Oncotarget, Vol. 9, No. 24 (2013), p.17181-98.

3. Hjerrild J.N, Wobbe A, Stausholm M.B, Larsen A.E, Josefsen C.O, Malmgaard-Clausen N.M, Dela F, Kjaer M, Magnusson S.P, Hansen M, Svensson R.B and Couppé C, ‘Effects of Long-Term Physical Activity and Diet on skin Glycation and Achilles Tendon Structure’, Nutrients, 11 (2019) p.1409.

4. Crane J.D, MacNeil L.G, Lally J.S, Ford R.J, Bujak A.L ,Brar I.K, Kemp B.E, Raha S, Steinberg G.R and Tarnopolsky M.A, ‘Exercise-stimulated interleukin-15 is controlled by AMPK and regulates skin metabolism and aging’, Aging Cell, 14 (2015), p.625-34.

Active individuals had significantly thinner stratum corneum and increased reticular dermis collagen content when compared with the sedentary individuals

Spotlight

Regenerative medicine has been the buzz term of the aesthetics field for some time now. Referring to the branch of medicine that aims to develop innovations to regrow, repair or replace damaged or diseased cells, organs or tissues, its use in aesthetics has often involved adipose-derived mesenchymal stem cells (ADMSC). These cells are collected via liposuction and the adipose sample undergoes a purification, emulsification and filtration protocol to isolate the stem cells.1,2,3 The literature suggests that these living cells have the ability to differentiate, regenerate and ‘turn back the clock’ once reinjected.4,5 However, for many aesthetic practitioners, the use of ADMSCs are not a viable option for their patients, preventing it from becoming a mainstream treatment in medical aesthetics.

What is Uvence?

Uvence is a relatively new concept pioneered and co-founded by London plastic, aesthetic and reconstructive surgeon Mr Olivier Amar and CEO Reece Tomlinson. It is a treatment approach that aims to bring regenerative medicine into non-surgical clinics to improve cosmetic concerns for skin quality and bioremodelling. Mr Amar says, “We know that ADMSCs have fantastic potential for regeneration and skin health for improvements such as discolouration, plasticity and elasticity, and there is a huge interest in this area. In 2001 Zuk et al. explained that fat can improve the skin thanks to the ADMSCs and we know that the highest yield of them comes from our fat.1 For a practitioner to obtain these ADMSCs, however, they need to harvest fat and prepare it appropriately – and to achieve this you need to be a surgeon trained to extract fat.” Mr Amar explains that Uvence aims to make this treatment accessible for the first time to cosmetic doctors and other surgeons.

How Uvence works

A small amount of up to 40cc of adipose tissue is extracted from the patient under local anaesthetic via micro-cannula liposuction by a surgeon at a Uvenceapproved clinic. Blood is also extracted to screen for a standard profile of communicable infections. The tissue is then transported in a temperature-controlled and monitored manner to a Uvence processing and storage facility. Once there, it is prepared using a regulated,

quality-controlled process to be made into Uvence Super Enriched Tissue prior to cryopreservation and storage.

Over the next five years the Super Enriched Tissue may be dispatched on-demand to Uvence-approved clinics for a variety of applications in skin rejuvenation. When the patient wants to use their Uvence Super Enriched Tissue, it is defrosted, and the viability of the live cells is checked. Once confirmed as viable, it is delivered by specialist courier in pre-loaded 1ml syringes to the patient’s preferred clinic, where the trained practitioner will reinject the product on the same day. Typically, four syringes are used for a treatment and may be injected or applied through microneedling. “The product is injected very superficially, creating a thin layer under the skin typically in the face, hands and neck. It’s very synergistic to other aesthetic treatment offerings. You don’t create volume with Uvence, so it can be used alongside dermal fillers. You are creating better skin, texture and cells and the results improve over time,” Mr Amar says.

In terms of risks or complications, Mr Amar explains that the injection is a simple process and the risks are no different to any other injectable. He adds, “Optimal results require skill and artistry, which is why using experienced, trained cosmetic doctors is important.” He adds, “There is of course the potential for contamination with the product itself, but there are many precautions in place to prevent this in our zerotolerance quality-controlled process.”

Patient demand and selection

According to Mr Amar, patients who are particularly thin might not be good candidates due to the need to take an appropriate fat sample, however most patients who are of a healthy weight can be considered. He also says that patients of all ages and skin types who want to see an improvement in their skin tone and texture can benefit from this treatment. He explains, “Uvence is ideal for those who are looking for a personalised cosmetic treatment that does not consist of any synthetic materials and compounds. I have certainly seen that patients are becoming more conscious of the products they are treated with and many are looking for a more natural and personalised approach. They like the idea of using their own body

“Ours was one of the first clinics to embrace Uvence and see its potential as a treatment, on its own and in combination with others. The potential for the rejuvenation of the skin is a really exciting part of its appeal especially in combination with other treatments such as fillers, botulinum toxin and radiofrequency. It also allows more doctors than ever before access to this great treatment in a standardised way with easily repeatable results.”

Dr Rita Rakus

and cells for rejuvenation.” The organic and natural market is showing substantial growth, with a recent study indicating it grew 23% in 2019 and suggesting that 79% of people are more likely to buy a beauty product if it is labelled ‘organic’.7 Mr Amar adds, “I have also seen an interest in this treatment approach particularly from the younger generations – it will be a fantastic option for those who want to try to prevent the signs of ageing.”

The future of Uvence

Mr Amar explains that although there is plenty of evidence for the safety and benefits of this procedure, Uvence is currently conducting its own clinical studies to gather data on the cell viability, quality and quantity of fat for Uvence’s specific protocol.

The Cadogan Clinic in London was the first clinic to provide Uvence and Mr Amar says that the company is working with various other clinics to create Uvence-approved centres for fat harvesting and others for reinjecting. “There is a lot of compliance behind approving clinics and COVID-19 is not helping us here, but we have a lot of clinics interested. We are hoping to have more practitioners offer this treatment in due course.”

Mr Amar says that Uvence is currently focusing on the aesthetic market but is eager to benefit patients further afield. “The next step is to branch into gynaecology to help functional and cosmetic gynaecology issues. Beyond gynae is hair and orthopaedics! We’re really just at the beginning.”

He notes that Uvence is not reinventing the wheel, explaining, “It’s about upgrading a treatment that is already used so that it is more refined, standardised, efficient and qualitycontrolled, while also making it available to more practitioners and patients.” Mr Amar concludes, “I think the potential is huge – Uvence provides an easy way for practitioners to have access to a new treatment and the procedure is completely standardised, ensuring that the patient undergoes the same bespoke treatment every time.”

REFERENCES

1. Zuk PA, et al., Multilineage cells from human adipose tissue: implications for cell-based therapies, Tissue Eng, 2001 Apr;7(2):211-28.

2. Palumbo P, et al., Methods of Isolation, Characterization and Expansion of Human AdiposeDerived Stem Cells (ASCs): An Overview, Int J Mol Sci. 2018 Jul; 19(7): 1897.<https://www.ncbi.nlm. nih.gov/pmc/articles/PMC6073397/>

3. Zuk PA, et al., Human Adipose Tissue Is a Source of Multipotent Stem Cells, Mol Biol Cell. 2002 Dec; 13(12): 4279–4295.

4. Uyulmaz et al., Nanofat Grafting for Scar Treatment and Skin Quality Improvement, Aesthetic Surgery Journal, Volume 38, Issue 4, April 2018, Pages 421–428. <https://academic.oup.com/asj/ article/38/4/421/4818349>

5. Menaces, S, et al., Subcutaneous Injections of Nanofat Adipose-derived Stem Cell Grafting in Facial Rejuvenation, Plastic and Reconstructive Surgery - Global Open: January 2020 - Volume 8 - Issue 1 - p 2550.

6. About Uvence, 2020. <https://uvence.co/about/>

7. Organic Beauty and Wellbeing Market 2020, Soil Association, 2020. <https://www. soilassociation.org/media/20474/sa_beauty-and-wellbeing-report_2020.pdf>

“Our goal is for Beyond Beauty to take pride of place in every clinic waiting room and be the go-to information source for consumers. This special magazine is designed to inform patients of what to expect from treatments and encourage them to become loyal, returning visitors to aesthetic clinics. No frills, no fluff – the content will be purely educational, written in language that patients will understand and trust.”

BRINGING THE WORLD OF AESTHETIC MEDICINE TO YOU

Aesthetics Awards

After such a difficult year, we are delighted to present some muchneeded positivity and excitement by announcing the 2020 Finalists for the prestigious Aesthetics Awards!

Voting and judging is now open until January 31, before the Winners, along with Commended and Highly Commended Finalists, are announced on March 13.

Regulations permitting, we will hold the most glamorous ceremony of the year following the Aesthetics Conference and Exhibition (ACE) 2021, where you can network and celebrate with all your aesthetic friends and colleagues!

Certain categories will be partly judged and partly voted-for by you, giving you the opportunity to celebrate the products you value and thank the suppliers who do so much to support the running of your practice.

Your opinion counts, so head to our website to check out the Finalists on the following pages and login to aestheticsawards.com to cast your votes today! Voting will consist of 30% of the final score in the applicable categories. Please

note that voting is monitored through IP addresses and individuals can only vote once per category. Multiple votes under the same name will be discounted from the final total. Multiple votes from within organisations will also be monitored.

HOW DOES THE STRINGENT JUDGING PROCESS WORK?

We are proud to have an esteemed judging panel with a diverse range of skillsets consisting of more than 60 aesthetic professionals. Six judges will be assigned to each category and are chosen specifically for their knowledge and expertise in that area, as well as to ensure that conflicts of interest are avoided.

Due to the high quantity of exceptional entries, unfortunately, not everyone is able to become a Finalist in 2020.

Feedback is available upon request and we encourage all entrants to enter again in 2021.

Yusra Al-Mukhtar (Dr Yusra Clinic)

Miss Jonquille Chantrey (One Aesthetic Studio)

Dr Cormac Convery (Ever Clinic)

Tom Cryan (Thérapie Clinic)

Sunny Dhesi (Rutland Aesthetics)

Dr Tara Francis (Enhance By Tara)

Dr Anna Hemming (Thames Skin Clinic)

Dr James Olding (Max Aesthetics)

Dr Tanja Phillips (Dr Tanja Phillips Medical Aesthetic Clinic Ltd)

Dr Poonam Ram (North House Dental Practice)

Dr MJ Rowland-Warmann (Smileworks)

Dr Linea Strachan (Dr Linea Aesthetics)

Mary White (Outline Clinic)

Dr Vincent Wong (Vindoc Aesthetics)

SURGICAL RESULT

Mr Mo Akhavani (The Plastic Surgery Group)

Mr Yannis Alexandrides (111 Harley St.)

