December 2021: The Evolution Issue

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22 ON 20 TI E RA S! AC I S T E N G OP








Merz Aesthetics UK & Ireland

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at Reporting forms and information for Republic of Ireland can be found at Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to or on +44 (0) 333 200 4143. Merz Pharma UK Ltd, Ground Floor Suite B, Breakspear Park, Breakspear Way, Hemel Hempstead, Hertfordshire HP2 4TZ MERZ AESTHETICS is a registered trademark of Merz Pharma GmbH & Co. KGaA.

Understanding PRP CPD Dr Priya Shah explores the efficacy of PRP as a monotherapy

Emerging Trends in Aesthetics

Practitioners reflect on the developments of the last 12 months

Sponsored by Merz Aesthetics UK & Ireland M-BEL-UKI-1293 Date of Preparation November 2021

Managing Sharps Injuries Latest guidelines from the ACE Group World on minimising risk when handling sharps

Evolving Your Platform

Adam Haroun explores how to set your clinic apart using the latest trends

THEIR LOOK *Juvéderm® offers a range of facial fillers to answer a variety of needs, each of which is administered at a different dermal layer. We believe natural-looking, long lasting results are achieved by enhancing your client’s features, not changing them. The Juvéderm® Vycross® range of fillers includes five tailored products designed for a specific area of the face at the optimum dermal level. Which means you can offer your clients a bespoke and tailored treatment to help suit their needs.

To find out why Juvéderm® could work for your clients and your clinic on every level, visit

Produced and Funded by Juvéderm®. UK-JUV-2150067 March 2021 ©2021 Allergan. All rights reserved. Model treated with Juvéderm®. Individual patient results may vary. Adverse events should be reported. Reporting forms and information can be found at Adverse events should also be reported to Allergan Ltd. or 01628 494026.

Reduce inflammation and redness Speed post-procedure recovery Increase patient comfort levels Reduce patient downtime Enhance results “Being able to treat inflammatory skin conditions, revitalise tired and ageing skin, as well as to deliver results for pain management and wound healing has broadened both my in-clinic and at-home treatment offering. Most importantly, my Celluma devices have taken our patients’ results and satisfaction to the next level.” Miss Sherina Balaratnam MBBS, MRCS, MSc (UCL) Surgeon and Cosmetic Doctor Medical Director, S-Thetics Clinic Beaconsfield, Buckinghamshire (UK)


+44 (0) 203 981 3993

Contents • December 2021 08 News

The latest product and industry news

18 News Special: Exploring Remote Prescribing

Aesthetics explores the issues around practitioners and remote prescribing

20 Aesthetics Conference & Exhibition is Back for 2022

Register now for the UK’s leading clinical conference

CLINICAL PRACTICE 23 Special Feature: Emerging Trends in Aesthetics

The Clinical Advisory Board look back on 2021 and outline trends for next year

29 CPD: Understanding PRP Efficacy

Dr Priya Shah explores the efficacy of PRP as a monotherapy for skin ageing

News Special: Exploring Remote Prescribing Page 18

35 Keep It Simple

Keeping lip treatments simple for patients who prefer a natural look

39 Case Study: Treating M-Shaped Lips

Dr Sarah Hart presents a case study of treating M-shaped lips

42 Exploring the Physiology of Black Skin

Two practitioners outline the differences between Caucasian and black skin

44 Large Volume Treatment Plans Using the Merz Portfolio

Can we achieve surgical outcomes using a non-surgical approach?

47 Applying Acoustic Wave Therapy to Aesthetics

Dr Ashwin Soni explores the use of acoustic wave therapy in aesthetics

51 Managing Sharps Injuries

Nurse prescriber Sharon King and Dr Martyn King outline how to minimise the risk of blood-borne viruses

54 Ultrasound Imaging

A visionary approach to the use of ultrasound imaging

55 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 57 Exploring Vaccination Policies

Catherine Hawkes explains the legal hurdles of mandatory vaccinations

61 Evolving Your Platform for the New Year

Adam Haroun explores the way to leverage the hottest trends into 2022

65 Practice Building with EMSCULPT NEO

Mr Matt James discusses how the EMSCULPT NEO has benefited his practice

66 Optimising Patient Satisfaction

Psychologist Kimberley Cairns explores how trauma-led practice can improve patient satisfaction

68 Mastering the Mid-face with Revanesse

Revanesse causes a stir within the aesthetics industry following its CCR launch with Dr Arthur Swift

69 In the Life Of Dr Arthur Swift

The plastic surgeon outlines how he gained popularity across the globe

70 The Last Word: Blended Learning

Nurse prescriber Lisa Waring discusses blended learning in aesthetic training

NEXT MONTH IN FOCUS: BODY • Nipple Volumisation Using Filler • Threads for the Body

Special Feature: Emerging Trends in Aesthetics Page 23

Clinical Contributors Dr Priya Shah graduated dentistry in 2002 from King’s College London and has a MSc in Skin Ageing and Aesthetic Medicine. She is the founder of Dr Priya Shah Facial Aesthetics, London and a trainer with Botulinum Toxin Club. Dr Yalda Jamali is a UK-trained medical and cosmetic doctor. She holds a Level 7 postgraduate qualification in Aesthetic Medicine. She is the owner of Dr Yalda Clinics in the UK. She has recently relocated to Sydney to continue her practice. Dr Shahd Twijiri is a UK-trained qualified dental surgeon, holds a Master’s qualification in Medical Visualisation and Human Anatomy from the University of Glasgow and a postgraduate qualification in Aesthetic Medicine. Dr Sarah Hart graduated from Otago University, New Zealand. After initial training in psychiatry, she started practicing in cosmetic medicine. She is a Censor and Senior Education Faculty member for the New Zealand Society of Cosmetic Medicine. Dr Ashwin Soni is a US and UK-trained plastic surgeon and the owner of The Soni Clinic, located in Surrey and Berkshire. He relocated to the US completing his plastic surgery training at Cornell, Johns Hopkins, and the University of Washington. Sharon King is a registered nurse, an independent prescriber and has a MSc in Non-Surgical Aesthetic Practice. She has worked within aesthetic practice for almost 20 years. She runs Cosmedic Training Academy and is a co-founder of the ACE Group World. Dr Martyn King is a GMC registered doctor and the director of Cosmedic Skin Clinic, Cosmedic Online and Cosmedic Pharmacy. He is the medical director of the ACE Group World. He has completed a Master’s Degree with distinction in non-surgical aesthetic practice.










TEOSYAL® PureSense ULTRA DEEP and TEOSYAL RHA® 4 are trademarks of the firm TEOXANE SA. These products are gels that contain hyaluronic acid, and 0.3% by weight of lidocaine hydrochloride (local anesthetic can induce a positive reaction to anti-doping tests). In the case of known hypersensitivity to lidocaine and/or amide local anaesthetic agents, we recommend not use lidocaine-containing products and please refer to products without lidocaine. TEOSYAL® PureSense Ultra Deep exists also without lidocaine: TEOSYAL® ULTRA DEEP. TEOSYAL® PureSense ULTRA DEEP and TEOSYAL RHA® 4 are class III medical devices and are regulated health product bearing the CE marking (CE2797) under this regulation. For professional use only. Please refer to instructions for use. The product availability depends on registration, please contact your local distributor. Please inform the manufacturer TEOXANE of any side effects or any claim as soon as possible to the following address:

Editor’s letter As we watch the leaves fall from the trees, put on a few extra layers and approach the time of fun festivities, we at the journal love to reflect on the developments of the past year, and what’s to come for 2022. That’s why the theme of this month is ‘evolution Shannon Kilgariff in aesthetics’! We have interviewed some Acting Editor & of our Clinical Advisory Board members to Content Manager gauge their thoughts on what’s trending now @shannonkilgariff and beyond – have a read on p.23! Also in the journal this month is a fascinating article on remote prescribing, following the huge media attention on the subject this month. We spoke to practitioners about what’s going wrong and how we can improve the specialty on p.18. The team were delighted this month to go to several industry events – reports on p.16 – which really have highlighted the importance of faceto-face learning and networking! Don’t forget, we are hosting ACE on March 11 & 12 and free registration is now open – more info on p.20. The conference will also feature the prestigious Aesthetics Awards

on the evening of the second day – Finalists will be announced in the January 2022 journal (good luck to all entries) and tickets will sell out, so secure your tables now! This month also sees the release of the Winter issue of our patient educational magazine! As our magazine and content has evolved over the past year, we’ve decided, with expert input from the aesthetic community and our wonderful readers, to rename the magazine to Beauty Uncovered which we believe will better represent what we are all about. You will have received a free copy with your journal if you are a Full Member or medical aesthetic professional subscriber within our database, so we hope your patients love it! If you would like to order more copies for your clinic, get in touch with As we near the end of the year, I would like to personally thank each and every person who has supported the journal, as well as our fabulous events – CCR, ACE, the Aesthetics Awards and the upcoming new Beauty Uncovered Live event launching in May 2022. It’s always a pleasure to continue to educate the aesthetic profession and community and we look forward to seeing you all again next year!

Clinical Advisory Board

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


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

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

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

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

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

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

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

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

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

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


PUBLISHED BY PORTFOLIO MANAGEMENT Alison Willis Director T: 07747 761198 | EDITORIAL Shannon Kilgariff Acting Editor & Content Manager T: 0203 196 4351 | M: 07557 359 257 Leonie Helm Acting Deputy Editor T: 0203 196 4268 Holly Carver Journalist | T: 0203 196 4427 Ellie Holden Content Writer | T: 0203 196 4427 DESIGN Peter Johnson • Senior Designer T: 0203 196 4359 |


Aesthetics Journal


ADVERTISING & SPONSORSHIP Courtney Baldwin • Event Manager T: 0203 196 4300 | M: 07818 118 741 Judith Nowell • Business Development Manager T: 0203 196 4352 | M: 07494 179535 Chloe Carville • Sales Executive T: 0203 196 4367 | Emma Coyne • Sales Executive T: 020 3196 4372 | MARKETING Aleiya Lonsdale • Head of Marketing T: 0203 196 4375 | Aimee Moore • Marketing Manager T: 020 3196 4370 | Abigail Larkin • Marketing Executive T: 020 3196 4306 |



Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Chloe Carville,

Aesthetics Media

© Copyright 2021 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

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





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

#Aestheticsjournal Dr Galyna Selezneva @dr_galyna Thank you so much to the editorial team at the Aesthetics journal, incredibly important topic to discuss and something I feel passionate about!

#Education Dr Raul Cetto @drcetto Wrapping up a three-day trip to Budapest including both theoretical and practical updates on facial anatomy and dermal filler techniques.

#Masterclass Anna Kremerov @anna_medical_aesthetics What a fantastic day at the Sinclair masterclass. I was honoured to be asked to speak and present my clinical cases alongside my colleagues.