Mr Daniel Ezra (Moorfields Eye Hospital)

Dr Grant Hamlet (The Hamlet Clinic)

Mr Dirk Kremer (Harley St. Aesthetics Ltd)

Mr Dan Marsh (The Plastic Surgery Group)

Mrs Sabrina Shah-Desai (Perfect Eyes Ltd)

Mr Tunc Tiryaki (Cadogan Clinic)

INDIVIDUAL PRACTITIONER FINALISTS

THE SUMMIT BY RAJ ACQUILLA AWARD FOR RISING STAR OF THE YEAR – NEW CATEGORY

Dr Marwa Ali (The Wellness Clinic)

Dr Manav Bawa (Time Clinic Medical Aesthetics and Wellness)

Dr Zahra Fazal (Tweak Facial Aesthetics)

Dr Jemma Gewargis (Aesthetics By Dr Jemma)

Alice Henshaw (Harley Street Injectables)

Dr Ana (Anahita) Mansouri (Kat & Co aesthetics)

Dr Helen McIver (Dr Helen McIver)

Dr Aileen McPhillips (Aesthetics by Dr Aileen)

Dr James Olding (Max Aesthetics)

Dr Alexander Parys (Dr Alexander James Aesthetics)

Nina Prisk (Update Aesthetics)

Dr Hannah (Hoda) Ranjbar (L1P Aesthetics)

Dr Elle Reid (Paragon Aesthetics)

Dr Emily Swift (Dr Swift Aesthetics)

Rebecca Taylor (Rebecca Taylor Aesthetics)

THE SPRINGPHARM AWARD FOR AESTHETIC NURSE PRACTITIONER OF THE YEAR

Sara Cheeney (Pure Perfection Clinic)

Emma Coleman (EMMA COLEMAN SKIN)

Jane Laferla (Laferla Medical Cosmetics)

Claudia McGloin (The New You Clinic)

Jacqueline Naeini (Cliniva Medispa)

Lisa Niemier (Clinic Visjeune)

Julie Scott (Facial Aesthetics Ltd)

Lisa Waring (Facetherapy NI)

Mary White (Outline Clinic)

Cheryl Marshall Williams (S-Thetics)

Susan Young (Young Aesthetics)

THE GET HARLEY AWARD FOR MEDICAL AESTHETIC PRACTITIONER OF THE YEAR

Miss Sherina Balaratnam (S-Thetics)

Dr Nestor Demosthenous (Dr Nestor’s Medical Cosmetic Centre)

Dr Ifeoma Ejikeme (Adonia Aesthetics)

Dr Uliana Gout (London Aesthetic Medicine)

Dr Anna Hemming (Thames Skin Clinic)

Dr Ioannis Liakas (Vie Aesthetics Ltd)

Dr Brian W. McCleary (Burgess Hyder Dental group)

Dr Devang Patel (Perfect Skin Solutions)

Dr Sophie Shotter (Illuminate Skin Clinic)

Dr Sobia Syed (CAREFORSKIN)

Dr Rekha Tailor (Health & Aesthetics)

Dr Vincent Wong (VinDoc Aesthetics)

CONSULTANT SURGEON OF THE YEAR –NEW CATEGORY

Mr Mo Akhavani (The Plastic Surgery Group)

Mr Sotirios Foutsizoglou (SFMedica)

Mr Ali Ghanem (The Aesthetic Regenerative Clinic)

Mr Dalvi Humzah (P&D Surgery)

Mr Gerard Lambe (Reflect Clinic)

Mr Dan Marsh (The Plastic Surgery Group)

Miss Rachna Murthy (Aesthetic Clinical Training Academy)

Mr Adrian Richards (Cosmetic Courses)

Mrs Sabrina Shah-Desai (Perfect Eyes Ltd)

Hyaluronic acid filler

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Aesthetics Around the World

Practitioners from across the globe share their specialty insights

Los Angeles, US Anusha Dahan, nurse prescriber

On training: “I’ve worked in aesthetics for 17 years and trained all over the world. In the UK I’ve attended Dalvi Humzah Aesthetic Training courses for anatomy knowledge, Mr Ayad Harb’s course for non-surgical rhinoplasty and Dr Raj Acquilla’s training for full face aesthetics. Unfortunately, there’s not much training on offer in the US other than from the product manufacturers. In my opinion, this can be limiting as injectors all follow the same patterns and are only able to learn about FDA-approved indications, which can restrict them from achieving holistic results. I’ve missed being able to travel this year and learn from others. You have great training opportunities in Europe, so I would definitely encourage everyone to look further afield for different perspectives and new insights!”

On product selection: “One of the great things about aesthetics in the US is FDA approval. Compared to the UK where there are hundreds of dermal filler products on the market, we’re only able to use those that are FDA-approved, meaning they have a high safety profile. The downside is that products cost a lot more than in the UK, with many manufacturers running tier systems whereby the more product you buy, the cheaper it is. This means it can be really expensive for those starting out and many find it difficult to get their business off the ground. It also means that newer practitioners can be tempted to rush procedures and get through more product to get their money’s worth, which of course opens up the patient to more risk.”

On Asian vs. Caucasian patients: “Young Asian patients have always embraced filler injection. The Asian face is usually quite round and flat, so they previously had to rely on things like nose or chin implant surgery to give their face more projection. Since fillers have been available, they’ve offered a less risky alternative with minimal downtime. They are very popular amongst patients as young as 18 wanting to improve their nose and chin projection, as well as their overall face shape. On the other hand, I also see a lot of young Caucasian ex-pat patients here in Hong Kong, who are surprised when I explain how filler treatment can benefit them. They say, “Am I that old? I thought you only have filler in your 50s!” Caucasian patients tend to request botulinum toxin treatment for lines and wrinkles first, while it’s the complete opposite for Asian patients. That said, masseter toxin injection is very popular here as it’s marketed as ‘faceslimming injections’ – with that, everyone flocks to get it done!”

On ‘fly-by’ doctors: “One of the main issues we have here in Hong Kong is ‘fly-by’ doctors, who are usually practitioners from Korea or Russia who fly here for a couple of days, set up a makeshift clinic over several adjoining rooms in a hotel and treat multiple patients for a cheap price. There’s often a ‘middle-man’ who arranges everything and has lined up patients prior to their visit. As well as the cheaper prices, they market these doctors as highly-regarded professionals, who patients would be crazy to miss seeing while they’re in the country, suggesting that it would be an ‘incredible, once-in-a-lifetime chance’ to be treated by them. Of course, things go wrong and the patient never hears from them again. A number of us reputable practitioners have reported our concerns to the local police and health authority, but haven’t got very far. I think we need to raise global awareness of this issue as I’m aware it happens in many other countries too – if we can educate patients to only go to practitioners who will follow-up with them after treatment or partner with local practitioners who can, we can hopefully begin to eradicate the problem.”

Central, Hong Kong Dr Stephanie Lam, plastic surgeon

Brussels, Belgium

Dr Benoit Hendrickx, plastic surgeon

On complication management: “As more and more practitioners start getting involved in injectables around the world, we see more complications. Vascular complications are by far the most dreaded; even a thorough knowledge of vascular anatomy cannot exclude this completely. It would therefore be beneficial to find a way to get a comprehensive overview of the arterial anatomy of each individual patient and be able to visualise their arteries in an easy manner each time we want to perform filler injections. It has taken years of development but I have made such a technology. Essentially, how it works is that the practitioner provides an MRI prescription to the patient (according to a protocol that we have developed and published), the MRI images are uploaded to a protected server, the arteries are identified, intracranial vessels are removed, a 3D model is built and made available to the practitioner, who can now see the anatomy of his/her patient in augmented reality on his/her smartphone. The images below summarise it well. This will be a game changer in the cosmetic medicine world, reducing the risk of one of the most dreaded complications! We’ve rolled out this technology in Benelux, France and Australia first, and will begin next year in the UK. Will likely present it at the ISAPS non-surgical symposium in the UK in March.”

Segmentation of subcutaneous arteries

On stem cells: “Some consider stem cells the holy grail of medicine. Having spent four years studying them for my PhD, I can say that they are very powerful in certain types of recovery, but their effect is variable. In my opinion, adipose-derived stem cells are perhaps most promising (as opposed to bone marrow or embryonic stem cells), although there is an opportunity for induced pluripotent stem cells (iPSC), which are mature cells that have been brought back to a stem cell state. Mesenchymal stem cells, like adipose-derived stem cells, have immune suppressive characteristics so could even be used on different patients. Nowadays, there’s a huge industry behind stem cells and patients think they’re ‘sexy’ so they ask for treatment. While in my opinion there is no real hard evidence that it actually is worth going through the effort, I would say if you do liposuction anyway so they’re easy to get, there’s ample fat, and patient demand, then go for it.”

Infrared thermally enhanced MRI without contrast

Subcutaneous arteries visualised in Augmented Reality

Future Spotlight: Robot-Assisted Injection

Aesthetics speaks to Dr Emmanuel Elard about the future of robots for botulinum toxin injections

Can you even imagine a world where a robot injects your patient for you? It sounds surreal, doesn’t it… even impossible. But according to French aesthetic practitioner Dr Emmanuel Elard, founder and CEO of technology company NextMotion, the concept isn’t far from reality. He has pioneered technology that he says can and will have the capability to inject your patients with botulinum toxin and dermal filler for you, potentially changing the injectable landscape as we know it. It’s called Light Enabled Neuro-robotic Arm (LENA),1 and here we speak to Dr Elard about the evolution of this robot-assisted injection technology and when it might come to market.

Why robotics?

Robot-assisted surgery is already being used in other areas of medicine such as ophthalmology,2 with study findings indicating advantages of robotics over manual procedures during retinal surgery.3 According to Dr Elard, much like the robotics used in ophthalmology, he believes robot-assisted injection technology can help to implement safe and extremely precise treatments for optimum patient satisfaction in aesthetics. “It’s all about precision, consistency and reproducibility,” Dr Elard explains. “When you look at aesthetic injectable treatments, one of the issues we face as practitioners is that it’s impossible to treat a patient in the exact same way as you did the time before, following the

exact same parameters such as pressure, technique, location, depth and amount, and this can make your patients have varying results,” he says, explaining, “All patient are different and you can’t inject everyone in the same way. With LENA, for the first time it’s possible to have very precise, tailored injection parameters and consistently achieve these time after time. If the results aren’t quite right for the patient, such as if they want a more dynamic look for a toxin treatment or the opposite, we can just easily adapt the parameters.” Dr Elard adds that he believes the technology could also create safer treatments. He says, “With more precision, this approach could be safer than a practitioner injecting, and could result in less bruising and pain and just help us offer better treatments for our patients.”

How does it work?

Firstly, as normal, the practitioner would conduct a thorough medical assessment of their patient. “As part of this assessment, the practitioner will scan their patient’s face and map it via the NextMotion App, reporting all the injections points required on the face,” explains Dr Elard, adding, “For each injection point the practitioner will input the doses, the depth of injection and the product the patient requires for their treatment. The face map and parameters are then recorded in the NextMotion system and are sent to the LENA robot. Under supervision by the practitioner, the robot is able to target the patient and analyse their face through artificial intelligence (AI) and inject the exact points as instructed during the assessment.” AI refers to the simulation of human intelligence in machines that are programmed to think like humans and mimic their actions.3

When asked if this technology could simply put aesthetic practitioners out of a job, Dr Elard laughs, “This is the main question aesthetic practitioners are asking about this new innovation! These aren’t crazy robots that inject all by themselves; it’s like another tool for your clinic. My vision of the future is that robots and practitioners will allow for combined skills to bring a better outcome, security and satisfaction for the patient because they will complement each other.” Dr Elard adds that the

technology could allow practitioners to perform more treatments, expanding their practice. “One practitioner could potentially supervise many different robots at once – the device could be controlled, monitored and manipulated by a qualified assistant, while the practitioner sets up the treatment plan, conducts a full consultation and supervises the treatment process.”