#Event Julie Scott @facial_aesthetics I have had the honour to present at the @wigmoremedical open day in London. I am proud to be part of the Wigmore faculty #education #Conference Dr Rachna Murthy @drrachna_murthy Fantastic seeing colleagues and friends at the inaugural Aesthetics United Charity Conference

FDA warns against needle-free injector pens The US Food and Drug Administration (FDA) has issued a safety communication regarding the use of needle-free injection devices for fillers. According to the FDA, the needle-free devices are marketed as Hyaluron pens, Hyla-Pen, microinjectors, non-invasive injection pens, non-invasive nebuliser syringes, high pressure pens or sprayer pens. The association has not approved any hyaluronic acid or other lip and facial fillers for over-the-counter sale for at-home use or for use with needle-free injector devices. The FDA is monitoring how these unapproved devices are sold online as part of the agency’s actions on unapproved products on online marketplaces and will take additional actions as necessary. Binita Ashar, director of the Office of Surgical and Infection Control Devices in the FDA’s Centre for Devices and Radiological Health, said, “The FDA is warning the public and healthcare professionals not to use needle-free devices. The FDA’s priority is protecting patients, who may not be aware of the serious adverse events that have been reported in connection with this use, such as permanent damage to the skin, lips and eyes.” Plastic surgeon Dr Ashwin Soni, who wrote on needle-free injector pens for Aesthetics, commented, “I am in support of the FDA warning. There cannot be precision with injector pens, with regards to the depth of penetration and dispersion of the filler, and there have been many complications globally from the use of these devices.” Education

BCAM celebrates exam achievements Nine British College of Aesthetic Medicine (BCAM) members have passed the newly introduced Masters-level MBCAM examination. Passing the examination allows them to progress to full membership in the College. The exam is the culmination of more than two years of training, led by consultant plastic and aesthetic surgeon Mr Dalvi Humzah. The full membership allows members to promote their clinics in the clinician search area of the BCAM website, as well as sitting on the BCAM board after six months and voting at the Annual General Meeting. The first sitting of the multi-choice paper was held virtually on September 28 with online proctoring. An Objective Structured Clinical Examination (OSCE) will be added in 2022 when all other existing routes to full member status will be phased out. The OSCE was postponed this year due to COVID-19 restrictions. The current list of full members who have recently passed the exam are Dr Matin Ahmadi, Dr Arturo Almeida, Dr Sally Antcliff, Dr Tauqueer Abbas Awan, Dr Manav Bawa, Dr Giuseppe Fiore, Dr Claudia Morley, Dr Ivona Paravic and Dr Omer Riaz. BCAM president Dr Uliana Gout commented, “This is a significant milestone and couldn’t come at a better time as BCAM celebrates its 20th anniversary. We are determined to further our mission of leading the aesthetic medicine area, supporting our members and working with stakeholders to promote safety and patient education.”

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021





Vital Statistics

Registration for ACE opens Registration for the long-awaited Aesthetics Conference & Exhibition (ACE) has officially opened! At this year’s event, we have some exciting sponsors including aesthetic manufacturer Teoxane UK who will be the Headline Sponsor. Insurance provider Enhance Insurance will be sponsoring the In Practice agenda, which has been adapted from the previous Business Track, to outline some business tips and tricks to implement into your clinics. Event manager of ACE and CCR, Courtney Baldwin, commented, “We are so excited to welcome you back to ACE next year. After CCR – our first in-person event since the pandemic – it has been great to reunite the aesthetics industry once again and to continue to educate medical aesthetic practitioners on the latest techniques, products and regulations which are making their way to the aesthetics market. We continue to value all of your support over the past two years and hope to see you at ACE in 2022.” The conference will be taking place at the Business Design Centre, London on March 11 and 12, 2022. To find out more, turn to p.20 and register through the ACE website now.

Online videos will make up more than 82% of digital content in 2022 (Cisco, 2021)

In a study of 100 best-selling ‘natural’ skincare products, 58% included at least one synthetic ingredient (The Derm Review, 2021)

More than two thirds of 1,212 respondents agreed that wrinkled, natural complexions were more attractive than cosmetically enhanced faces (Cosmetic Surgery Solicitors, 2021)


Merz collaborates with Aesthetic Entrepreneurs Global pharmaceutical company Merz Aesthetics has partnered with business growth company The Aesthetic Entrepreneurs. The Aesthetic Entrepreneurs was founded by Richard Crawford-Small and Rick O’Neill who help build aesthetic brands and assist them with business growth. Together the companies will launch a new membership platform named the Business Accelerator Programme, which aims to support aesthetic practitioners by investing in training, coaching and mentorship, explains Merz. The programme will involve live workshops as well as online content and courses, with feedback and evaluation given throughout. Gillian Kennedy, UK and Ireland country manager for Merz Aesthetics, commented, “The team at Merz are delighted to be working with The Aesthetic Entrepreneurs to help practitioners develop the skills, expertise, and awareness to cope in an increasingly complex landscape. The Aesthetic Entrepreneurs team are passionate about business transformation as they have seen first-hand the positive impact it has on individual businesses and peoples’ lives.” Crawford-Small and O’Neill added, “As founders of Aesthetic Entrepreneurs, we are incredibly excited to be working with Merz Aesthetics. We have a shared vision, to work together to shape the future of aesthetic medicine, and build ethical, profitable businesses. This programme enables aesthetic practitioners to widen their skill set commercially, personally and professionally. We’re focusing initially on businesses that have had a few years in the market, share our vision and values and recognise they need some support. Often these businesses are a little overwhelmed, but want rapid growth and are committed to achieving success. The Business Accelerator Programme will help them achieve this”

Data of 44,689 adults from 27 EU countries has found that 47.9% of the European population over 18 years old had declared at least one dermatological condition in the past 12 months (EADV, 2021)

40% of consumers now prefer to book appointments online, up 15% over the past five years (Patient Access Journey Report, 2021)

A survey of 6,381 respondents indicated that mistreatment is a common experience for LGBTQ+ surgery residents (JAMA Surgery, 2021)

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021


Events Diary 11th-12th March 2022 Aesthetics Conference and Exhibition 2022

12th March 2022 Aesthetics Awards 2022




InMode announces new KOL Aesthetic manufacturer InMode UK has unveiled dental surgeon and aesthetic practitioner Dr Uma Jeyanathan as its new key opinion leader (KOL). As a KOL, Dr Jeyanathan will focus on the Lumecca IPL and Morpheus8 treatments whilst developing some treatment protocols, explains InMode. Dr Jeyanathan said, “I’m delighted to be a KOL for InMode. I’ve used the InMode platforms for a couple of years now, and it’s been a fantastic investment for our clinic. We’ve been getting excellent and consistent results for our patients with both Morpheus8 and Lumecca, treating various skin types and indications. I’m looking forward to working closely with InMode to train colleagues in the industry, educate patients and continue to explore the versatility of the technology.” Recruitment

Cutera unveils new advisory board Training

New London ultrasound course to take place A new foundation ultrasound course launched by aesthetic practitioner Dr MJ Rowland-Warmann will be taking place in December. The two-day Facial Ultrasound for Aesthetic Practice course will cover the basics of ultrasound, the fundamentals of how ultrasound works, recognition of structures in the face often treated with dermal fillers, and the different filler types and complications they can cause. Speakers include aesthetic practitioner and phlebologist Dr Leonie Schelke and dermatologist Dr Peter Velthuis from the Netherlands, consultant orthopaedic surgeon Mr Ansar Mahmood, consultant aesthetic oculoplastic surgeon Mrs Sabrina Shah-Desai, and aesthetic practitioners Dr Steve Harris and Dr Rowland-Warmann. Dr Rowland-Warmann said, “Ultrasound is the future of aesthetic medicine. Rarely has a development come along that will make such a difference to patient safety. Practitioners should recognise how ultrasound can elevate their practice and set them apart as practitioners who care about the safety and welfare of their patients and the accuracy of their results.” The course will take place on December 5-6, 2021 at BMA House in London.

Aesthetic technology manufacturer Cutera has formed a Secret RF Advisory Board. The board all currently use the brand’s range of radiofrequency microneedling technologies, with the aim to gather the board’s insights and feedback relating to the technology and its clinical possibilities, ensuring optimal usage and future product development. Board members include aesthetic practitioners Dr Tapan Patel, Dr Ifeoma Ejikeme, Dr Tatiana Lapa, Dr Rishi Mandavia, Dr David Eccleston, Dr Nestor Demosthenous, Dr Sabika Karim, Dr Preema Vig, dental surgeon Dr Yusra Al-Mukhtar and ENT consultant and facial plastic surgeon Mr Kambiz Golchin. Tim Taylor, UK country manager, said, “We are delighted to announce the Secret RF Advisory Board, who really are the ‘dream team’ in terms of a panel of experienced experts, completely unrivalled anywhere in device-led aesthetic medicine. The Advisory Board tick all the boxes for us as a brand, and we feel they are the perfect group to work with.” Skincare

Croma adds new products to portfolio Aesthetic manufacturer Croma-Pharma has expanded its face mask range as well as adding the Anchor Plus PDO thread to its product offering. The mask portfolio offers two full face masks, as well as masks for specific areas of the face including the eyes, lips, and expression lines. The additions include the Calming mask which is designed to protect against harmful environmental factors, and the Rejuvenating mask which aims to refresh dehydrated skin and improve skin elasticity. The new masks for specific facial areas include the Energizing eye mask which moisturises and reduces signs of fatigue; the Regenerating lip mask aims to moisturise whilst softening and plumping the lips; and the Firming laugh line mask which can smooth the appearance of wrinkles. The Anchor Plus thread is a stronger, more durable thread that can be used to lift heavy skin including submental, cheekbone areas, lower face and neck. The thread is CE certified and double-arrow shaped to enable fixation of heavy tissue and improved lifting, according to Croma.

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021




Clinical Advisory Board

Mr Dalvi Humzah steps down as Clinical Lead Consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah will step down as Clinical Lead of the Aesthetics Clinical Advisory Board (CAB) at the end of the year. The CAB comprises members of various professions within the aesthetics specialty, who share their expertise and experiences to ensure the latest clinical updates and standards are passed on to readers. Mr Humzah said, “It has been a great pleasure to be part of the Aesthetics journal over the last eight years as a member of the board and subsequently the Lead. During this time the journal has developed with great editors like Amanda Cameron, Chloé Gronow and Shannon Kilgariff; the latter two have worked with the board as they came through the ranks of the journal.” Mr Humzah added, “Now we have a strong CAB and editorial team with support from Easyfairs, it is time that I should move on from the Lead post and allow the team to continue to develop the journal, as well as ACE, CCR, the Aesthetics Awards and new Beauty Uncovered brand into the future. I am looking forward to seeing the Board and journal develop and hope to keep meeting all my colleagues from the past, present and future during these exciting times ahead!” Acting editor and content manager of the Aesthetics journal Shannon Kilgariff, said, “Myself and our editor Chloé are grateful to Mr Humzah for his continued help, dedication and support and for everything he has done for the Aesthetics portfolio. I am looking forward to announcing our new Clinical Lead in the January 2022 journal – stay tuned!” Patient education

Patient magazine announces new name The quarterly consumer magazine launched by the Aesthetics journal earlier this year Beyond Beauty has announced an exciting new name. Now called Beauty Uncovered, the magazine is dedicated to sharing up-to-date and factual information about the world of aesthetics and cosmetic surgery and aims to enhance patient knowledge, build trust and promote positivity in this fast-growing specialty. Acting editor of the Aesthetics journal and Beauty Uncovered magazine, Shannon Kilgariff, said, “Launching a new brand is always a learning curve, and as our magazine and content have evolved over the past year, we’ve decided, with expert input from the aesthetic community and our wonderful readers, that the new name Beauty Uncovered would better represent what we are all about. I am delighted to announce our fabulous new name and I am looking forward to working with the team to drive the brand forward. I am also excited about our patient-centric event – Beauty Uncovered Live – which will take place at the Business Design Centre in London on May 7-8 next year. Stay tuned for the details!” Remember, you can purchase Beauty Uncovered magazine for just £2 and retail it in your clinic for £5.99, or give it away to your patients to further their knowledge on the latest treatments. You can also encourage patients to get it delivered straight to their door for £20 per year.

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

NOVEMBER EVENTS Last month, the BACN welcomed Merz Innovation Partner Freya Carlsen, BACN regional leader for Northern Ireland Aine Larkin, and brand marketing strategist Adam Haroun to the InFocus webinar to discuss everything members needed to know about BELOTERO Revive. The webinar invited members to engage with and use the knowledge of the Merz Innovation Partners to understand the application of BELOTERO Revive. The recording is available in the member’s area of the BACN website.

LOOKING BACK Thank you to every member who committed to the BACN in 2021. 2020 was a difficult year for the association, following the collapse of numbers during lockdown. The BACN is proud to have grown throughout 2021 and welcome new members to the organisation, whilst continuing to support a band of loyal aesthetic nurses who renew each year. The BACN is also grateful to its new regional leaders that are based around the country. This has improved local support to members and has relit the networking opportunities for nurses on a regional level. There were several changes to the BACN in 2021. Most importantly, the launch of the new Code of Professional Conduct which all members follow. This code has allowed the BACN to consolidate its place as the guardian of best practice for aesthetic nurses, and thanks to all who helped to publish it.

LOOKING FORWARD The BACN has a busy year planned throughout 2022! The first round of regional meetings will be taking place after a two-year break. They will be running from the end of January until the end of March across 14 locations in the UK. The BACN will be continuing to offer monthly digital content, along with marketing digital content and business hints and tips. BACN Speciality Competency Framework for Aesthetic Nurses will be relaunched and will offer a robust framework for nurses to work against. There will also be announcements about a mid-year national get-together along with the BACN Autumn Aesthetic Conference that will be running at the end of 2022! This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021


Getting Visible in 2022

Photographer Hannah McClune’s monthly tips on how to strengthen your business through branding




Harley Academy to host Neauvia masterclasses Training provider Harley Academy will be holding injectable masterclasses sponsored by medical aesthetics company Neauvia. The masterclasses are free for aesthetic practitioners to attend through the Harley Academy website and will be hosted in London, Manchester, Loughborough and Glasgow during December. Harley Academy trainers Dr Tristan Mehta, Dr Emily MacGregor and Dr Marcus Mehta will be demonstrating Neauvia’s products on live models. During the masterclass, the trainers will show Neauvia’s holistic approach to aesthetics and the HA-PEG dermal fillers. Seasonal

Have you had a photoshoot, or taken photos yourself, and something was not quite right? It can be hard to know why a photo is not strengthening your brand. There is a simple answer: beautiful images aren’t enough, they need to be strategic. Create your photos with a strategy in mind. Your images need to be taken with intention. Now is the time to develop this strategy to be aligned with your 2022 marketing plan. The goals for your business should fit with the content you share, and consider them to ensure your business is seen by your patients and increase bookings. The key principles when creating images thoughtfully begin with: • Reflecting on how 2021 has been • Deciding how you want 2022 to look Then, most importantly, turning those 2022 dreams into an action plan. It is easy to work with a daily tactical approach, simply managing what you have happening each day. Stepping back, taking time out to consider how you want to grow and what you want for your business is hard, however, the long-term thinking and strategic approach is the best way to get visible. Build a 2022 marketing plan to reference throughout the year; SMART goals confirmed, a step-by-step plan with directions and knowledge on how to achieve them. Members of Visible Collective have 2022 marketing plan support included in their annual subscription as well as four photo sessions a year. If getting more visibility and increasing your revenue is a priority for you, visit for details on how to join. This column is written and supported by Hannah McClune, owner of brand photography company Visible by Hannah.

AestheticSource launches festive gift sets Clinical distributor AestheticSource has launched its seasonal products for 2021. Curated from the AestheticSource portfolio, each gift set enables practitioners to provide sampling kits to their patients. The first set is called #CustomerGifting, to recognise your most loyal patients; #ExploreNewProducts is for patients to trial new products with portable mini sizes; #AddedValue is to utilise as a ‘gift with purchase’ when a course of treatments is booked; #SantasHelper for gifting ideas to suit every budget; and #Repurchase to introduce patients to new brands and encourage repurchase. Other gift sets include the All I Want For Christmas by skinbetter science which includes a cleansing gel, scrub mask, two AlphaRet Peel Pads and a cosmetic bag; the Skin Active Christmas Crackers by NeoStrata which contains a Cellular Restoration, Firming Neck Cream and Lifting Serum; and the Professional At-Home Mini Facial Crackers by Exuviance, which includes a cleansing crème, glycolic polish and deep hydration overnight mask. Skin

Medical Aesthetic Group unveils new treatment Aesthetic product supplier Medical Aesthetic Group has launched the GlycoAla skin treatment. The treatment combines hyaluronic acid with GlycoAla Gel, which contains 2% aminolaevulinic (5-ALA) encapsulated in glycolic acid nanospheres. This helps to stabilise its absorption into the skin and promote results, the company explains. The treatment consists of four steps and can be used on the face, neck, chest, hands and back. Firstly, the skin is exfoliated and cleaned with GlycoAla Ultrasonic Skin Blade. The GlycoAla gel is applied and massaged into the skin. The product is placed in an incubator to prime it, the gel is removed, and the patient is placed under an LED light. The treatment aims to reduce the appearance of pore size, increase skin firmness and hydration, decrease the appearance of wrinkles, and reduce the effects of an oily complexion, explains the company.

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021




Aesthetics Awards

Early Bird Awards tickets close on December 31 Entry for the Aesthetics Awards 2022 has now closed, and finalists will be announced on January 1 in the Aesthetics journal and online on January 4. New sponsors for categories include: aesthetic supplier Heathxchange which will sponsor the Best Non-Surgical Result Award, skincare brand AlumierMD which will sponsor Rising Star of the Year Award, British manufacturer Aesthetic Technology Ltd will sponsor Best Clinic London, aesthetic manufacturer Sterimedix will sponsor the Supplier Training Provider of the Year Award, skincare platform GetHarley will be sponsoring the Medical Practitioner of the Year Award and insurance provider Hamilton Fraser is the new sponsor for Best Clinic South England. The ceremony will take place at the Royal Lancaster Hotel, London on March 12 and the Early Bird Rate for tickets to attend will end on December 31. Collaboration

Transform Hospital Group partners with charity Independent healthcare provider Transform Hospital Group has partnered with burn and scar charity the Katie Piper Foundation. The company will be providing complimentary treatments within its hospitals and clinics across the UK to those receiving rehabilitation through the Foundation. The charity was established in 2009 by Katie Piper, a model and TV presenter who experienced severe, permanent scarring and partial blindness after an acid attack, and provides restoration and rehabilitation services to people with burns and scars. CEO of Transform Hospital Group Tony Veverka commented, “It’s a privilege to be working with the Katie Piper Foundation. By working together with the Foundation, we hope to make a positive difference to those who are facing exceptionally challenging circumstances.” Training

BAAPS introduces new mentorship scheme The British Association of Aesthetic Plastic Surgeons (BAAPS) has introduced a scheme to build a relationship between young plastic surgeons and experienced senior colleagues. Under the scheme, the development of a series of mentorships aimed at post-FRCS (Plast) trainees approaching the end of their training will be supported. This provides structure and guidance for mentors, acting as ‘Host Centres’ and their mentees. The benefits of the scheme include having a highly qualified assistant, a colleague to participate in aesthetic practice audit and research, enhancing surgical skills and CPD through teaching and discussion and mentee involvement in the patient journey. There will also be an opportunity for mentees to present their work at the BAAPS Scientific Conference to a national and international audience and certification.


Join us in 2022 on 11 & 12 March at the Business Design Centre in London for two days of discovery, learning and networking at the Aesthetics Conference & Exhibition (ACE), the UK’s leading event for non-surgical medical aesthetics. After a year that has changed life as we know it, we recently hosted an incredible CCR and welcomed more than 3,300 members of the aesthetics community back together once more. Next up is ACE 2022 and we are sure you are ready to dive right into the next unmissable medical aesthetics event. What to expect at ACE 2022 With exclusive takeovers from Headline Sponsor TEOXANE as well as aesthetic giants Galderma, Allergan, Prollenium, Croma and more, all content is free to attend, including symposiums and masterclasses, making this a truly unmissable event. Learn the latest on aesthetic injectables, regenerative therapies, lasers, skincare, chemical peels, aesthetic devices, and everything you need to run a successful clinic and deliver excellence for your patients. Expand your knowledge, witness exclusive product launches, and widen your clinic offering with the wealth of knowledge, content and experiences on offer. The exhibition features more than 80 leading companies showcasing the very latest aesthetic technology for you to discover. Centered around a world-class programme delivered by leading medical suppliers, ACE 2022 is a must-attend event for non-surgical medical professionals. We can’t wait to see you at ACE 2022. Register now to book your free seat in our incredible sessions. H E A D LI N E SPONSOR


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New study highlights practitioner skin prep practice Manufacturer Clinical Health Technologies has conducted a study to establish what skin preps were being used by aesthetic practitioners across the UK. A total of 200 practitioners were contacted who offer botulinum toxin and dermal filler services. 42% were found to be using antimicrobial solution Clinisept+, which is manufactured by Clinical Health Technologies, while 35% used alcohol, 9% used chlorhexidine and 14% used ‘something else’. The products used by the 14% included baby wipes, micellar water, tea tree oil, rose water and witch hazel. Ross Walker, director of Clinical Health Technologies, said, “We are delighted that Clinisept+ is now the UK’s leading skin prep amongst injectable practitioners, but the industry still has a long way to go in terms of adopting best practice to maximise patient safety. We are going to increase our efforts to educate practitioners on the importance of using an effective skin prep before injectable procedures. We will be repeating the research next year and hopefully will record fewer practitioners that are not providing basic levels of antimicrobial protection.” Achievement

Aesthetic Nurse Software reaches milestone Clinic management system Aesthetic Nurse Software (ANS) has reached more than 1,000 members. The company supports aesthetic practitioners to manage their clinics and has seen an increase in practitioners looking at ways to save time and streamline its administration duties. Independent nurse prescriber and founder of ANS, Jo Hayward, said, “Reaching this goal of 1,000 clinics means the world to us at ANS. We have spent six years developing the software and taking on board feedback from so many amazing practitioners to provide an incredible product to support them in their clinic. This is a huge achievement for our team, and we want to thank every single practitioner that has supported us along the way, as well as the wonderful people we have worked with, within the industry.”