When asked about pricing, Dr Elard says he is aiming for the technology to be affordable. He notes, “It will cost about the same as a big laser. The goal is to have something affordable and for practitioners to be able to utilise great new technology to move the industry forward.”

The future of robot-assisted injection

According to Dr Elard, the medical certification process for LENA is currently under way and the plan is to launch the first injector robots by spring 2022. Dr Elard says, “We have validated the proof of concept and are conducting a pre-clinical study with a hospital in Paris. We have so far injected silicone face models and, through CT scans, have found that the device can inject the correct volume in the exact position requested. The next step will be testing on cadavers and working on the specifications. If everything goes well, we can expect to launch in the next two years.”

Dr Elard explains that the focus is currently on the device’s capability for administering botulinum toxin injections, but following the success of LENA for toxin, its use for injecting hyaluronic acid will be explored. “Hyaluronic acid injection is the final goal, but it requires a lot of different skills and parameters so will happen a bit

later. I think it’s absolutely a possibility for the future!” Dr Elard notes that one consideration for this technology is that both the public and industry need to be open to it. “This concept really excites me and the technology is there and is coming, but I understand that people might not be ready for it just yet. I am thinking a few years ahead in the future, but I know that this will happen in our industry! The goal is to get perfect consistency between injectors and the injections we provide to our patients. I believe this technology will improve injection precision, predictability and safety.”

What do you think about the use of robot-assisted injection in aesthetics? Tell us your thoughts on Instagram @aestheticsjournaluk

REFERENCES

1. Say hello to LENA, the very first robot injector, NextMotion, 2020. <https://www.nextmotion.net/ aesthetic-robot>

2. Robotics and ophthalmology: Are we there yet?, Indian J Ophthalmol. 2019 Jul; 67(7): 988–994. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6611303/>

3. Charters, L, Robotics: Allowing surgeons to perform the seemingly impossible, Ophthalmology Times, Sep 2020, Volume 45, Issue 15. <https://www.ophthalmologytimes.com/view/robotics-allowingsurgeons-to-perform-seemingly-impossible>

4. Frankenfield, J, What is Artificial Intelligence? Investopia, 2020. <https://www.investopedia.com/ terms/a/artificial-intelligence-ai.asp>

side. She had been attending a clinic under the neurologist regularly but was unhappy with a lack of continuity of care and eventually stopped attending the clinic seven years ago. Her main objective was to decrease the pain associated with muscle spasms and to improve her facial symmetry. The patient felt that her condition not only altered her facial aesthetics, but also caused speech and chewing impairment, difficulty expressing emotions, hyperlacrimation and ectropion, and most significantly affected her ability to express her emotions and smile.

Consultation

Case Study: Treating Facial Palsy with Botulinum Toxin

Peripheral facial nerve palsy refers to facial nerve damage from various medical conditions such as infection, trauma, malignancy, autoimmune conditions, and pregnancy. The most common disease causing peripheral facial nerve palsy is idiopathic facial paralysis, also known as Bell’s palsy.1 Reactivation of herpes simplex virus type 1 is known to be the most common cause of idiopathic Bell’s palsy, however in most cases aetiologies are not revealed.2 Bell’s palsy can be classified into acute, subacute, and chronic. Most commonly, the condition is unilateral; however, patients with bilateral facial palsy are also known.3

There is a broad spectrum of disorders associated with facial nerve paralysis that can be generally attributed to the three main pathological mechanisms: the denervated ipsilateral nerve, synkinesis of a nerve with paresis or partial recovery from complete facial paralysis, and contralateral hyperkinesis.3,4,5 Patients with complete flaccid facial paralysis, as well as the synkinetic and hyperkinetic patients, have a significant impact on their life quality.5

There are an extensive range of available treatments for facial reconstruction and reanimation, including but not limited to nerve grafting, muscle transfers, fat grafting, microsurgical patches,

rhytidectomy, correction of lagophthalmos and blepharoplasty,6 however, following these, most patients have persistent facial asymmetries that require continued follow up. In long-term management, botulinum toxin A (BoNT-A) injections remain a vital tool in the treatment of patients with facial paralysis, particularly in the case of synkinesis, contralateral hyperkinesis and general facial imbalance.7

Case study

Patient presentation

A 56-year-old Caucasian woman presented to me with concerns of altered facial aesthetics and facial asymmetry as a result of suffering from chronic Bell’s palsy. The patient had a history of idiopathic right-sided Bell’s palsy since 2000, resulting in synkinesis with contralateral hyperkinesis. Her initial medical treatment included a two-staged facial palsy reconstruction procedure followed by the direct release of tethering in the right nasolabial area and fat grafting. Nine years ago, she had a fascia lata sling operation to improve the perioral symmetry at rest. An unresolved facial asymmetry accompanied by muscle soreness and neck pain was further treated under an NHS neurology team with regular BoNT-A injections to the affected

The mechanism of facial paralysis was carefully explored during the consultation and all previous facial reanimation procedures noted. A careful physical examination was performed. This included detailed photo documentation and videography to analyse the patient’s face in rest and after a series of voluntary movements. The video of the patient’s usual speech pattern was also recorded to help in evaluation and assessment of her synkinesis. Any resting asymmetries were noted before asking the patient to complete a series of voluntary facial movements such as frowning, brow elevation, full eye closure, smile, pursing lips, and showing lower teeth.

In comparison with the unaffected left side, the right side had fewer wrinkles due to lack of muscular traction on the dermis. The lack of muscle movements on the paralysed side resulted in the facial imbalance, and the non-paralysed side of the face presented deviations in the periorbital, nasal and perioral regions, even in a relaxed state.

Starting from the upper to the lower face, on the attempt to raise the patient’s eyebrows, the frontalis muscle on the affected side failed to elevate, but exhibited a light degree of contraction when the patient was asked to close her eyes. There was also notable brow asymmetry as a result of corrugator asymmetry. The brow on the affected side was at a higher position at rest and failed to elevate with the contralateral brow, however, elevated with smiling. The palpebral fissure narrows with a smile, and there was a significant tightness of the affected mid-face region. There was a poor excursion of the modiolus and notable mentalis and platysma activation with smiling on the synkinetic side. A greater smile aggravated the existing asymmetry, and the unaffected side overcompensated for the affected synkinetic side.

Current techniques for treating long-term

Independent nurse prescriber Anna Kremerov discusses her treatment approach for Bell’s palsy using botulinum toxin type A

facial paralysis were discussed. Previous treatment to re-establish the facial symmetry, such as nerve grafting, muscle transfers, fat grafting and microsurgical patches, unfortunately, were unable to achieve a desired facial balance in the past. It was also discussed with the patient that the best results could be further obtained with a variety of techniques such as a rhytidectomy, correction of lagophthalmos and blepharoplasty.8 Finally, the role of the botulinum toxin in the management of facial paralysis was discussed, and it was advised that this treatment modality remains an essential tool in the management of facial paralysis and can significantly improve facial asymmetry.8

Treatment approach with botulinum toxin to improve facial asymmetry was discussed with the patient, along with the advantages and possible side effects. A two-week cooling-off period was implemented before agreeing to go ahead. It was important that she could think carefully about the treatment, weighing benefits against possible side effects. We decided to go ahead with treatment and the patient signed all relevant informed consent forms.

Treatment

It is essential for practitioners to understand that facial palsy is complicated by ipsilateral synkinesis and contralateral hyperkinesis, and both sides of the face are affected. It is therefore crucial to treat and evaluate the unaffected side as well as the affected side.9,10 Makeup was removed before the procedure, and the area was carefully disinfected with Clinisept+ Prep & Procedure. The patient was also offered topical anaesthetic cream despite the fact this is rarely required, but it was declined. My product of choice was Botox, as this is the brand I commonly use in my practice. 100 units of BoNT-A per vial

was diluted with preservative-free 0.9% sodium chloride to a concentration of five units per 0.1 ml. The treatment was performed with a 32 gauge hypodermic needle and a 1ml syringe was used during the procedure. Based on experience, I have found that procedure is more comfortable if performed with a 32 gauge needle.

The entire forehead was treated to address all the above asymmetries. A total of 12.5 units were administered intramuscularly in the glabellar complex and 15 units in frontalis muscle.

In the periorbital region, visible palpebral narrowing with smiling on the affected side was treated with small doses of BoNT-A close to the upper and lower lid margins in the pretarsal orbicularis oculi muscle, as it is known to contribute to the palpebral narrowing.10 The prominent lateral orbital was treated on both the affected and the unaffected side to achieve symmetry. A total of 20 units were used in the periorbital area bilaterally.

In the lower face, there was a notable asymmetric smile, caused by loss of function of the lip depressors, and strong activation of mentalis and platysma with smiling on the synkinetic side. This part of the face was treated with five units to weaken the intact depressor anguli oris, eight units to treat the entire mentalis muscle and 15 units to treat abnormal platysmal activation.

After the treatment, light pressure was applied to the injection sites, and the treated area was again carefully disinfected with Clinisept+ Prep & Procedure. It is imperative to discuss post-procedure care with the patient and to highlight the importance of the aftercare in the prevention of possible side effects. Following treatment, the patient was advised to avoid makeup, exposure to heat, keep her face clean, avoid alcohol, NSAIDs and physical activity for the next 24 hours.

Possible complications of botulinum toxin injections were discussed with the patient, and she had previously been advised that the medication is safe and effective, and that allergic reactions are rare. The most common side effects are local tissue responses such as erythema, oedema, pain, headache and short-term hyperesthesia.11 The patient was advised that the treatment outcomes could be appreciated after two weeks, and a twoweek follow-up appointment was scheduled to review and to perform any additional treatment as necessary.

Post-procedure and follow up

At the two-week review, the patient was thrilled with the results. Even at rest, there was a significant improvement in the overall facial balance and harmony of her face. She reported improvement in her speech and chewing process. Most significantly, she felt happy about achieving improvement in facial symmetry and being able to express her emotions and smile in confidence.

She was advised to attend a routine follow-up appointment to assess her progress, and repeat the treatment to maintain results.

Conclusion

Administration of BoNT-A injection has been proven to be effective in reducing muscular hyperkinesis in patients with residual facial asymmetry after primary surgery for facial palsy, improving aesthetic and functional facial recovery with few adverse events.8

This non-surgical treatment may be a necessary step for patients following surgical treatments.

It is essential to understand that facial palsy is complicated by ipsilateral synkinesis and contralateral hyperkinesis, and both sides of the face are affected. Therefore, it is crucial to treat and evaluate the unaffected side as well as the affected side 10

Anna Kremerov is an advanced nurse practitioner and a registered prescriber. She has a Master of Science in Advanced Clinical Practice as well as Level 7 in Injectables for Aesthetic Medicine. Kremerov is the founder and clinical director of Anna Medical Aesthetics.

Qual: ANP, NIP, MSc

Patient pictured before and two weeks after botulinum toxin injections, on rest and smiling

Model for illustrative purposes

The beauty of the season

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For more information, ask today at: info@relifecompany.co.uk To register for training, sign up today at: ukrelifemasterclass.com

If you are unable to attend our final training sessions of 2020, we will be reopening our doors for you in 2021. In the meantime, we hope you enjoy a wonderful holiday season as the year draws to a close.