LABthetics release seasonal gift sets Skincare company LABthetics has unveiled four new Christmas gift sets. The sets include the Winter Skin Rival, an at-home mini microneedling set; the Winter Glow Festive aiming to protect and renew the skin with a conditioning milky cleanser, an antioxidant protector serum and a vitamin C, E and aloe vera moisturiser. The Hydrate and Renew contains an exfoliating salicylic cleanser, a restorative serum and a vitamin A renewal cream; and the Winter Skin Essential Prep set contains an enzyme peel mask, conditioning cleanser and a mini serum collection. Director and founder of LABthetics, Emma Caine, commented, “The holiday kits are a collection of our favourite best-selling medical grade at-home skincare. The sets include something for all skin types with a focus on restoring skin health in the winter months.” Milestone

EMSCULPT administers one million treatments Device manufacturer BTL Aesthetics has celebrated administering one million treatments with body contouring device EMSCULPT. In three years, the company explains that globally an average of 21 EMSCULPT Classic treatments/unit and 39 EMSCULPT NEO treatments/unit are administered every month. Vice president of US marketing for BTL Aesthetics, John Ferris, said, “In just over three years, we have accomplished this milestone with the support of all our stakeholders and the trust consumers put in the EMSCULPT brand and providers. This achievement is not only history in the making, but a testament to the efficacy and impact of EMSCULPT and EMSCULPT NEO.” Skin

PCA Skin introduces new peptide serum Cosmeceutical brand PCA Skin has launched the ExLinea Pro Peptide Serum. The serum aims to minimise the appearance of fine lines and wrinkles with a neuropeptide treatment. According to the company, the product can help lift, tighten and firm skin, reduce skin roughness and increase moisturisation and hydration. In a clinical study conducted by PCA Skin, 31 female participants between the ages of 35 and 55 years old with Fitzpatrick types ranging from I to III used the serum. When applied twice daily over 12 weeks, subjects showed a statistically significant lifting and tightening effect after one application. After four weeks, subjects showed a significant reduction in the appearance of fine lines on the forehead and around the eyes and mouth and 100% showed visible improvement in skin smoothness, lifting and tightening.

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021




On the Screen

Successful Galderma takeover with Aesthetics Pharmaceutical company Galderma conducted an exclusive social media takeover with the Aesthetics journal during November. The takeover included a 15-minute Fix with acting editor and content manager Shannon Kilgariff and aesthetic practitioner Dr Munir Somji on the Aesthetics Instagram, where they discussed Galderma’s new collagenic technology Sculptra and why Dr Somji enjoys using this on his patients. Kilgariff said, “It was great to feature Sculptra across our social media platforms in November following its relaunch. Dr Somji provided some interesting tips for implementing into your practice in his Q&A which I’m sure will be helpful to many practitioners.” To watch the live, visit @aestheticsjournaluk on Instagram. On the Scene

Wigmore Medical Open Day, London Aesthetic supplier Wigmore Medical invited 100 medical aesthetic practitioners and 13 companies to the Royal Society of Medicine on November 13 for its first London open day since the pandemic. The event featured three interactive agendas, including an injectables agenda, a medical agenda and a business, equipment and hair agenda. In the injectables agenda, the day started with a talk by aesthetic practitioner Dr Ahmed El-Houssieny on his tips for opening a new clinic. Highlights of this agenda included an overview on skin preparation using Clinisept+ by Clinical Health Technologies director Ross Walker, who also launched the new patient hypochlorous product Clinisoothe+ at the event. Aesthetic practitioner Dr Vania Hiratsuka-Dalmedo discussed her experiences using the new Stylage Lips Plus product, nurse prescriber Anna Baker explored the IBSA Derma portfolio, and aesthetic practitioner Dr Ivona Igerc explored non-surgical thread rejuvenation. Consultant plastic and aesthetic surgeon Mr Dalvi Humzah provided an interesting botulinum toxin update, looking at forehead anatomy, dosage, injection accuracy, and off-label uses. In the medical agenda, ZO Skin Health featured across the talks. Nurse prescriber Kristeen Geddes explored using the range to treat rosacea and pigmentation, nurse prescriber Julie Scott talked about combining ZO with Dermalux LED, and Dr Lauren Jamieson and Geddes discussed how to retail the range and consult patients. The business, equipment and hair agenda featured an interactive talk by Baker, who explored the use of LED for all types of skin concerns. Aesthetic practitioner Dr Lisa Godfrey did a virtual presentation on PRP in hair loss, and aesthetic practitioner Dr Zoya Diwan spoke on radiofrequency microneedling and acne scarring in skin types IV-VI. The afternoon featured talks from branding professional Russell Turner on branding, business consultant Vanessa Bird on selling, and digital marketing strategist Mark Bugg on local SEO. Mr Humzah added, “The Wigmore Open Day was a well-attended event. The Injectable session covered lip, lower face, skin rejuvenation and a four-pillar strategy covered by Dr Vania Hiratsuka-Dalmedo, Dr Chris Rennie and Dr Kim Booysen respectively. There were opportunities to meet a select group of companies and network with colleagues at this great venue. Congratulations to Danny Large and the team for arranging this successful event.” The next Wigmore Medical Open Day will take place on May 7-8 at the Royal College of Physicians.

News in Brief GetHarley celebrates festive season Skincare platform GetHarley will offer all patients free delivery throughout December as a celebration of the festive season. A personalised Christmas greeting card and surprise gift with purchase will be delivered to customers. Charmaine Chow, CEO and founder of GetHarley, said, “We know that customers enjoy the small touches and love surprise gifts and to celebrate this season we are running our best offer yet – a gift and free postage and packaging. We hope this increases orders made in December to help our practitioners’ revenues over the festive period.” Lynton launches new business school Laser and IPL manufacturer Lynton has launched the Lynton Business School. The business school is in collaboration with Richard Crawford-Small, co-founder of The Aesthetic Entrepreneurs. The programme will have on-demand sessions which will help Lynton customers with their knowledge and understanding of growing their businesses, explains Lynton. The six session topics include: goals, customer avatar, pricing, digital marketing, content creation and product launch strategy. The programme will be available exclusively to Lynton customers. Circa Skin recruits new head of sales Aesthetic distributor Circa Skin Ltd and skincare brand WOW Facial has appointed Tracy Abraham as its new head of sales and training for the UK and Ireland. In her role, Abraham will be in charge of the sales portfolio and help to evolve the training for the customers, explains Circa Skin Ltd. Head of global sales Caroline Gwilliam commented, “We are thrilled to have Tracy on board with us. Tracy brings a wealth of clinical and commercial experience and we cannot wait to watch her shine in this role.” Laboratories Monteceuticals launches in the UK Skincare distributor Laboratories Monteceuticals has become the exclusive distributor of Swissforce Pharma in the UK and Ireland. The company have collaborated with its partner laboratory in Switzerland, Swissforce Pharma, to distribute the products. Swissforce’s products include the Age Spot Serum which aims to reduce the appearance of age spots and uneven skin tone; Perfect Legs which aims to enhance the legs whilst strengthening the skin; Age Spot Forte to reduce the appearance of dark spots; and Perfect Skin, a cleanser to remove residue of makeup and impurities.

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021




Chloe Aucott, Dr Manav Bawa, Dr Priya Verma, nurse prescriber Lauren Turner, Dr Thuha Jabbar, Dr Wafaa El Mouhebb, Dr Mansouri, Dr Aran Maxwell-Cox and Dr Arreni Somasegaran. The new world stage opened with a talk on the millennial market by Dr Yusra Al-Mukhtar and Dr Bibi Aesthetics reports on the AUCC conference Ghalaie, followed by a session on topical eye contouring On November 20 delegates travelled to the Sofitel Hotel, London, solutions with Miss Murthy. Other talks included the to attend the first Aesthetics United Charity Conference (AUCC). rise of the social media influencer with Dr Elle Reid and Dr Zainab AlFounded by aesthetic practitioners Miss Lara Watson and Miss Mukhtar, building a boxset business with Richard Crawford-Small, the Priyanka Chadha, the conference was designed to raise money for art of clinical photography with Dr Yusra Al-Mukhtar and Dr Zainab AlRefuge and NHS Charities Together. The event was split into three Mukhtar, introducing two major Sinclair innovations MaiLi and Lanluma stages: the main stage, the workshop stage, and the new world stage. with Dr Sabika Karim, and a panel discussion on how to build a brand The main stage opened with a talk on facial transformations with with founders of Glowday Joby and Hannah Russell, PR consultant non-surgical aesthetics by Mr Benji Dhillon, which was followed by Sophie Attwood, marketing consultant Ron Myers and Dr Ghalaie. The anatomical lessons for cosmetic injectables by Mr Naveen Cavale, day ended with a closing ceremony, thank you and announcement trials and tribulations of the non-surgical rhinoplasty by Mr Ash Labib, of raffle winners by Miss Watson and Miss Chadha, followed by how to differentiate yourself from the competition by Dr Kuldeep networking drinks for delegates. Minocha, and periorbital rejuvenation techniques by Mrs Sabrina Shah-Desai. After lunch, the presentations resumed with nurse prescriber Sharon Bennett discussing the future of aesthetic nursing, Dr Tapan Patel spoke on being a global practitioner under the spotlight, and Dr Raj Acquilla explained the algorithm of beauty. The workshop stage featured talks on injectables and skin health by Dr Ana Mansouri, the future of fat loss by Dr Natalie Geary, powering practitioners of the future with Miss Rachna Murthy, and a live session of The Guinea Pig Podcast with Dr Maryam Zamani and the previous editor-at-large of Vogue Fiona Golfar. This stage also saw the presentation of case studies by the conference's rising stars, Dr Conference Report

Aesthetics United Charity Conference, London

Conference report

IAAFA, Windsor

Conference and awards ceremony highlights Aesthetic practitioner Professor Bob Khanna hosted the International Academy of Advanced Facial Aesthetics’ (IAAFA) annual conference and awards ceremony at the De Vere Beaumont Estate in Windsor on November 20. There were 182 delegates and 15 exhibitors at the event, which aims to bring practitioners together to integrate aesthetic knowledge to enhance and regulate patient care. The conference featured talks from Professor Khanna on temporomandibular disorders and bruxism and how to avoid common mistakes in the chin and jawline. He highlighted the importance of tailoring your treatments to individual patients and not feminising men or ‘alienising’ women. Directors of national practitioner register Save Face, Ashton Collins and Brett Collins, presented on how to differentiate yourself from lay non-medic injectors and provided an overview on the newly-launched Qualification Council For Cosmetic Procedures

qualifications that are regulated by The Royal Society For Public Health. In her talk on how to avoid patient complaints, cosmetic account executive of Hamilton Fraser Insurance, Shelly Hemmings, highlighted that the treatment journey doesn’t end when you finish the treatment and the importance of remaining available to your patient afterwards. Another highlight was a presentation by aesthetic practitioner Dr Patrick Treacy, who discussed the patient motivations for aesthetic procedures. He said the face is one of the most important stimuli and is a primary method of communication, while discussing the social importance of beauty. For those from a dental background, facial aesthetic dental surgeon Dr Manrina Rhode provided tips for transitioning from dentistry to facial aesthetics. Following the conference was the annual charity ball and awards ceremony. With 250 attendees, the event supported the Ruth Strauss Foundation,

which helps families facing the death of a parent in the UK. Aesthetic practitioners Dr Anjuli Patel, Dr Sarah Cuffin, Dr Sarah Khalil, Dr Ranjeet Rai and Dr Donna Mills were congratulated for winning awards. President and founder of IAAFA, Professor Khanna, said, “Having created IAAFA in 2005, it gave me such pleasure to witness the enthusiasm and joy amongst the attendees. Being able to raise £29,199 for the RSF on behalf of my dear friend Sir Andrew Strauss was a real bonus for me and my amazing team. None of this would be possible without the hard work that my wife Sonia puts in with our team. I am truly grateful for everyone who attended and I look forward to seeing you all at IAAFA 2022 on November 19.”