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My skin says how I feel

The Definisse™ range from RELIFE. relifecompany.co.uk PP-RL-UK-0163. November 2020. GB20020

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Treating Lipoedema

Dr Aamer Khan

Lipoedema is a condition that is being seen more commonly in our aesthetic practices. It was first described by Allen and Hines in 1940 as a condition characterised by abnormally poor resistance to the passage of fluid into the tissue from the blood, thus permitting oedema to occur.1

Many patients who present to clinics with this issue have already consulted with their GP and have been assessed by various specialties in NHS hospitals, with little to no satisfaction. There appears to be a general lack of recognition and understanding of the condition, with a survey of 251 members of the Vascular Society of Great Britain and Ireland revealing that only 46.2% of the consultants were able to recognise the disease.2 It is at a time like this that these patients may choose to see an aesthetic practitioner as a last resort. This is because they see it as an aesthetic, body contouring issue, and there has been an increased awareness of aesthetic body sculpting in the media over the past few years. As such, it is important for us to have some understanding of this not so uncommon but little understood condition, so that we can manage these patients to either treat them ourselves or refer them to appropriate peers.

What is lipoedema?

Lipoedema is a progressive condition in which abnormal, excessive subcutaneous fat is deposited in the lower and sometimes upper limbs. Its distribution is symmetrical, and can cause pain with impairment of function, as well as psychological distress; both of which can affect daily activities and life.3 The differential diagnosis

of lipoedema includes conditions presenting with swelling or excessive adiposity of lower limbs, mainly represented by lymphoedema and obesity.4 The incidence is approximately one in nine women of post-pubertal age, with the age of onset usually between 18 and 30. The condition is usually progressive.5,2

Causes of lipoedema

Often, women who suffer from lipoedema are told that their leg girth is due to their excess of calorie intake, poor diet and lack of exercise, or that the women in their families just ‘have big legs’. Indeed, many of my patients say that they have seen their GP and have been told to lose weight and improve their diets. Many state that they have tried ‘everything’ and their limbs do not change. As their disease progresses, they return to their physicians with increasing leg swelling and weight.

As a result of a fixation on their increasing weight and growing body habitus, coupled with today’s ‘fat-shaming’ society attitudes, women with lipoedema frequently suffer from significant psychosocial distress, and can develop anxiety, depression, eating disorders, and isolation.3 Though lipoedema can occur with concomitant obesity, it will not reduce in response to exercise or weight loss.3 Lipoedema adiposity is associated with limbs only, whereas adiposity of obesity is global.

The actual cause of lipoedema is still unexplained, however there are various hypotheses about its pathophysiology:

• Genetic: the condition has repeatedly been described in familial clusters, so a genetic predisposition is assumed.6

• Hormonal: lipoedema usually first presents itself during pubescence so is generally thought to be estrogen-mediated.7

• Vascular/lymphatic: another pathophysiological hypothesis involves primary microvascular dysfunction in the lymphatic and blood capillaries.8 This, in turn, is thought to be due to a hypoxic stimulus brought about by excessive expansion of adipose tissue.8,9

• Inflammation: The perception of pain associated with lipoedema is thought to be due to hypersensitivity of the regional sensory nerve fibres through an inflammatory process. This theory is based on single case reports, and there is absence of any valid studies supporting the increase of proinflammatory markers in such patients.

Diagnosis

The diagnosis is generally made on clinical grounds after the exclusion of differential diagnoses such as lymphoedema and obesity.4 In cases of more advanced oedema, other classical causes should be considered, such as:4

• Chronic venous insufficiency

• Deep vein thrombosis

• Idiopathic cyclic oedema

• Oedema because of cardiac disease

• Oedema of hepatic disease

• Oedema of renal disease

• Myxoedema

• Orthostatic oedema

The diagnostic criteria of lipoedema are as follows:5

• Bilateral and symmetrical manifestation with minimal involvement of the feet or hands

discusses the treatment options available for patients presenting with lipoedema

• Minimal pitting oedema

• Negative Kaposi-Stemmer sign (for lymphoedema)

• Pain and tenderness on pressure

• Easy bruising

• Persistent enlargement despite elevation of the limbs

• Persistent enlargement despite weight loss

• Arms affected in 30% of the cases

• Surface skin hypothermia

• Orthostatic oedema worsens in the summer

• Unaffected by caloric restriction

• Telangiectasias

The clinical constellation of the major manifestations of the disorder appearing together that point toward the diagnosis of lipoedema include: tissue tenderness, a feeling of tightness, and an excessive tendency toward haematoma formation, with worsening symptoms over the course of the day, in a patient with a bilaterally symmetrical, disproportionate proliferation of fatty tissue on the limbs but not on the hands/feet. Particular attention should be paid to the timing of the onset of the symptoms (namely after puberty), and the course of progression over time.

Therefore, a good history obtained from the patient is in the establishment of the correct diagnosis. Getting a medical summary from the patient’s GP is also a useful source of corroboration of the history, and any referrals to a specialist and results of investigations can prove to be invaluable.

The advanced stages of lipoedema are associated with various problems, and it is at this time that it attracts more serious attention from doctors and surgeons:

• A fluid load exceeding the capacity of the lymphatic system can cause secondary lymphoedema (lipo-lymphoedema) in any stage of the disease.3

• Mechanical irritation from large fatty deposits near the joints can macerate the skin, causing sores and possible infection.10

• Deposits on the thighs and around the knee joints can also interfere with normal gait and cause secondary arthritis.10

Examination

The three stages of lipoedema are characterised by progressive changes in the structure of the skin surface:

Stage I: small nodules, reversible oedema

Stage II: walnut-sized nodules, reversible or irreversible oedema

Stage III: folds and divots over deforming, larger fat masses and macro-nodular change

Stage IV: stage III, with accompanying lymphoedema, potentially KaposiStemmer sign positive

Lipoedema is also classified by morphology:

Type I: affects buttocks

Type II: affects thighs

Type III: affects the entire lower limbs

Type IV: affects the arms

Type V: affects the lower legs

The symptoms and subjective degree of suffering are not necessarily correlated with the disease stage.10

Consultation

If a provisional diagnosis of lipoedema is made, it is important to ensure that the patient has access to the correct care and follow up from a specialist (usually a vascular surgeon, or a lymphoedema specialist) who regularly treats such cases. We might have to find out who is experienced, and refer directly, as GPs may have little, or no knowledge in this area to be able to do this. Remember that psychological or psychiatric support may also be necessary.3

The specialist will then carry out further investigations, and offer management. Most investigations are to exclude differential diagnoses.

Patients should be fully informed about the nature of the disease and the fact that it is chronic and progressive. They should be told in an open and honest way about all the treatment options and their effectiveness and about the ways they themselves can actively influence the disease, covered below in the conservative management section. They should also be offered the option of professional help in coping emotionally and physically with the disease. As lipoedema is a chronic, progressive condition, the patient should be given adequate informative material as soon as the diagnosis is made, along with contact data for the relevant self-help organisations such as Lipoedema UK.

Treatments

Radiofrequency-assisted liposuction

In my personal experience as a member of the British Association of Body Sculpting, and using radiofrequency-assisted liposuction (RFAL) since 2009, I have seen and treated more than 500 cases of pre-diagnosed lipoedema.

Radiofrequency targets water molecules and sets up an electromagnetic resonance, which heats them up. The area for treatment is tumesced to turgor and the heated water molecules in turn heat the tissues. There is an internal and external thermistor, so that the energy is cut off at predetermined levels.

The internal target temperature is 70 degrees Celsius and the surface skin temperature is 40 degrees Celsius. These temperatures achieve a number of goals by targeting the tissues between the thermistors:11

The patient should be given adequate informative material as soon as the diagnosis is made, along with contact data for the relevant self-help organisations

1. Sub-necrotic tissue trauma and coagulation resulting in lipolysis

2. Interstitial fibrous band contraction with the stimulation of microfibrosis, which holds the tissues tight like an internal compression system

3.

Tissue remodelling and tightening

In my experience, RFAL is a useful tool in treating and remodelling skin tissues. The ideal cases are stages 1 and 2, of all morphologies of lipoedema, and multiple treatments may be necessary to achieve the desired outcomes. Late stage 3 will require a complex management approach, with tissue debulking.

In my experience, benefits are still there after 11 years. This appears to be a better outcome than with liposuction alone and may be due to the additional benefit of radiofrequency-induced tissue remodelling. However, there are no direct comparative studies of the two techniques.

Conservative management

Ever since lipoedema was first described, the consensus medical recommendation has been that patients should be advised to accept the condition and modify their mode of living accordingly.12 The classic components of conservative management as follows: manual lymph drainage, on a regular basis if necessary:

• Appropriate compression therapy with custom-made, flat-knitted compressive clothing (compression classes II–III)

• Physiotherapy and exercise therapy

• Psychological/psychiatric therapy

• Dietary counselling and weight management

• Patient education on self-management

However, reports that several weeks of in-patient treatment (with complex decongestive physiotherapy, manual lymphatic drainage and intermittent pneumatic compression, along with multi-layered compression bandaging) can be beneficial and do not imply any longterm benefit compared with outpatient treatment.13

Cryotherapy

With advances in exercise technology, there is new evidence that cryotherapy and exercising cryo-chambers target and reduce white fat content of the body and hyperbaric oxygen chamber sessions that improve tissue oxygenation may play a part in managing patients with lipoedema in the future.14,15 Other developments with microwave, deep impact therapies, and even electrical myo-stimulation therapies may hold hope of some benefit. Further evidence is still required as to the effectiveness of these therapies.

Liposuction

If the symptoms persist and impair the patient’s quality of life, the potential indication for liposuction should be considered. Its therapeutic benefit has not yet been evaluated in any randomised, controlled trials. The long-term therapeutic benefits of surgery are now being investigated in a prospective, randomised multicenter trial sponsored by the German Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA). For the time being, surgical treatment is only available privately.

Surgical debulking

In advanced stages of the disease, with accompanying lymphoedema, the involved tissue is so fibrotic that liposuction cannot adequately reduce its volume. In such cases, open surgical debulking (dermato-fibro-lipectomy) may be indicated. In cases where there is excess overgrowth of tissues, surgical excision of the skin may also be necessary.

Conclusion

With it often being a misunderstood condition, it is important for medical and surgical aesthetic practitioners to be aware of what treatments are available to help patients who present to their clinics in hope of finding a solution to lipoedema. I feel that further research into the different types of energy-assisted liposuction and their effects on lipoedema would be useful is assessing which would benefit patients with lipoedema. This requires time and resource, as well as experienced practitioners carrying out the treatments.

Dr Aamer Khan graduated from The University of Birmingham in 1986 and has knowledge in areas including human psychology, psychiatry, surgery and dermatology. He decided to become a full time aesthetic practitioner in 2005 because of his love for aesthetic and regenerative treatment. Dr Khan is the co-founder of the multi-award winning clinic Harley Street Skin and has dedicated the past 15 years to performing cosmetic and non-surgical procedures.

Qual: MB,ChB

With it often being a misunderstood condition, it is important for medical and surgical aesthetic practitioners to be aware of what treatments are available

A summary of the latest clinical studies

Title: A 12-Month Study to Evaluate Safety and Efficacy of Polymethylmethacrylate-Collagen Gel for Correction of Midface Volume Loss Using a Blunt Cannula as Measured by 3-D Imaging

Authors: Katz B, et al.