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021

Aesthetic Technology Ltd. T: 0845 689 1789 E: W:




of Cosmetic Nurses (BACN) Sharon Bennett and chair of the British College of Aesthetic Medicine’s (BCAM) Regulatory, Ethics and Professional Standards Committee Dr John Curran to find out industry stances on remote prescribing for cosmetic purposes.

Misuse of remote prescribing

Exploring Remote Prescribing Aesthetics looks into the ethical issues around medical aesthetic practitioners and remote prescribing Last month, The Sunday Times published an investigation exposing four medical professionals running side-line businesses in which they prescribed botulinum toxin for patients they’d never met.1 Using an app called Faces, doctors and nurses are able to connect with non-medics and provide them with access to the prescription-only medicine (POM). A reporter from The Sunday Times posed as a beautician on the app and contacted medics whose profiles suggested that they were prescribing remotely, requesting advice on how to obtain prescriptions for patients. Out of the seven medics that were contacted, four agreed to help.1 During conversations with the medics, it was suggested by them that patient safety was the responsibility of the practitioner and

not the prescriber, and that it was okay to prescribe without having contact with the patient.1 This is not the first time prescribing has been highlighted as an issue within the aesthetics industry; in 2015 it was reported by the BBC that an aesthetic doctor practising on Harley Street received a 12-month suspension from the General Medical Council (GMC) as a result of teaching non-prescribing nurses how to illegally obtain botulinum toxin.2 Immediately following the BBC’s investigation, the GMC tightened its prescribing rules, banning medicines such as toxin from being prescribed remotely, meaning practitioners must now always hold a face-to-face consultation with the patient for these types of drugs for cosmetic purposes.2 With the latest report once again bringing the problem to the forefront of the specialty, we spoke to the chair of the British Association

Bennett explains that remote prescribing in medicine exists for a very good reason in order to provide members of the public with medications when they are unable to see the doctor for various reasons, and the consultation is often done via telephone or video call. She says, “It’s an important part of the medical industry, but the problem comes when remote prescribing is used as part of cosmetic practice. This is when doctors/nurses/dentists are prescribing for non-medical practitioners who they have never seen at work, and they don’t know their ability or their qualifications. The prescriber also does so having had zero contact with the patient themselves, and this leaves the patient in a very vulnerable position.” According to Dr Curran, the lack of face-to-face interaction between prescriber and patient may result in some serious complications. He says, “Remote prescribing means that the patient does not have the benefit of a proper face-to-face consultation and examination by a prescriber, who must only prescribe within the scope of their competency. It is recognised that cosmetic injectable treatments may give rise to life-changing complications such as vision changes and disfigurement, so every patient deserves to be treated by a prescriber whose first concern is the patient’s health and safety, and acts ethically within the framework set out by the regulators to ensure safe practice.” Dr Curran also emphasies that the prescriber remains responsible for the medicine prescribed, including taking reasonable

Current prescribing laws GMC According to the GMC, you must carry out a physical examination of a patient before prescribing non-surgical cosmetic medicines, such as botulinum toxin or other injectable cosmetic medicines. Therefore, you must not prescribe these medicines remotely.3 GDC The General Dental Council (GDC) states in its guidance that dentists must not remote prescribe (for example via telephone, email, or a website) for non-surgical cosmetic procedures such as the prescription or administration of toxin or injectable cosmetic medicinal products.6

NMC According to the Nursing and Midwifery Council (NMC), remote prescriptions or directions to administer should only be used in exceptional circumstances and not as a routine means to administer injectable cosmetic medicinal products.4 GPhC In 2020, the General Pharmaceutical Council (GPhC) updated its guidance to state that ‘pharmacist prescribers must make sure that anyone they delegate the administration of the products to is a healthcare professional with the appropriate training and skills to administer and carry out the procedure’.5

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“Every patient deserves to be treated by a prescriber whose first concern is the patient’s health and safety, and acts ethically within the framework set out by the regulators” Dr John Curran

steps to ensure safe administration and is accountable for what happens to the patient after treatment. He says, “I would remind my colleagues of the four Ds of medical negligence: Duty of Care, Dereliction of that duty, Directly having a causal relationship to the outcome of treatment, and Damages. Providing a prescription to assist a third party, who is unlicensed to prescribe or hold a stock of that medicine, to carry out a potentially harmful procedure against the direct instruction of your professional body, is unethical. Should damages occur, the patient should have redress against such a poor standard of care.”

Reporting prescribers If you suspect that one of your colleagues is remotely prescribing to non-medical injectors, Bennett recommends that the first step you should take is to speak to them directly about the seriousness of the situation. She notes, “I would suggest that you contact them and just let them know that you’re aware of what’s going on, telling them this isn’t something they should be implementing and actually educating them on why it’s unethical. Some people aren’t aware of the guidelines, even though they should be, and they may just need them to be explained. If they are aware, I think if people realise the spotlight is on them and understand further of the seriousness of what they’re doing, they

should hopefully be less likely to keep going through with it.” Dr Curran agrees, adding that if you know the practitioner you should approach the colleague in question in order to establish the facts, before going on to report them. He says, “Should there be concerns that the practitioner is failing to demonstrate the insight that this practice is unethical and contravenes the guidance of the regulator, then the matter should be escalated to your relevant association, such as BCAM, the Joint Council of Cosmetic Practitioners, or the BACN, and the relevant governing body, such as the GMC, GDC, or NMC.” Bennett adds that if enough people report the same person, it is likely that there will be an investigation into their practice. “The problem with reporting someone is that usually there’s a lack of evidence, and evidence is needed in order to take action,” she explains, adding, “So a lot of the time we rely on patients for that evidence, but of course they’re usually quite reluctant to come forward and are worried about speaking out. This is why patient education is so important, because they need to be aware of how dangerous this can be if it’s allowed to continue. Even if there is a lack of evidence from patients, if someone is reported multiple times by practitioners then it’s more likely to be taken seriously, so I do still encourage medical professionals to take the initiative to contact the relevant authorities.”

Response from the NMC Chief executive and registrar for the NMC, Andrea Sutcliffe, commented in relation to the recent reports on prescribing, “The NMC is deeply concerned by these findings and they will look carefully at concerns where they are raised. The regulator has highlighted that prescribers should always thoroughly assess patients to identify and minimise risks as per the Royal Pharmaceutical Society’s Prescribing Competency Framework, which they have adopted for prescribers.6 They also make it clear that remote prescribing is unlikely to be suitable for injectable cosmetics and recommend face-to-face consultations.”

The next steps In a letter to the GMC, which has been supported with 300 signatures of agreement from fellow healthcare professionals working in aesthetics, aesthetic practitioner Dr Steven Land suggests that the current guidance for doctors, nurses and dentists be updated to reflect those of the GPhC. Dr Land writes, “We feel this is a step that should be mirrored by both the GMC, GDC, and the NMC. It would surely be a fairly simple act and would also show that the GMC has acted quickly and decisively to protect the public in view of the recent news stories.” He continues, “Of interest we also note that the GMC is in the process of updating the Good Medical Practice guidance and if you felt that this change in guidance did require wider consultation then this would seem to be an ideal opportunity to do it. We firmly believe though that this guidance needs issuing now and being acted upon firmly and decisively when necessary to prevent further patient harm and the damage to our collective reputation.” Bennett notes that she is currently in talks with the NMC about updating current guidance, and Dr Curran concludes that BCAM is relying on the professional regulators to take prompt and decisive action to remove the licence to practice, as an independent prescriber, from any person wilfully ignoring their guidance on this matter. REFERENCES 1. Shanti Das, Medics sign off Botox to patients they never see, 2021, <> 2. Guy Lynn, Harley Street Doctor Suspended Over Botox Practices, 2015, <> 3. General Medical Council, Good practice in prescribing and managing medicines and devices, 2021, <https://www.gmc-uk. org/ethical-guidance/ethical-guidance-for-doctors/goodpractice-in-prescribing-and-managing-medicines-and-devices> 4. Nursing Times, NMC issues Botox Injection Advice, 2011, https://> 5. General Pharmaceutical Council, Guidance for pharmacist prescribers, 2019, < default/files/document/in-practice-guidance-for-pharmacistprescribers-february-2020.pdf> 6. General Dental Council, Guidance on Prescribing Medicines, 2013 < guidance-documents/guidance-on-prescribing-medicines. pdf?sfvrsn=2e82e39c_2> 7. Royal Pharmaceutical Society, Prescribing Competency Framework, < prescribers-competency-framework>

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Aesthetics C & Exhibition is

Register now for the UK’s leading clinical confe 11 & 12 March 2022 at the Bus

We are delighted to announce that ACE is back for 2022! After a year that changed life as we know it, the medical aesthetics community will finally reunite for ACE 2022. Centred around a world-class programme delivered by leading medical suppliers, ACE 2022 is the must attend event for non-surgical medical professionals. Expand your knowledge, witness exclusive product launches and widen your clinic offering with the wealth of knowledge, content and experiences on offer. Taking place on March 11 & 12 at the Business Design Centre in London, ACE 2022 is the learning hub for aesthetics. The conference provides clinical sessions, business workshops and masterclasses for aesthetic practitioners, delivered by leading brands, trainers and experts. All content is free and gives attendees CPD points towards their annual accreditation.

Leading brands and exclusive new products With the complications of the last 18 months, the industry’s most respected manufacturers and suppliers can’t wait to reunite with their community and share their latest innovations. The extensive exhibition will play host to 80+ leading brands showcasing the very latest in aesthetics and helping delegates to keep their clinics

“TEOXANE will host educational symposiums in the auditorium space, whereby we will be discussing the fundamentals of assessment, anatomy, technique and product selection with the support of five of our International TEOXANE Faculty” Jordan Sheals, Teoxane UK deputy country manger

and practices up to date. With so many product launches having been delayed, ACE will be the perfect place to discover the latest aesthetic products and technologies for your clinic.

TEOXANE Headline Sponsor Proudly making their debut as our Headline Sponsor at their first event since 2019, we couldn’t be prouder to announce our partnership with TEOXANE for ACE 2022. TEOXANE will take over the Main Auditorium to host two days of free educational content including symposiums in partnership with their international faculty, reinforcing the company’s dedication to providing exceptional world-class clinical education to aesthetic practitioners. Jordan Sheals, deputy country manager, said, “The entire TEOXANE team are excited to return to ACE as Headline Sponsor in 2022 and see practitioners across the UK gather together to further knowledge – after a two-year hiatus, the buzz of this live, educational exhibition cannot be beaten! At ACE, TEOXANE will host educational symposiums in the auditorium space, whereby we will be discussing the fundamentals of assessment, anatomy, technique and product selection with the support of five of our International TEOXANE Faculty.”