Published: Dermatologic Surgery, November 2020

Keywords: Dermal Filler, PMMA, Filler

Abstract: Although polymethylmethacrylate (PMMA)-collagen gel is approved for correction of nasolabial folds, there are no reports characterizing safety and efficacy in the midface, an area where fillers are often used in clinical practice. The objective was to determine the safety and efficacy of PMMA-collagen gel for long-term volume restoration in the midface. In this prospective, single-center, 12-month study, 23 subjects with a pretreatment Midface Volume Deficit Scale (MFVDS) grade of 3, 4, or 5 were treated with PMMAcollagen gel. Efficacy was measured by the investigator and blinded reviewers using the MFVDS at 3, 6, and 12 months. Subject Global Aesthetic Improvement Scale (SGAIS) and physician GAIS (PGAIS) ratings were collected at 3, 6, and 12 months. Improvement in the MFVDS score from baseline was significant at all post-treatment time points (p < .0001). All subjects with baseline MFVDS grades of 5 (severe) or 4 (significant) had a grade of 0 (none) or 1 (minimal) at 12 months. Subject GAIS (SGAIS) and PGAIS ratings of improved or much improved were 100% at Month 3 and were maintained at 12 months (PGAIS = 100%, SGAIS = 91.3%). All adverse events were minor. Polymethylmethacrylate-collagen gel is safe and effective for long-lasting correction of midface volume deficit.

Title: A 12-Week, Prospective, Non-Comparative, NonRandomized Study of Magnetic Muscle Stimulation for Improvement of Body Satisfaction With the Abdomen and Buttocks

Authors: Fabi S, et al.

Published: Lasers in Surgery and Medicine, November 2020

Keywords: Muscle Stimulation, Body Contouring, Devices

Abstract: Magnetic muscle stimulation (MMS) is a relatively new energy-based technology that provides a non-invasive option for body contouring through stimulation and toning of underlying skeletal muscles. This study was conducted to examine the safety, efficacy, and body satisfaction scores of MMS using a CoolToneTM prototype for the aesthetic improvement of abdominal and buttock contour. Male and female participants aged 22-65 years received 4 MMS treatment sessions to the abdomen and/or buttocks. Body Satisfaction Questionnaire (BSQ) scores for abdomen and/or buttocks were assessed at baseline, immediately post final treatment, at 4 weeks (primary endpoint), and 12 weeks post final treatment. Subject-rated Global Aesthetic Improvement Scale (SGAIS) was assessed at 4 weeks post final treatment (secondary endpoint), and 12 weeks post final treatment. A Subject Experience Questionnaire (SEQ) was used to assess treatment satisfaction and perspectives at 4 weeks and 12 weeks post final treatment. Adverse events (AEs) were monitored throughout the study. Treatment of the abdomen and/or buttocks with MMS was well-tolerated and demonstrated significant improvement in aesthetic appearance through the 12-week post final treatment study duration.

Title: Skin Necrosis and Vision Loss or Impairment After Facial Filler

Injection

Authors: Rauso R, et al.

Published: The Journal of Craniofacial Surgery, November 2020

Keywords: Complications, Filler, Nerosis

Abstract: Purpose of the present study is to objectively evaluate the number of severe vascular complications, represented by skin necrosis and vision loss or impairment, following facial filler injection. The investigators implemented a review of the literature including articles published on PubMed database without limitation about year of publication, including all reports concerning skin necrosis and vision loss or impairment related to the injection of fillers for cosmetic uses. The search highlighted 45 articles and a total of 164 cases of skin necrosis and vision loss or impairment after injection of different substances. The injection site most frequently associated with complications was the nose (44.5%), followed by glabella (21%), nasolabial fold (15%), and forehead (10%). Results of the present study suggest that injectable filler can cause severe complications even in expertized hands. Treatments in the new defined “Dangerous triangle” must be carefully carried out. Despite our expectations, the highest rates of severe adverse events have been associated with autologous fat transfer practice.

Title: Skin Pigmentation Polymorphisms Associated with Increased Risk of Melanoma in a Case-control Sample from Southern Brazil

Authors: Reis L, et al.

Published: BMC Cancer, November 2020

Keywords: Pigmentation, Melanoma, Skin

Abstract: Melanoma is the most aggressive type of skin cancer and is associated with environmental and genetic risk factors. It originates in melanocytes, the pigment-producing cells. Single nucleotide polymorphisms (SNPs) in pigmentation genes have been described in melanoma risk modulation, but knowledge in the field is still limited. In a case-control approach (107 cases and 119 controls), we investigated the effect of four pigmentation gene SNPs (TYR rs1126809, HERC2 rs1129038, SLC24A5 rs1426654, and SLC45A2 rs16891982) on melanoma risk in individuals from southern Brazil using a multivariate logistic regression model and multifactor dimensionality reduction (MDR) analysis. Two SNPs were associated with an increased risk of melanoma in a dominant model: rs1129038AA and rs1426654AA [OR = 2.094 (95% CI: 1.106-3.966), P = 2.3 10-2 and OR = 7.126 (95% CI: 1.873-27.110), P = 4.0 10-3, respectively]. SNP rs16891982CC was associated with a lower risk to melanoma development in a log-additive model when the allele C was inherited [OR = 0.081 (95% CI: 0.008-0.782), P = 3 10-2]. In addition, MDR analysis showed that the combination of the rs1426654AA and rs16891982GG genotypes was associated with a higher risk for melanoma (P = 3 10-3), with a redundant effect. These results contribute to the current knowledge and indicate that epistatic interaction of these SNPs, with an additive or correlational effect, may be involved in modulating the risk of melanoma in individuals from a geographic region with a high incidence of the disease.

Building YOU into

Independent

There’s a commonly-used adage that I like to share over and over again. It says, “People will forget what you said, they will forget what you did, but they will never forget how you made them feel.”1 I’m sure almost everyone has heard this before and many of us apply this quote to our daily lives (even without knowing it). But have you ever applied it to your business?

If you haven’t, you should relate this principle not only to how you interact with patients when they’re on your treatment chair, but in everything you do, from training employees, to creating your marketing plan, to writing the front page of your website. The way you make people feel is paramount – it’s what makes you unique.

What’s your USP?

Following on from this, ask yourself what is your unique selling proposition? I’ve heard many practitioners say their USP is treatment safety or a high level of clinical care. These are important standards, of course – but a patient will expect this from any clinic they visit. Safety and care are not unique to any one clinic. Similarly, I’ve also seen practitioners with treatment-centred USPs – for example, big lips. However, big lips are a trend, and we all know how quickly beauty and aesthetic trends can fade and change. I believe practitioners who build their businesses on this will eventually be left in the dust. Therefore, if you’re searching for what does set your clinic apart from the rest, consider this: YOU are your USP.

After all, people invest in people. Robert Cialdini, a professor of

psychology and marketing at Arizona State University, has said, “It’s not just that people want to deal with someone they like. It’s that they want to deal with someone who likes them, and who is like them. People trust that those who like them won’t steer them wrong.”2

We are all aware that new patients are usually nervous about entering into the world of aesthetic treatments, often using all the tools available to thoroughly do their research. Prospective patients are looking for someone (key word here is someone, not something) who will reassure them that a treatment will achieve the desired results, that they will be safe in seeking this treatment and that their money won’t be wasted. So, when you – your name and face, not your logo or clinic – are greeting a patient as the first thing they see on your website, social profile or ad, and next to your face is a quote stating your goals as a practitioner, this is going to reassure them a lot more than a banner slideshow with stock photos, lovely professional photos of your clinic, or even stunning before and afters.

What kind of practitioner are you?

Patients buy into and remain loyal to the person who will take them on a journey to their desired results, so never underestimate the power of you. A business physically can’t be empathetic – but you can. A business doesn’t have life experience – you do.

Therefore, I think that knowing who you are as a practitioner and owning it, is one of the best ways to market your business. Are you young, vibrant and on trend, personally able to deliver the latest and greatest just-released tweakments? Own it, market it, and you will attract patients looking for that. Alternatively, maybe you’re a little more mature and your approach is to take things slow, putting patience and empathy above all else. Communicate that clearly to prospective patients, and those who appreciate your approach will be attracted to your practice.

Knowing who you are as a practitioner and owning it, is one of the best ways to market your business

Whichever ‘flavour’ of patients you attract, they will have chosen to come and see you because they are invested in what makes you unique, having already assumed that you’re safe, experienced and insured. Once you do bring them into clinic and provide them with an excellent treatment, you’ve won their loyalty. If your USP is you, patients will remain loyal as they know they can’t get you at the clinic down the road.

Putting this into practice

So how do you do this? Communicate your approach. Communicate it through your facial expression and clothing when you are having your headshots taken, and put these headshots everywhere. Use your headshot as your profile picture instead of your logo, or at least underneath your logo. In today’s world you have to be visual and it won’t help your business to be bashful or hide under the parapet.

Post videos of yourself on social media and your website as if you’re talking directly to your patients. In your writing, whether this is on your website or brochure, stay away from the royal ‘we’ and don’t be afraid to write in the first person. With everything you share, be relatable and be yourself.

Be prepared to feel a little vulnerable if this is new to you, but trust that it will bring you more engagement and will help to grow your business in the end. Writing in the first person and putting your face on camera will probably feel strange at first, but don’t forget you can always have friends and family review these for you before publishing. These people will know who you truly are, so if they feel your content doesn’t reflect YOU authentically, they should tell you.

This method can even apply to larger clinics with multiple practitioners. Ultimately all practitioners within one clinic should unite along a similar ethos, and this is what should be presented to potential patients. Think of what integrates your team in this case – maybe you have an injector, an aesthetician, and a dermatologist offering differing treatments, for example. What unifies them beyond working from the same premises? Is it a personal touch that makes patients feel they can open up the minute they settle

down on the treatment chair? Or is it that they all have decades of experience and a patient could go nowhere else to get the same breadth and depth of knowledge when considering treatment? Conversely, maybe it’s that each practitioner is extremely efficient and can therefore cater to ‘lunchtime’ appointments for patients who have no time to chat and need a safe, effective treatment to fit into their busy schedules. There will be something uniting your practitioners that therefore forms the basis of your ethos as a team and as a business. Use this, and don’t forget that it is still your specific team that is your USP. Each team member can communicate this and put out the same type of content mentioned above, still speaking from the first person, either individually or in group videos for example. Once this is communicated, the different personalities and approaches of individual practitioners should also be presented to potential patients.

Things to consider

One thing to keep in mind should you decide to embrace putting yourself forward as the face of your brand is that there may be complications down the line. Primarily, if your end goal is to sell your business, it might be tricky to find a buyer to take over a patient base that has heavily invested in the practitioner instead of the clinic. However, I believe this can be overcome by finding the right buyer, or, in this case, the right practitioner to take over. It may be a lengthy process, ensuring that your replacement has the same values as you do, introducing them to your patients, and finally beginning a long handover process that will end with your patients trusting you to step away completely. It’s nothing new to write into a buying agreement that you stay in the business for a year to facilitate this handover. Difficult, perhaps; lengthy, definitely; but doable and worth it in the long run. This is because above all, the business you’re selling will have an expansive, loyal base of patients promising a sustainable income to the right buyer.