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Conference s back for 2022!

erence, bringing the Aesthetics journal to life on siness Design Centre, London

Free, world-class educational content Confirmed takeovers from brands include Allergan, Galderma, Prollenium, HA-Derma and more, with masterclasses and symposiums taking a deep dive into innovative techniques and delivering excellent standards. For TEOXANE’s exclusive two-day content, leading aesthetic practitioners who will be featured, include Dr Lee Walker, Dr Raul Cetto and Dr Kam Lally, aesthetic surgeon Mr Benji Dhillon and consultant aesthetic oculoplastic surgeon Mrs Sabrina Shah-Desai.

NEW! In Practice agenda – success for your clinic

Previously the Business Track – the new In Practice agenda, sponsored and supported by Enhance Insurance, will feature the latest business insights, tips and advice from experts across the field of aesthetic medicine. The key destination for all your business support requirements, this new channel educates via a dedicated conference, as well as through specific exhibitors at ACE and CCR to provide solutions and services. From social media, marketing, and diversifying your patient base, to launching new devices, enhancing your clinic and patient safety, there will be something for everyone to learn and discover.

ACE 2022 is your next medical event Discover the latest medical aesthetic innovations. Learn from leading KOLs and practitioners. Share experiences and learnings with peers and colleagues. Network with your industry and rediscover how amazing it is. Register now for ACE, the must-attend event for every medical aesthetic practitioner. Details of the complete conference agenda for ACE, including clinical session details from conference leaders TEOXANE, Allergan, Galderma and Prollenium will be revealed soon. For any further event information, and to register for free, please scan the QR code below.


Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021



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Emerging Trends in Aesthetics The Aesthetics Clinical Advisory Board members look back on what’s gained popularity in 2021 and trends to look out for next year Reaching the end of a year always brings about a period of reflection, with people looking back over the last 12 months and evaluating what’s been achieved and what’s changed. As a dynamic and fast-paced industry, this is particularly important in aesthetic medicine as it’s a specialty that is constantly evolving every day. Coming out of lockdown at the beginning of the year and seeing the reintroduction of networking, events and training, has meant

Eye treatments A growth in popularity Consultant oculoplastic surgeon and blepharoplasty specialist Miss Elizabeth Hawkes notes that there has been a growth in patients presenting for eye treatments over the last 12 months, which she partly attributes to the COVID-19 pandemic. She comments, “As we all know, mask wearing and video calls have brought far greater attention to the periocular region. In the last year, the number of patients attending my clinic has doubled. This trend appears to be continuing and even increasing month on month. With the ongoing prioritisation of video conferencing, we are looking at ourselves more than ever!” Upper-eyelid surgical blepharoplasty remains the gold standard management for excess upper eyelid skin or fat. Treatment options for the lower eyelid have expanded over the past year, as clinicians are developing new methods given the increase in demand. “Techniques have definitely been refined over the last year,” explains Miss Hawkes, adding, “When I first began cometic eyelid surgery there were several different lower eyelid blepharoplasty surgical techniques described in the literature with no consensus about best practice. However, within the oculoplastic community, we now have general consensus on the importance of repositioning the fat, rather than just removing it. Before


Figure 1: Surgical upper eyelid blepharoplasty before and after six weeks

there has been a bigger influx of new products, techniques and developments than ever before. The industry’s hunger for knowledge shows no signs of slowing down, meaning this will only escalate in the year to come. To celebrate everything the specialty has achieved in 2021, Aesthetics spoke to three aesthetic practitioners and Clinical Advisory Board members to look back on the last 12 months, and to give us their predictions for what 2022 might have in store!

Tightening and supporting the muscles means less skin needs to be removed, resulting in less invasive and safer surgery.” She adds that bespoke non-surgical eye and facial rejuvenation techniques (e.g. botulinum toxin and dermal filler) are also increasing in popularity to delay, but not remove, the need for subsequent blepharoplasty surgery. More surgical practitioners are combining both invasive and non-invasive methods into their practice. Continuing patient education Over the last year, Miss Hawkes has observed a rise in patients discussing their procedures, and being honest about what they’ve had done. She explains, “There is a lot less negativity surrounding aesthetics now, which is refreshing to see. I think social media has played a significant role. For example, one of my patients used her Instagram account to document the post-operative journey after her blepharoplasty. Another has a WhatsApp group with friends dedicated to discussing her procedure and recovery! I believe this openness will continue and become the norm.” What will be big in 2022… Miss Hawkes also believes that energy-based devices will continue to grow in popularity. She has incorporated the Morpheus8 radiofrequency microneedling device into her treatment offering over the last 12 months. “As an example, facelifts are typically associated with long downtime and patients are frequently enquiring for less invasive options to improve skin quality. Energy-based device on the face and neck for tightening and rejuvenation can deliver faster results with less recovery time and risk.” Miss Hawkes explains. Miss Hawkes notes that while she currently doesn’t use ultrasound in her clinic, it’s something she would like to incorporate in 2022. She comments, “Over the last year or so, I’ve seen how helpful it can be for our industry. At the moment I don’t offer non-surgical rhinoplasties to my patients because of how dangerous they can be in terms of causing blindness, but being able to scan the area prior to treatment would mean that I would be able to carry out this procedure in a safer manner and avoid vessels. In addition, I’ve always thought that there was a big place for treating the glabellar in aesthetics, but this is often shied away from because of the risks involved. Again, the use of ultrasound will be useful for ensuring that this can be done with minimal chance of risk.”

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Ultrasound A growing technique Ultrasound has been a buzzword in aesthetics for a few years now, but it has been within the last 12 months that it’s really emerged as a more common part of aesthetic practice. Consultant plastic and reconstructive surgeon Mr Dalvi Humzah notes that a lot of this can be attributed to the devices becoming more accessible. “I remember four years ago myself, Dr Kate Goldie and Dr Simon Ravichandran did a presentation on how useful ultrasound could be, but we demonstrated it with a huge clunky machine that was so difficult to transport anywhere,” he laughs. “While people liked the presentation and acknowledged it was a good idea at the time, everybody noted the impracticality of expecting clinics to get these massive (and expensive) devices.”

The only way for ultrasound to evolve is if more people have knowledge on the subject

Now, ultrasound technology has developed and practitioners can access it as portable, handheld devices. Mr Humzah comments, “This not only helps with accessibility, but it also means that the price is a lot lower. Before, they would cost clinics upwards of £20,000 and now they’re available for a quarter of the price, which is definitely contributing to the rise in ultrasound use.” Current handheld devices on the market include Clarius and VScan, which Mr Humzah has used in his clinic, while others available include Butterfly IQ, Lumify, and Sonoinject. As an early advocate for ultrasound, Mr Humzah believes that it’s a welcome addition to the specialty’s interest in preventing complications. “Scanning your patients prior to injecting means that you can see their anatomy, identify where the large blood vessels are and therefore plan where your injection points are going to be. This helps to minimise the risk of complications, such as causing a vascular occlusion. It can also help to monitor the outcomes of the treatment and help treat complications,” he notes. For more information on the benefits of ultrasound, you can read Introducing Ultrasound to Your Clinic by Dr Kim Booysen on the Aesthetics website.1 The next steps for ultrasound Although there has already been a growth in popularity for ultrasound, Mr Humzah notes that there is still a long way to go. “Most ultrasound devices, although useful, have not been

Figure 2: Ultrasound scan of the neck. There has been a superficial injection of filler immediately under the skin. Deeper to that is the muscle and the blue-red structure is a vein and artery deeper to the injection

developed specifically for the aesthetics specialty. Rather, they have been designed for general healthcare, and we have been able to apply these to aesthetics,” he says. “So, I think the next step for ultrasound use in aesthetic medicine is working with companies to get ultrasound technology that is really tailored to aesthetics, and I’m currently in talks to get the ball rolling. My hope is that in the next 12 months we can expect to see ultrasound technology that is more aesthetics-friendly.” In order for people in the industry to further understand ultrasound, Mr Humzah adds that it’s important for practitioners to attend courses on the topic, something which his training academy will be offering next year, one of several new courses starting to emerge. “The only way for ultrasound to evolve is if more people have knowledge on the subject, and more people are discussing it and using it,” he adds. What will be big in 2022... As well as a continuation in ultrasound development, Mr Humzah believes that over the next 12 months the industry will see a rise in the use of multi-modality treatments. He says, “While we used to just look at things singularly, for example a filler treatment or a toxin treatment, we are now starting to look at how these different procedures can work together to produce optimal results. In particular, I think the use of energy-based devices alongside other procedures will gain momentum.” Mr Humzah also notes that next year will see the launch of some new botulinum toxins to the UK market. He says, “While for years the UK has only had Azzalure (Abobotulinumtoxin), Bocouture (Incobotulinumtoxin) and Botox (Onabotulinumtoxin) available, new toxins to look out for next year include Jeuveau (Parabotulinumtoxin) by Evolus, Hugel Botulax (Letibotulinumtoxin) by Croma-Pharma and Alluzience (Relabotulinumtoxin) by Galderma. The key thing to consider in 2022 when it comes to toxins is the dosage and longevity of the products.”

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021


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Injectables New injectable products enter the market 2021 has seen the launch of several new dermal fillers in the UK, for example Revanesse by Prollenium and Neauvia Organic, explains aesthetic nurse prescriber and chair of the British Association of Cosmetic Nurses, Sharon Bennett. “While I used to only use Restylane, I now also treat with Revanesse in my practice, and it really has delivered some amazing results to my patients,” she says, adding, “The unique selling point for this product is that the particles are spherical, which helps with smoother and more even results.” This year has also seen the relaunch of Sculptra by Galderma, a poly-L-lactic acid filler for rejuvenation. Bennett says, “Previously I used to only use hyaluronic acid fillers, but I’ve started to also incorporate this product into my practice as there’s a lot of knowledge behind it and I’ve seen it produce some great results. As I start to use it more, I’m excited to see the outcomes it will give my patients.” Unfortunately, explains Bennett, this year she has also noticed a rise in white-label products. She says, “Online pharmacies and Facebook sites are full of people putting their own branding on these products, and there is no real information about where they come from or the data/research behind them. For the large majority of these products, you can’t actually find out anything about them, which of course is worrying because there’s no way to know what their safety profile is. As medical professionals we need to steer away from these products, because we always need to be able to back up the choices we make with science and results.” Emerging techniques Bennett notes that she has seen a rise in practitioners using a layering technique when injecting dermal filler. “This refers to more than one formulation being used in a single area,” she says, explaining, “For example, when we are treating the mid-face, we may inject deep along the periosteum to give some projection, and then we’ll overlay with a softer product using a cannula to give a smoother more rounded appearance. Personally, I’ve found this approach delivers the best outcomes, and it’s what I tend to use on a lot of my patients now.” Bennett also notes that she has started to use a threading technique using filler, which has also become more popular in order to help create a lifted appearance in the jawline,

cheeks, and hairline. “This supports the skin and gives it some resistance,” she says. “Sometimes when the skin is a bit loose and lax, you need more than just a volumiser as this can provide the patient with an amazing lift as well as with plumping,” Bennett explains. She adds that the use of both cannulas and needles in aesthetic practice is important and she believes more practitioners should incorporate both into their treatments. She says, “Although it’s less common than it was, I still see people who will only use one or only use the other, but I think if you want to achieve the best results you really have to be well versed in both techniques and be comfortable with either instrument in your hand. I don’t think I could ever achieve the results I want just by using one of the two, especially for facial lifting! In addition, in terms of safety there are a lot of times where it is more appropriate to use a cannula than a needle, for example when treating large surface areas. So, this is something that will hopefully gain more popularity as time goes on.” Changes to device regulation Bennett notes that another big change that occurred this year was the announcement that CE marking would soon cease to be recognised in the UK, as a result of Brexit. She states, “This year marked the start of a transitionary period for medical devices, where the UKCA mark will replace the CE mark. The marking process will have to be carried out by a UK Approved Body instead of (or as well as) an EU Notified Body and will follow our own set of rules and regulations. This will be fully implemented in 2023, and only products approved and tested to UKCA may be placed onto the market in Great Britain.”2 Bennett explains that this may make a difference to how many products are available on the market, and which products you have in your practice that you can continue to use, provided that the new process is more stringent. The UKCA mark will not be recognised on the Northern Ireland market, and a CE mark or CE UKNI mark will be needed.2 What will be big in 2022… Bennett believes that next year will continue to see the development of energy-based devices. She notes, “Think about how radiofrequency is now commonly combined with other technologies like microneedling, and how popular this has become! I think this sort of thing will only develop and get bigger, because it means we can treat more than one concern in just one treatment. This is convenient for both the practitioner and the patient, and can deliver some amazing results.”