Conclusion

I feel that in the aesthetic field, you cannot afford to be a faceless practitioner who is not emotionally invested, and nor can your clinic afford to be led this way. Patients are seeking elective treatments in a saturated market, and you need to find a way to make them emotionally invest in you or else you’ll lose them. Really embracing yourself as the face of your brand is the best way to do this, so remember – YOU are your USP!

Julie Scott is an independent nurse prescriber with more than 25 years’ experience in the field of plastics and skin rejuvenation. In 2003, Scott left her position as a clinical nurse specialist for a renowned group of London plastic surgeons to set up her own practice in Essex called Facial Aesthetics. Since then, Scott has taken a holistic approach to treating patients, offering the most up-to-date medically-led aesthetic treatments in a tranquil countryside setting.

Qual: RGN, NIP

REFERENCES

1. Quote investigator, They May Forget What You Said, But They Will Never Forget How You Made Them Feel, <https://quoteinvestigator.com/2014/04/06/they-feel/#:~:text=In%20conclusion%2C%20 based%20on%20current,in%20the%20years%20after%201971>

2. Rockwood, Kate. “6 Psychological Tricks That Will Make People Buy Anything.” Inc.com, Inc., 8 Mar. 2017, <www.inc.com/magazine/201703/kate-rockwood/ready-to-sell.html>

Becoming an Aesthetic Trainer

Despite being an unregulated sector, there are many organisations which focus on the teaching, training and assessment of aesthetic medicine. Becoming an aesthetic trainer is often seen as the next step in a medical aesthetic practitioner’s career, showing one’s development in experience and knowledge to a level which allows you to teach and share this with others. Whilst there are excellent trainers out there, we have all attended courses or sessions that were less effective, and becoming a good trainer is not necessarily as easy as just turning up and dispensing knowledge. Currently, due to the differing requirements (if any) for who can become a trainer, training and education quality varies, there are no set industry minimum requirements for subject knowledge, practical experience, or assessments of competence as a trainer when individuals wish to set up educational or training events. To be an effective trainer, it is important for practitioners to be passionate about educating a new generation of practitioners and have the skills which allow them to do this to a high standard. This article will explore how you can move from being a practitioner to a trainer in aesthetics, or, if you are newer to the industry, what you might need to consider if it’s something you may want to explore as you move through your aesthetic career.

Current landscape

Education exists at different levels, often related to the setting. The formal education can be crudely differentiated into undergraduate and postgraduate, or higher-level training. Most people will recognise the emergence of Level 7 training, which in higher education terms is equivalent to a master’s degree or postgraduate certificate.1,2 This is seen in both the private education sector and within higher institutions, such as universities.

Education in aesthetics occurs in many different forms, settings and levels. Some common forms include:

• Face-to-face training, both clinical and theoretical

• Mentoring

• Small or large group sessions

• Conferences

• Networking events

• Sponsored training events

• Live or pre-recorded webinar-based sessions

• Online learning

• Home self-learning

• Written materials, such as journals and books

• Dissemination of clinical research

Some education providers in aesthetics have specific regulatory requirements around who can be a trainer, assessor or examiner, depending on the course, while others do not.

Routes to becoming a trainer

Training course providers

There is an increasing number of training course providers in the private sector, covering education in aesthetics across all modalities, ranging from basic injectable training through to device-based therapies. The learner often obtains a certificate of attendance or course completion following successful achievement of these ‘CPD style’ courses. These providers generally have a team of educators who have experience in the modality being taught, and a perceived competency in the modality. Often, no specific training or educational requirements govern the training faculty, with each provider making an independent selection decision as to who their trainers may be.

It is important to understand the requirements of a training provider awarding organisation, so that you can apply for appropriate roles based on your own experience and qualifications. If you are looking to become a trainer for this kind of institution, then typically the strategy here is to directly approach the organisation and ask them if you can get involved with their educational activities. Practitioners may be invited to observe a few sessions so that the provider and existing trainers can get some understanding of your potential as a future trainer. It may be beneficial to have undertaken some of the provider’s courses as a delegate, so you have a first-hand understanding of the teaching provided and requirements of their trainers. If you are successful enough to join an educational provider as a trainer, it is important to check the organisation you work for has appropriate indemnity in place for their trainers, who in some cases are directly supervising other healthcare professionals (the students or course delegates) to treat patients. In some circumstances, this may be something you need to seek through your own insurance provider.

Level 7 academies

Various training course providers are able to offer formal qualifications through an affiliation with an awarding organisation; a third-party company in the private sector such as Vocational Training Charitable Trust (VTCT).3 These organisations will formally oversee students enrolled on respective

Dr Vikram Swaminathan and Dr Paul Charlson

explain how you can evolve from aesthetic practitioner to aesthetic trainer and assessor

Recommended characteristics for all trainers, assessors or examiners

There is no clear pathway to becoming a successful aesthetic trainer, examiner or assessor. As discussed, selection is often very specific to each individual organisation. However, based on our experience, certain characteristics and skills will help:

• Clear understanding of the role of interest and its responsibilities

• Excellent communication and language skills

• Comprehensive knowledge of the subject matter

• Understanding of the course or session objectives

• Teamworking skills

• Ability to consider and adapt to a learning environment

• Potential to elicit the learner’s needs at the start of an educational activity to maximise their learning

• A positive attitude towards education

• Supportive nature within training and assessment activities

• Time management and session planning skills

• Reflective practice to critique your teaching, assessing or examining skills and continue to improve

affiliated courses. The awarding bodies are themselves governed by and registered with an approved government regulatory body in the education sector, such as OFQUAL. Trainer requirements are set by the course provider based on the curriculum and awarding body. Traditionally, Level 7 course providers require their trainers to have obtained a formal teaching qualification (at Level 3 or greater) and have a minimum number of years’ experience in the specialty. This is variable between academies, depending on their affiliated awarding organisation. There are often other conditions in place within postgraduate training providers, where clinical trainers may not be able to assess or examine students within the same organisation. To maximise your chances of achieving a role in a Level 7 academy, it is beneficial if the trainer has achieved the qualification (or equivalent) being taught. In addition, other experiences of postgraduate training will add weight to your application. However, even with these CV boosters, selection can just be down to how good you are at teaching and mentoring other healthcare professionals.

Higher institutions

Many universities now offer qualifications in aesthetic medicine, such as Queen Mary University, University of South Wales and Manchester University.4,5 These courses do not generally provide a professional competence framework, such as injecting competency, but aim to offer integrated knowledge and the application of critical skills enveloped within high quality professional

behaviours.5 Therefore, the trainer teaching roles and responsibilities are likely more theoretic than practical.

The students on these courses are expected to acquire a comprehensive knowledge base that can be applied to their future or current clinical practice. Trainers within these courses often come from the existing health and life science departments at the university, or through existing academic teaching affiliations. This may include clinical lecturers, professors and honorary teachers. The educational faculty is often led by higher institution academics, such as clinical or research professors, with specialist interests in the field of aesthetic medicine.

There are associated roles within these educational teams for sector specialists and trainers, who are able to provide their extensive experience and clinical knowledge to the course for the benefit of the students.

These roles are normally advertised formally by the institution and often involve an interview process for lecturer positions within the university, which will scrutinise the applicant’s teaching, research and general academic credentials. Holding a formal teaching qualification and a track record of research and publications within the field or within healthcare in general will help to boost your chances of success in this area.

Brand-focused training

A significant proportion of educational opportunities for aesthetic practitioners occur through brand-focused routes, often with clinical product manufacturers or distributors. Most pharmaceutical product manufacturers, distributors and suppliers will be represented by clinical product specialists or key opinion leaders (KOLs).6 These individuals are not always healthcare professionals; however, most well-known brands tend to rely on an aesthetic practitioner-led trainer team. There are often opportunities for trainers at local, regional, national or international levels. Each company will have its own criteria or methods to select suitable KOLs.

From our own experiences, the starting point to becoming a company KOL is often to have good relationships with members of the sales teams (such as your local sales representative or business development manager). This will help you get noticed by the company. A strong brand awareness and evidenced history of their product use shows that you are a potential experienced practitioner with their product and the associated interventions. There are no specific academic requirements for sponsored educators, such as formal teaching qualifications or an academic research background, however, you find that some KOLs come with an extensive CV of both and in an increasing

Education and training in aesthetics can be extremely rewarding. It is important to consider your path to become a trainer carefully

competitive environment these things can help set you apart.

As such, it is important to maintain communication with your preferred sector partners as this may one day lead to an education opportunity within that organisation. It also shows these partners that you have a keen interest in their service and products and could be a good ambassador for their organisation in future.

Start your own brand

Many practitioners choose to not work within other educational organisations and just start their own training academy. Our sector allows for this route to be an option. There are many individuals who have significant experience working in the sector who have progressed to create successful training activities. This route will ‘self-label’ the individual as a trainer who can go on to deliver courses for other practitioners. It often requires some approval or certification of the training materials from an insurer or CPD provider, but beyond that is often not regulated by any external organisations. This is a viable option for practitioners looking to deliver some CPD-style training and share their experiences with other practitioners in the sector. It is important for the practitioner to be extremely competent in the area being taught, and ideally demonstrate evidence for why they are suitable to teach others. It is recommended that the practitioner training a delegate, and potentially certifying that delegate has achieved course competences, are themselves able to evidence achievement of the course competencies and have gone beyond this level. This could range from published evidence of clinical experience, a record showing a high level of competence in the procedure, or even completion of a formal teaching qualification.

Examiner and assessor roles: beyond ‘trainer status’

Assessment in the aesthetic sector is essential in order to maintain and improve the standards achieved by practitioners completing the various types of courses. Postgraduate academies (such as Level 7 training academies) require examiners to perform assessment roles for marking assignments, direct observation of procedural skills (DOPS), as well as during objective structured clinical examinations (OSCEs). A trainer may also be acting as an examiner or assessor. A comprehensive understanding of the course learning objectives and assessment outcomes is key to be successful

in these roles. There can be a conflict if a trainer has delivered education to the same individuals they are assessing. Increasingly, validity of a course will require moderation by external as well as internal assessors. There is potential, similar to certain trainer roles, that there will be a requirement to hold an assessor’s qualification, usually at a minimum Level 3, although there is no sector specific route at present.

It is essential that assessors separate themselves from their teaching role to remain impartial. These roles require additional skills and attributes; experience and knowledge alone are not enough.

It has been well publicised that several medical specialties have moved towards credentialing practitioners who are practising as sub-specialists within their specialty. Aesthetic organisations and societies are also looking towards appropriate assessment methods and processes to meet these needs and modernise the standards within the specialty. Both the British College for Aesthetic Medicine and British Association of Cosmetic Nurses are developing assessment processes which would require examiners and assessors. Likely requirements for these individuals could include:

• Several years of experience in the field

• Clinical competence in associated interventions

• Formal education, training or assessor qualifications

• Fellowship to the Higher Education Academy7

Furthering your career

Education and training in aesthetics can be extremely rewarding. It is important to consider your path to become a trainer carefully, especially in an increasingly competitive sector that has no regulation on training requirements or who can become a trainer. A comprehensive knowledge of the subject matter, extensive experience in the treatment modalities, as well as a good understanding of the educational landscape in the aesthetics sector is essential for success, as well as patient safety. Completion of education courses and memberships to appropriate academic, professional and educational societies can all help to show commitment towards an academic aesthetic career and evidence good teaching or assessing practice, which is seen as desirable to potential employing educational organisations.