How to keep updated in 2022 With the industry constantly evolving, it’s important to stay up-to-date with all the latest developments next year. Joining industry associations such as the British College of Aesthetic Medicine or the British Association of Cosmetic Nurses, can be a great way to learn from your fellow colleagues and discuss the latest developments in the field, as well as for having people to turn to for support. Conferences also play an integral role for being able to network, attend talks on the newest trends, and view the most recent product launches on the market. The Aesthetics Conference and Exhibition (ACE) will take place on March 11 and 12 at the Business Design Centre (see p.20), and CCR will take place on October 13 and 14 at ExCel, so make sure to register your interest now – we can’t wait to see what next year has in store!

REFERENCES 1. Kim Booysen, Utilising Ultrasound in Aesthetics, 2021, < introducing-ultrasound-to-your-clinic> 2. GOV.UK, Medical Devices Conformity Assessment, 2021, <>

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021


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Understanding PRP Efficacy


Dr Priya Shah explores the difficulty in determining the efficacy of platelet-rich plasma as a monotherapy for skin ageing Platelet-rich plasma (PRP) is an emerging skin rejuvenation treatment. Being readily available, cost-effective for both patient and practitioner, and having minimal downtime and side effects, PRP presents an attractive treatment option suitable for all skin types. Media-induced popularity of the ‘vampire facelift’ and PRP for self-healing, as well as clinic advertising campaigns claiming high patient satisfaction, are merely anecdotal in contributing to PRP hype and public misunderstanding of PRP efficacy.1,2

Where PRP fits in with antiageing PRP is a non-ablative treatment preserving epidermal integrity upon administration but it has the capability to elicit epidermal and dermal changes for skin rejuvenation, increasing dermal papillae and releasing growth factors (GF). It stimulates natural collagen with regenerative healing.3 Healthy skin architecture results from a fine balance in the dynamic equilibrium between extracellular matrix (ECM) deposition and matrix metalloproteinases (MMP) degradation.4 Most antiageing treatments target the dermis using injury to stimulate fibroblasts resulting in deposition of collagen, elastin, glycosaminoglycans (GAGs) and also fibrillin at the dermoepidermal junction (DEJ).5 Treatments using microinjury show fine, well-organised fibres with old dense abnormal elastic material moved downward towards the reticular dermis due to neocollagenesis.6 In a study of 24 participants, El-Domyati et al. reported significant objective quantitative increase in collagen types I, III, and VII after multiple microneedling sessions for atrophic acne scars, with a reduction in abnormal elastin level.7 Increased production of GAGs such as hyaluronic acid (HA) and chondroitin-4/6-sulfates has been stimulated in cultured human adult fibroblasts by recombinant human interleukin-6.8 Being just one of many chemokines capable of stimulating paracrine/autocrine ECM deposition by fibroblasts this is an example of the many pathways that could be positively influenced in skin rejuvenation by regenerative PRP treatment. As HA production reduces with age, skin treatments focus on HA delivery through topical means or direct intradermal injections The blood is placed in a centrifuge

Platelet poor plasma Platelet rich plasma Red blood cells

Withdraw blood

Whole blood

Separate the platelets

After centrifugation

Extract platelet rich plasma

Figure 1: The process of extracting and injecting platelet-rich plasma

avoiding the need to cross the epidermal barrier. Currently retinoic acid (RA) is regarded as a gold standard topical skin rejuvenating treatment having been widely researched.9,10 Topical all-trans RA can restore collagens I and VII, restore the fibrillin-rich microfibrillar network of the papillary dermis,11 reduce MMP-1 expression, normalise GAG production and reduce wrinkle appearance.12 Finding a treatment comparable to RA capable of positively targeting and inducing deposition of key structural skin components at multiple cellular and molecular levels which leads to true skin rejuvenation would be desirable of PRP treatment to demonstrate efficacy. With no single treatment offering mechanisms to restore the juvenile condition of skin, this topic remains of high interest to the scientific aesthetic industry. Currently, optimal rejuvenation is achieved using multi-modality treatment to satisfy patient needs, tolerance and goals. Some non-surgical treatments have side effects or fail to yield desired results. PRP has been studied both as a monotherapy for enhancing natural regenerative potential, or in combination with more established treatments such as hyaluronic acid fillers, microneedling and laser resurfacing for adjunctive or synergistic effects through acceleration of wound healing.2

PRP mechanism of action PRP is derived by centrifuging a whole blood portion to remove red blood cells and leave a concentrate of conditioned plasma rich in platelets. This high platelet concentration plays a critical role in wound healing, inducing clotting and initiating repair with increasing experimental and clinical evidence identifying platelets as modulators of inflammation and tissue regeneration.13 Exogenous or endogenous platelet activation induces release of bioactive peptides from their α-granules.13 These include GFs, cytokines and ECM modulators that mediate signalling pathways, stimulating cell regeneration and repair.14 Hence upon reinjection into the skin, PRP can mediate and enhance an individual’s own autologous regenerative potential (Figure 1).15 As illustrated in Figure 2, PRP potentially induces not only ECM remodelling by increased MMP expression to remove photodamaged ECM components and stimulates fibroblast proliferation and collagen synthesis, but also PRP affects blood vessels, adipose-derived stem cells and keratinocytes, thus influencing skin repair and rejuvenation at many levels by deposition of key structural components.15 The plasma component of PRP also contains fibrin, fibronectin and vitronectin which bind cell adhesion molecules which in turn induce cell migration, attachment, proliferation, differentiation and ECM accumulation.16 Inject area with PRP Platelets are used in regenerative medicine for alopecia, dental, oral surgery, orthopaedic and dermatological

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021




applications.17 Before treatment implementation, medical professionals require both evidence of PRP efficacy and understanding of the mechanism of action to justify use for treatment.18 Data for PRP usage in dermatology is dispersed widely throughout the literature. Some studies indicate PRP induces neocollagenesis and deposition of other matrix components by fibroblast stimulation.19-22 Due to lack of standardisation of methodologies, there are a limited number of studies definitively confirming PRP efficacy for induction of fibroblast ECM deposition. Currently dermatological PRP use outpaces the evidence justifying a firm scientific background and this gap needs to be bridged.

approved through the 510(k) clearance process where lower risk devices can be considered equivalent to a previously cleared device in terms of safety and performance and not necessitating supporting clinical data. Patients must be informed of off-licence use. As per my research, in the UK, it was found that no central database exists listing all certified PRP devices. MHRA contracts out approval processes to various Notified Bodies (NBs). Manufacturers apply to a NB once they have the necessary Conformité Européenne (CE) marks for certification and they are then allowed to commercially sell their device.25,26 It can be concluded that PRP devices are poorly regulated in both the US and UK.

The functions of growth factors

Problems with current PRP preparation systems and a call for standardised classification

GFs are bioactive signalling molecules controlling growth, organisation and maintenance of cell activity in an autocrine, paracrine or endocrine manner by affecting cell proliferation, differentiation, apoptosis, morphogenesis, metabolism, wound healing and tissue homeostasis. They bind to specific receptors activating downstream signalling pathways to regulate gene transcription and ultimately stimulate a biological response in keratinocytes, fibroblasts, endothelial cells, adipose-derived stem cells and macrophages (Figure 2). This facilitates skin regeneration through inflammation, collagen and elastin synthesis, distribution and remodelling, tissue granulation and angiogenesis encouraging tissue restoration.16 Table 1 illustrates GF diversity. We now assume there are more than 1,500 GFs and regulatory proteins responsible for PRP action. An exact analysis is yet to be made.23

The regulation surrounding PRP and its use PRP application is not approved by the Food and Drug Administration in the US or by the Medicine and Healthcare products Regulatory Agency in the UK/EU. In the US, PRP separating devices are FDA Chemokines/cytokines

Adhesive proteins


Vitamin D-binding protein Plasminogen PAI TSP Fibrinogen Fibronectin Vitronectin a1-microglobulin

Small molecules Ca2+ ADP Serotonin Epinephrine Histamine



Enhance matrix proteases gene expression and clear tissue debris

In a 2019 systematic review by Maisel-Campbell et al. the authors stated that failure to report PRP concentration was a significant study limitation, with only two out of 24 identified studies detecting an effective supraphysiologic platelet concentration greater than 1,000,000/µL.27 Optimal platelet concentration is indicated to be 2.5 times higher than baseline in order to induce potent fibroblast stimulation to produce endogenous HA and endogenous procollagen type 1.28,29 In 2009, Giusti et al. identified optimal concentration for angiogenesis stimulation as 1.5 million/µL with lower or higher concentrations displaying a lower angiogenic potential.30 Hence, further investigation is required to define ideal platelet concentration. Consideration should be given to interpatient homeostasis variation which cannot be controlled nor fully standardised.31 With individual variation of baseline platelet counts, inconsistencies exist in quantifying measurements with an ongoing discussion regarding variable factors including description terminology, classifications (Table 2), PRP preparation systems (e.g. activators, number, speed and time of centrifugations, temperature, test tube materials), ideal volume,

Increased I and III collagen expression



Endothelial Cells

Endothelial cell proliferation and promotes nagiogenisis

Proteases/antiproteases a-2-macrogiobulin ADAMTSs MMPs

Adipose-derived stem cells

Promoting the proliferation and secretion of adiposederived stem cells


Produces keratin and promotes epidermal repair

Collagen production, improved skin barrier structure, increased facial tissue volume, and decreased bone resorption ultimately promote facial rejuvenation

Figure 2: PRP constituents and their effects in facial rejuvenation. Illustration adapted from Lei, Xu and Cheng, 2019

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021






Proposed function

Platelet derived growth factor


Enhances collagen synthesis, proliferation of bone cells, fibroblast chemotaxis and proliferative activity, macrophage activation

Transforming growth factor ß

TGF- ß

Enhances synthesis of type I collagen, promotes angiogenesis, stimulates chemotaxis of immune cells, inhibits osteoclast formation and bone resorption