Dr Vikram Swaminathan works from his clinics in the North West and London, and consults for organisations in the aesthetic, educational and healthcare sectors. He is currently a faculty member of the British Society of Aesthetic Examiners and Assessors (BSAEA), Royal Society of Medicine (RSM) Aesthetics Subcommittee, and an educational supervisor. Qual: MBChB, MBCAM, MPhil, PGCertTLCP

Dr Paul Charlson has a background is in general practice. He was a GP trainer and GP programme director as well as a QA tutor for the Yorkshire and Humber Deanery. Dr Charlson has 19 years’ experience in aesthetic medicine and is past president of BCAM. His work is mainly confined to dermatology and aesthetics and with clinics in London and Yorkshire. Qual: FRCGP, FBCAM, DPD, DOccMed, DRCOG

REFERENCES

1. GOV.UK, 2020, <https://www.gov.uk/what-different-qualificationlevels-mean/list-of-qualification-levels>

2. Manchester University, 2020, <https://www.manchester.ac.uk/ study/masters/courses/list/09805/msc-skin-ageing-andaesthetic-medicine/#course-profile>

3. VTCT, 2020 < https://www.vtct.org.uk>

4. The University of Manchester, MSc Skin Ageing and Aesthetic Medicine. <https://www.manchester.ac.uk/study/masters/ courses/list/09805/msc-skin-ageing-and-aesthetic-medicine/>

5. Queen Mary University of London, Aesthetic Medicine Online MSc. <https://www.qmul.ac.uk/postgraduate/taught/ coursefinder/courses/aesthetic-medicine-online-msc/>

6. Dr Martyn King and Sharon King, 2018, https://aestheticsjournal. com/feature/the-role-of-a-kol

7. Advance HE, 2020. <https://www.advance-he.ac.uk/fellowship/ fellowship>

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constrained by their own perception of their abilities and potential, while those exhibiting a growth mindset tend to make the most of opportunities and seek challenges. It is easy to surmise which of the two is more helpful for business owners to display (and thankfully Dweck’s research has proved that people can switch between the two).1

A great way to start is to focus on learning rather than current achievements, and that’s another reason why CPD is so essential.

Continuing professional development

As an aesthetics specialist, you are likely to spend a great deal of time and resources on ensuring your qualifications are up to date, and that you are able to offer the very latest treatments to your patients. But have you considered continuing professional development as a business tool too?

Amplifying Success

There’s a difference between running a good aesthetics clinic and running a great aesthetics clinic. The former requires you to be excellent at what you do – providing high-quality treatments for your patients – but that alone isn’t enough to elevate you into the very elite group of hugely successful clinics. I firmly believe that incorporating a range of business skills and tools into the daily running of your clinic, and having the right mindset, can make any aesthetics company more successful.

If you look around at the aesthetic clinic owners who are really at the top of their game – turning over huge profits, known far and wide for what they do, and achieving all of the goals they set down when they very first launched – I can almost guarantee they will have a few things in common. Firstly, and fairly obviously, they will be excellent at the aesthetic treatments they provide. The team will be at the top of their game, and patients will leave feeling thrilled with the service they’ve received.

But it will be more than that – they will also have put a huge amount of thought and effort into the business side of what they do: the tools and skills it takes to run a successful

company. While serving the patients using the clinic is always the primary aim, nobody goes into business to make a loss, and the success of the company absolutely depends on honing those skills, as well as the ones needed for aesthetic treatments.

There are so many ways that clinics can ensure they become more successful, and what works for you will be very much an individual magic formula that you will arrive at through taking yourself out from the day-today running of the clinic and concentrating time and effort on these business skills.

However, the three core areas I recommend clinics begin focusing on are mindset, continuing professional development, and developing a worthwhile business plan.

Psychology of success

The first thing to consider, and this isn’t simple but is so effective, is your mindset. Business success isn’t just about who can do what – it’s about your beliefs in your own ability and growth potential too. Psychologist Carol S. Dweck has spent years researching how people think in relation to learning, and has identified two major mindsets: fixed and growth. Those with a fixed mindset are

Firstly, are you thinking about your development in terms of how it will attract new patients to the clinic – and whether it might make the difference if someone was comparing you to another similar clinic in the area?

Internationally-acclaimed psychologist Dr Robert Cialdini came up with the six principles of persuasion – that is, how you can ethically persuade potential customers towards a sale – and one of the key ones is authority.2 His summary is: ‘What the science is telling us is that it’s important to signal to others what makes you a credible, knowledgeable authority before you make your influence attempt’.

So, the key is widening your focus so you’re thinking about how your CPD will build trust, credibility and authority among your patients. Having your qualifications on show (online as well as in your clinic) can be a real winner here. I wrote an article on exactly how you can do this in the September issue of Aesthetics called Building Trust to Establish Authority, so definitely have a read if you think it’s something you can work on.3 It’s worth looking at the other principles in Cialdini’s research as they are all really essential factors when it comes to building your business –factors such as how much we like a person, and whether something is offered to a patient before the point of sale (reciprocity) can start to build relationships and make all the difference to an indecisive buyer.

An impactive business plan

But even incorporating all of the above isn’t enough to completely elevate your business. They’re the equivalent of designing and

Alan S. Adams advises on the strategies needed to take your clinic from good to great

building the most beautiful sports car and then not learning how to drive properly –you’re going to get stuck somewhere along the journey.

In this case, you’re travelling towards success. And in some respects, success looks different for all of us. There are some who will have a specific financial goal in mind, others might want a holiday home or to pay off their mortgage, while for others the ultimate goal might be having the luxury of being able to step away from the day-to-day running of the clinic and enjoy a much better work/life balance, knowing their business will remain a success without them being there all of the time. And that’s why every clinic should have a detailed business plan – helping guide the direction you’re going in, keeping you on target and allowing you to recognise which areas of the clinic might need more of a focus.

However, having an ineffective business plan is pretty much the same as having no business plan – so it’s absolutely crucial to ensure you invest the proper time and effort into this process.

I originally developed my trademarked DEPTH model because so many of the patients I was working with had plans which were doomed to fail, so I wanted to share with them five steps that are all equally important when working through the process. The first is Destination – understanding your lifestyle goals such as where you want to live, how many days a week you want to work, and how many holidays you want, getting down as much detail as you possibly can about what you want your life to look like. Then comes Exploration – understanding exactly where you are as a business and then

exploring all of the options available to you in order to drive it forward, such as streamlining processes to provide cost efficiencies and making best use of marketing, admin systems, HR, pricing, positioning and all of the other aspects which come together in order to improve the success of your clinic.

Once you understand what you’re trying to achieve and all of the options available, it’s time to make the Plan – it should of course be detailed, there’s no point having one or two sentences jotted down on a scrap piece of paper. But equally, a 50-page document isn’t going to be easy to refer back to and plot your progress against. Around three or four pages provides a good amount of detail while keeping it manageable.

You’ve got your plan, now you need the Tactics which are going to push your business forward. While there might be urgent day-to-day things to deal with in your clinic, it’s key to focus on these tactics because of how important they are. What’s important should never give way to what is urgent. You must ensure you know how to make the most of these tactics too: it’s no use deciding you’re going to use social media to attract new customers if you have no idea how many hashtags to use, or what time of day to post, or the types of posts which are going to attract your ideal patient; this is where calling in an expert to guide you through the process can make all the difference. This might be a business coach to point out which tactics you should be using and/or someone with a specialism such as social media for business.

Another key focus is the clinic’s Health – find out which KPI figures are important to your business and monitor them at least on a

monthly basis. Stepping outside of the day-today running of the clinic in order to formulate and plan is absolutely vital, as is to continue doing so regularly thereafter to review the progress you’ve made and the next steps to achieve your goals. Do remember to keep goals specific, achievable and measurable: stating you’re going to increase your profits is none of those things, instead you should be setting smaller targets on the way to your ultimate earnings goal and detailing how you will achieve those targets. I outlined the DEPTH model in more detail in an article called Building Success in Aesthetics, published in the January 2019 journal, so do check that out for more information.4

Remember…

Success in the aesthetic industry isn’t a simple case of offering the very best treatments. It’s also down to how you market your business, how you work towards your goals, and how you show the difference between you and your competitors. Ultimately, the clinic is an enterprise which you should be able to step away from and everything you’ve put in place will continue like clockwork, so it’s about getting it to that point. If you think like an aesthetic treatment provider, then you’ll become a good one. But if you take the time out of the daily running of the clinic to plan, review and scale up then you really can take things to the next level.

Alan S. Adams is an awardwinning business coach, professional speaker, and bestselling author. The publication of his third book, The Beautiful Business: Secrets to Sculpting Your Ultimate Clinic focuses on the medical, cosmetic and aesthetic clinic sector.

Adams was a finalist in The Association of Professional Coaches, Trainers & Consultants’ Coach of the Year Awards, and has been recognised by Enterprise Nation as a Top 50 Advisor in the UK.

REFERENCES

1. Carol S. Dweck, Mindset: The New Psychology of Success, 2007. <https://static1.squarespace.com/ static/5df3bc9a62ff3e45ae9d2b06/t/5e88b620d 7a6d83f2fe39765/1586017925197/EBS+Mindset+The+New+Psychology+of+Success.pdf>

2. Influence at Work, Principles of Persuasion, 2020. <https://www. influenceatwork.com/principles-of-persuasion/#authority>

3. Alan Adams, Building Trust to Establish Authority, Aesthetics, 2020. <https://aestheticsjournal.com/feature/building-trust-byestablishing-authority>

4. Alan Adams, Building Success in Aesthetics, Aesthetics, 2020. <https://aestheticsjournal.com/feature/building-success-inaesthetics>

Those exhibiting a growth mindset tend to make the most of opportunities and seek challenges

Celebrating twenty years of Healthxchange Group

In The Life Of: Dr Kate Goldie

The aesthetic trainer discusses how she’s adapted to her new working routine

How I start my morning...

I like to make the most of my morning, so I always try to go for a walk on the beach with my dogs before I head into London for work. After just over an hours’ train journey, my first stop when I arrive is always Pret A Manger. I get myself an oat latte, as well as a coffee for my business manager and receptionist. Oh, and croissants! We always start our working day by having a catch-up over breakfast, discussing and planning our day before the rest of the team gets in. Our day-to-day schedule is quite complex at the moment, so I think it’s important that we always implement this, and it’s also just quite a nice way to start the morning!

Before COVID-19, 50% of what I did was training practitioners in person so my challenge recently has been working out how I can make virtual training as useful to people as possible. Recently I’ve been doing some international broadcasts to Australia and Asia, so we tend to get in and set up our filming equipment for around 8am. Once the broadcast is done, we’ll film some models for case studies to feature on the new Medics Direct training platform, which is set to launch early next year. At the minute, we’re trying to build a detailed portfolio of video examples for unique injection techniques.

My afternoons consist of…

We recently bought a blender, so my team has been trying to kickstart lunchtime with a blend of kale or spinach and blueberries. It makes you feel like you’re doing something positive for your body!

The first part of my afternoon is usually full of meetings. I’m currently working on a consensus paper with a group of global practitioners, so I spend a lot of time talking to them and writing it virtually. Once that’s done, I’ll move on to seeing patients – I would say that on average my days are about 50% business and 50% clinical. I see about 15-20 patients a day at an absolute maximum, which I think is because I work at a slower pace than other practitioners – I’m very meticulous!

I enjoy seeing my patients the most – every person who comes into my clinic is unique and it’s fascinating to me. There’s such magic in every individual person’s face, and you need to make sure you don’t lose that by making them look like everyone else.

Why I started in aesthetics…

To be honest at the start I thought it would be something I would just do for fun and pass through, but I just loved the industry and the people so much. Everyone who works in aesthetics is so creative and bold. The reason you start something and the reason you stay in something is very different.

My favourite treatment… Sculpting with fillers, for sure. I like to judge things as I go and be able to see the art forming in front of me.

My favourite hobby… Reading! Me and my family recently set up a challenge where we each had to pick one of the world’s top 100 books, and it had to be something we wouldn’t normally choose. I ended up with The Gulag Archipelago by Aleksandr Solzhenitsyn, so I’m currently making my way through that.

My working day typically finishes at around 7pm, but this always varies! Once I get home I like to relax with my partner and binge watch Netflix documentaries or read a book. He also recently got me a hammock for inside the house, so I like to sit in it after a long day – it’s become my small personal space of relaxation!

How my routine has changed…

Over the last few months I’ve had to adapt to a completely different working routine, and I’m sure this is something most people have experienced. For example, usually I would have blocks of days throughout the year which are solely for speaking at aesthetic conferences or events.

I love working that way because it means I can be absorbed in that one thing for three or four days and give it my complete focus. Now, because all events have been moved online, my work as a speaker gets mixed in with everything else throughout the day. I’ve had to learn how to move from project to project quickly, which is probably a good learning curve for me. What I also really miss about attending conferences is the camaraderie with everyone, especially right at the end.

I always think if you’re going to do something stressful, you need that celebration after! Recently we’ve started to implement virtual parties and cocktails at the end of the day when an event finishes, which is fun. It doesn’t match seeing everyone in person though!

My most memorable day…

About five years ago I was at a small meeting for the Royal Society of Medicine and I did a lecture on regenerative aesthetics. It was an important day in my career because the topic was about an entirely new structure; discussing how aesthetics can have a beneficial impact on the way that tissue ages.

Normally I’m not worried about doing presentations because I have done so many throughout my career, but I was nervous about this one because it was on something completely new and I’d never heard of anyone else doing a talk on it before.

To take an idea from my mind, research it, and then bring it to the aesthetics community was scary, but to hear other people say they thought it was interesting and give positive feedback was amazing. It definitely changed the way that I think about aesthetics in regards to human ageing, and I’ve been passionate about regenerative medicine ever since.

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The Last Word

Aesthetic medicine receives criticism for its lack of regulations and places great emphasis on the importance of procedures being carried out solely by medical practitioners. However, outside the fact that any lay person can be trained, medical practitioners are allowed to perform aesthetic treatments after only a one-day training course. Following my own experience on these courses, I personally do not believe they provide adequate training to allow practitioners to venture into the complex and potentially high-risk world of injectable fillers. This article aims to explain why, as well as what I believe practitioners should seek to do instead.

The one-day course

A typical one-day course commonly provides a morning of theory and observation of one patient and an afternoon of supervision, usually with each student treating one, or even just practising on a dummy. The student is usually then certified to carry out such a treatment, providing they gain appropriate insurance. In other fields of medicine, such as dentistry, short postgraduate courses exist to increase a practitioner’s skillset, as opposed to gaining the initial qualification to begin practising in the subject. A one day orthodontic course, for example, is frowned upon in the field of dentistry as it is not thought that a dentist can gain the full knowledge and skillset required in one day and without any form of examination of the dentist’s understanding and competency. Specific aesthetic procedures are often not directly covered through formal ‘dermal filler’ training courses and, although guidance has been produced by bodies such as the CPSA and JCCP,1,2 there are no legal definitive training requirements for each procedure. Moreover, there is no such thing as a ‘cosmetic’ specialty for medical professionals, making it difficult for patients to know if their practitioner is appropriately qualified or experienced in that particular field.3

I see aesthetic practitioners asking questions on forums on a daily basis, which I am sure would frighten their patient. “What product should I use to fill X,Y,Z?” and “How deep should I inject for…?” are regular questions I see and I feel this level of misunderstanding by individuals who are qualified to carry out such a procedure is unacceptable. Imagine seeing on a forum, “How

should I extract this particular tooth?” – such a practitioner would likely be advised to seek more training and assessment.

The traditional ‘see one do one’ concept has been shown to work in surgical teaching for medical students, but only when combined also with ‘teach one’. There are now arguments that this method is no longer applicable, mainly because of concerns for patient safety.4 I do not believe that it works well in aesthetics due to the complexity of the field, vast amount of new information not covered in any of the practitioners’ undergraduate courses, and great variations between each individual patient. I do not feel that observing and treating one patient under supervision, without the guarantee that the supervisor has even paid full attention, which I have personally experienced on courses, is adequate teaching and mentoring to gain a full qualification. I believe competency must be gained with a number of different and repeated treatments on a large number of patients under mentorship.

From my knowledge, many providers that grant qualifications to practise are offered to medical professionals with the assumption that they have prior knowledge of anatomy and general medicine. Whilst the latter is true, an assessment is not made of how relevant their previous training is to the field of aesthetic medicine. How many doctors, dentists, nurse practitioners, midwives and pharmacists know the in-depth anatomy of the glabellar complex, or could draw the path of the facial nerve and its varying depths prior to, or following, a beginner’s facial aesthetics course? Anatomy, and its variation amongst individuals, is a vast subject. Factor in the different types of treatments available, the treatment planes, the depth of injections, and the rheology of materials, it is clear that aesthetic medicine is a complex subject, requiring extensive knowledge and confidence in dexterity.

I have found that the more you learn, the more you realise you do not know, hence the reason why thorough training and supervision over an extended period of time is paramount, in my opinion.

The counter-argument

I do recognise that there can be some positives of one-day courses. Basic training does allow the medical practitioner to begin their career in aesthetics quickly, at a relatively low cost and without having to prepare for exams. It can also give them an insight into the field to determine if they are keen and would like to progress

Dr Helen McIver debates the effectiveness of one-day training for injectables

further, before investing more time and expense. It is also a way for experienced professionals in aesthetics to be able to run courses and share their enviable skills with novice practitioners, or those who are experienced looking to build upon their skills and learn new techniques, without the need to complete a post-graduate qualification in teaching.

Alternatively, we are now gaining access to many online resources which could be used to gain introductory information and allow practitioners to decide if they wanted to pursue the field further by investing in courses. I am therefore of the belief that the negatives of gaining qualification via a oneday course far outweigh the positives.

The solution

There are several solutions to this problem, some already in place and some which I believe should be enforced. Many courses providing an advanced postgraduate qualification in aesthetic medicine exist, namely the Master’s of Science, Diploma, Level 7 certificate and Level 7 Diploma. The Royal College of Surgeons (RCS) has produced guidance outlining standards for cosmetic practice (surgical and non-surgical), advising that attendance at training courses alone is insufficient to become competent in a procedure; direct training and supervised practice is also necessary; and a period of formal or informal mentorship is recommended.3

Prior to being able to treat patients without supervision, I believe that success in some form of written and supervised assessment should be compulsory in order to ascertain that the practitioner has understood what they have been taught, as well as being able to demonstrate an adequate level of competency in injectables. I feel that this should include an evaluation of a practitioner’s understanding of complication risk assessment and

management. This in turn ensures the safety of patients and an adequate level of quality of the work to be carried out, while also further protecting the practitioner. This movement is already coming to fruition, with associations such as the BCAM implementing an exam in order to gain membership.5 The CPSA has standards in place to provide solutions to the issues addressed, to ensure practitioners’ competence and patient safety, while the JCCP has specific requirements for joining its register in association with the CPSA.1 They promote practitioners to move away from lone practice and develop networks; recognise competence as appropriate knowledge, skills and behaviours, and believe that competence can only be achieved through appropriate supervision.6

I believe that practitioners’ expertise and confidence would improve by undergoing a mentorship programme at the start of their career in aesthetics. Having someone present in clinic to discuss treatment planning and provide supervision, guidance and constructive criticism would encourage development of critical skills and learning.

I myself enrolled onto the Level 7 Qualification in Injectables with a wellknown training provider for this reason. This comprised in-depth studying of many aspects of injectable medicine: from its history, anatomy and material science to the psychology and law associated with it; an OSCE examination, dissertation and several one-to-one observation and supervised training days, treating at least eight patients per day. I found this to be invaluable in my journey; feeling so much more confident and safer with my in-depth knowledge and experience, as well as having a wonderful support system around me, and now wonder how I ever treated patients prior to undertaking this intensive training course.

Summary

Aesthetics can be a scary field that can carry a high risk if left in the hands of someone with minimal training. This can lead to two things: one is a lack of confidence which can actually dissuade the practitioner from continuing in the field at all,7 and the other is overconfidence of the practitioner from a lack of knowledge and anatomical danger zones, which can lead to unsafe practice.

I believe that although short group courses provide some positives to practitioners and trainers, the training they provide is insufficient without continuing professional development. Enforced assessment and mentorship would be beneficial to both practitioners and patients in the long run, along with improving the standards of the aesthetic field, helping to bring it in line with other specialties of medicine.

Dr Helen McIver qualified as a dental surgeon in 2006. She has completed a Level 7 Course in Injectable Medicine with Harley Academy, comprising 40 oneon-one observed and supervised cases in botulinum toxin and dermal fillers treatments, as well as an OSCE examination and dissertation covering all aspects of aesthetic medicine. She is the principal medical practitioner of Dr Helen McIver, Professional Facial Aesthetics, based in Manchester, Cheshire and London. Qual: BDS, MJDF, RCS(Eng)

REFERENCES

1. JCCP, Standards to enter the JCCP Education and Training Providers Register, 2018. <https://www.jccp.org.uk/ckfinder/ userfiles/files/Education%20and%20Training%20JCCP%20 Standards%20for%20ET%20providers%20V14%20 September%202018.pdf>

2. JCCP Modality Standards & CPPD Requirements, p 1, 4. <https://www.jccp.org.uk/ckfinder/userfiles/files/CPPD%20 Requirements%20by%20modality.pdf>

3. Royal College of Surgeons, ‘Professional Standards for Cosmetic Practice’, (2013), p. 10, 20, 22

4. Plastic and Reconstructive Surgery 131(5):1194-201, Application of the “See One, Do One, Teach One” Concept in Surgical Training, May 2013

5. BCAM Strategy <https://bcam.ac.uk/2592-2/>

6. CPSA, CPSA Supervision Matrix, JCCP/CPSA Code of Practice, <https://www.jccp.org.uk/PractitionersAndClinics/jccp-cpsacode-of-practice>

7. Sebastian Cotofana and Nirusha Lachman, ‘The Superficial Face Dissection as an Example for Integrating Clinical Approaches, Authentic Learning, and Changing Perspectives in Anatomy Dissection’, American Association for Anatomy, (2019), Abstract

I am of the belief that the negatives of gaining qualification via a one-day course far outweigh the positives

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