Vascular endothelial growth factor


Stimulates angiogenesis, migration and mitosis of endothelial cells, increases permeability of the vessels, stimulates chemotaxis of macrophages and neutrophils

Epithelial growth factor


Stimulates cellular proliferation, differentiation of epithelial cells, promotes cytokine secretion by mesenchymal and epithelial cells

Insulin-like growth factor


Promotes cell growth, differentiation, recruitment in bone, blood vessel, skin and other tissues, stimulates collagen synthesis together with PDGF

Fibroblast growth factor


Promotes proliferation of mesenchymal cells, chondrocytes and osteoblasts, stimulates the growth and differentiation of chondrocytes and osteoblasts

in the Maisel-Campbell et al. systematic review (data studied inception to March 2015), four individual random controlled trials (RCTs), two individual cohort and 13 case series studies were identified.27 Although limited PRP literature for skin rejuvenation exists, meaningful effects and faster healing times with ‘75-100% of patients demonstrating physician-rated global improvement with 67% showing up to 50% improvement’ are claimed.27 Whilst best practice uses RCTs for evidence-based medicine, firm conclusions are not possible due to lack of PRP device standardisation, varying study protocols and inconsistent reporting. This makes quantitative analysis challenging, confusing our understanding of PRP mechanisms and where PRP fits in for comparative or adjunctive use within the non-surgical facial aesthetics arena. A large variation in outcome parameters is noted from studies so far. Clinical parameters are predominantly assessed ranging from patient satisfaction scores, physician scales, feedback questionnaires and pre- and post-treatment photography. Positive findings based on subjective patient satisfaction scores or objective practitioner observations using non-standardised outcomes and varying imaging techniques make data speculative and meta-analysis unrealistic, especially when performed in absence of quantitative evidence such as histological improvement, cytokine or gene assays. Literature analysis using the Motosko et al. literature review and the Maisel-Campbell et al. systematic review, demonstrates

Table 1: Growth factors in PRP and their biological functions24

technique, site, and frequency of administration.3,32-37 Additional cells remaining in PRP post-centrifugation add extra signalling proteins to the mix creating an unquantifiable number of potential outcomes with potential to act in anabolic, catabolic, proinflammatory, anti-inflammatory pathways and also immune response. PRP should contain minimal erythrocytes and leucocytes to limit proinflammatory cytokines producing free radicals and protease release respectively.32-34 Without optimal protocols, lack of standardisation creates differing PRP regenerative potentials making predictable treatment outcomes difficult to achieve. Three PRP classification systems have been proposed (Table 2). The clinical relevance of these classifications is yet to be evaluated.35,36 A 2019 literature review analysing all commercially available PRP separation systems showed vast variation in blood components and GFs, concluding future research should focus on component concentrations as well as optimal platelets, leukocytes, and GF concentrations for different fields of application.38 To date, no ideal classification system exists proving PRP efficacy with certainty for antiageing purposes and there are no comparative head-to-head studies investigating effects of different PRP preparations in skin rejuvenation. Fundamentally, establishing a better understanding of the biological and molecular basis of PRP is needed. Mass spectrometric analysis of PRP could help establish links with outcomes to improve the validity of PRP clinical efficacy.39



4-category: Based on differing leukocyte and fibrin content of the preparation37

1. Pure PRP (P-PRP)/leucocyte-poor PRP or leucocyte-reduced PRP (lrPRP) 2. Leucocyte-rich plasma and PRP (L-PRP): adds to inflammatory cascade especially the neutrophils 3. Pure platelet-rich fibrin (P-PRF) 4. Leucocyte and platelet-rich fibrin (L-PRF)

DEPA34 • Dose of injected platelets • Efficiency of production • Purity of PRP • Activation process was advocated in 2016 utilising biological parameters used in cell therapy to standardise systems with rankings from A-D

1. 2. 3. 4.

FIT PAAW3 • Centrifugation force • Iteration of centrifugation • Centrifugation time • Platelet concentration (baseline of patient’s whole blood and final PRP product) • Anticoagulant use • Use, type and amount of activator • Composition of white blood cells has also been proposed

1. 2. 3. 4.

Dose of injected platelets Efficiency of production Purity of PRP Activation process was advocated in 2016 utilising biological parameters used in cell therapy to standardise systems with rankings from A-D

Centrifugation force Iteration of centrifugation Centrifugation time Platelet concentration (baseline of patient’s whole blood and final PRP product) 5. Anticoagulant use 6. Use, type and amount of activator 7. Composition of white blood cells has also been proposed

Table 2: PRP classification systems3,31,34

Literature critique of current studies investigating PRP monotherapy efficacy Motosko et al. conducted a literature review analysing PRP data published from 2006-2015.2 This included seven studies using PRP alone for facial rejuvenation. They reported improvements in skin appearance to include texture, colour homogeneity, firmness, elasticity, solar elastosis, wrinkles, volume, dermal thickness, nasolabial fold severity, acne scars, erythema, melanin and patient satisfaction. From the 19 PRP monotherapy studies included

that approximately one third of the PRP monotherapy studies utilise objective instrumental analysis. Du and Lei used objective instrumental measures, VISIA Complexion Analysis System and skin computed tomography, linking them to an in vitro human organotypic skin model.40 Disadvantages of this model include that it recreates only part of normal skin organisation and function and is unable to mimic wound healing so cannot be reliably studied.41 The platelet concentration of PRP was confirmed as 1009.91±219.

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021




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x109/L. Collectively, results ‘indicated’ PRP treatment improved skin photoageing through regulation of MMP-1, tyrosinase, fibrillin and tropoelastin expression.43 Cameli et al., used a more robust study design correlating clinical, instrumental and flow cytometry assessment.42 This study confirmed an effective platelet concentration of 1680 x 109/L. However, lacking a control and not confirming histological changes, they left a significant gap in true justification for PRP use. Histological analysis of structural changes within the skin layers and correlation to mechanical and clinical changes would better justify the level of efficacy of PRP. Histological analysis was conducted in five studies (four case series and one individual cohort study), however, none identified mean platelet concentration of whole blood or PRP.4,43-45 Histological changes noted were increases in epidermal and dermal thickness, the number of fibroblasts, dermal collagen bundles, elastic fibre number and thickness and blood vessels however these studies were poorly designed, lacking scientific quantitative validation and relying on histological changes alone or by correlation to patient/ assessor scales complicated by variation in PRP devices and study protocols. Only Diaz-Ley and El-Domyati used blinded evaluators to minimise bias.4,43 A lack of scientific qualitative and quantitative evidence demonstrating histological improvement and without correlation to cytokine/gene assays means true PRP efficacy cannot be assessed due to variation in cellular content of each individuals’ blood.

variabilities amongst the literature. Despite wide acceptance of off-label PRP delivery using a range of diverse treatment strategies with no optimal treatment protocols, high quality clinical research is urgently required within the dermatology community to ensure scientific evidence-based justification and that patients receive evidence-based treatments. A controlled prospective clinical trial establishing a standardised baseline is urgently required as to date, no double-blind RCTs have evaluated clinical, instrumental, and histological findings together using contralateral control groups and with known quantification of platelet yield in both whole blood and PRP. Only by comparing studies with standardised research protocols and justified sample sizes taking patient diversity into account and incorporating objective assessment, can we determine the real efficacy of PRP and remove any controversy surrounding use of PRP with justified clinical evidence. Dr Priya Shah graduated dentistry in 2002 from King’s College London and has undertaken an MSc in Skin Ageing and Aesthetic Medicine. She is the founder of Dr Priya Shah Facial Aesthetics, London and a trainer with Botulinum Toxin Club (BTC). She focuses on delivering natural enhancements alongside educating patients on improving skin health. Qual: BDS, MSc in Skin Ageing and Aesthetic Medicine(Dist)

Other study limitations include: • Varying age range of study populations and uneven gender proportions.47,48 • Unjustified and imprecise sample size estimates.42,47,49 • Lack of industry regulation causing studies to be influenced by commercial interest with funding provided by manufacturers of centrifuges/blood preparation kits. The majority of studies do not justify reasons for device selection, and it is impossible to verify whether all these PRP types will achieve the same therapeutic effect and hence, evaluation is not standardised. • Varying volumes of blood drawn and processed (3.6ml-50ml) and differing PRP volume yields (0.2ml-7ml).50,51 • Variations in centrifugation systems: force, timing, single-spin, double-spin, anticoagulation and exogenous activation.46,48 • Varying platelet concentrations between patients: 524x109/L to 1680x 109/L.42,52,21 • Variance in the accepted number of treatments for efficacy (range is one to six).48,53 • Differing standardised intervals between treatments (two to four weeks).53,54 • Lack of a control making objective analysis difficult4,42,47 and variations in presence of blinding (no blinding, single-blinded, double-blinded).49,53,54 • Variance in PRP application techniques and sites of application across all studies: (topical application vs. intradermal injections).4,45,55,46 • Varying follow-up assessment periods (two to 52 weeks).4,49


Test your knowledge!

Complete the multiple-choice questions below and go online to receive your CPD certificate! Questions 1.

PRP skin rejuvenation treatment is also commonly known as a…

2. PRP studies to date…

Possible answers a. b. c. d.

Vampire facelift Red cell treatment Regenerative facial Kardashian treatment

a. Always show gross volumetric facial changes b. Use standardised treatment protocols c. Show epidermal and dermal changes for skin rejuvenation with increasing dermal papillae

d. Show increased skin wrinkling 3. PRP treatment protocols…

a. b. c. d.

Can be used on all skin types Can be used on oily skin Are always optimal Are performed at night only

4. An effective supraphysiologic platelet concentration is classed as...

a. b. c. d.

Below 1,500/µL Greater than 1,000,000/µL Between 10,000 – 20,000/µL Greater than 5,000,000/µL

a. Are always standardised using similar preparation and treatment protocols

5. PRP devices...

b. Are well regulated in the US and USA c. Always lead to improved clinical, instrumental and historiological changes

d. Are not well regulated and there are many study variables making data comparison difficult

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


The future of PRP Despite appearing promising there is a paucity of critical scientific evidence justifying PRP monotherapy use in skin rejuvenation. As discussed, there are a great number of study limitations and

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021






M-MA-UKI-1679 Date of Preparation November 2021






Advertorial Merz Aesthetics

Keep it Keep it Simple simple. Keeping lip treatments simple for those patients who prefer a natural look Keeping lip treatments simple for those patients who prefer a natural look.

The trend for ‘Russian Lips’ has risen in popularity through reality stars and social media influencers on platforms such as Recent years have seen a trend Instagram TikTok and TV shows like for larger,and more pronounced lips, Love Island. among millennials and particularly Z. The for “Russian Ingeneration a recent webinar, Drtrend Dan Shaffer led risen in popularity aLips” roundhas table discussion with Ronthrough Myers reality stars and Emma socialDavies media(Save (Consulting Room), influencers on platforms such Franks as Face) and Dr Brian Franks (Dr Brian Instagram andentitled Tik Tok and TVSimple’. shows Training School) ‘Lips Kept like Love Island. They explored the trend for larger lips discussing safety, personal preference, In apatient recentsatisfaction webinar,and Dr Dan Shaffer and whether or not led a round table discussion with a this trend has given more mature women Ron Myers (Consulting Rooms), skewed perception that lip fillers are always Emma Davies (Save Face) and Dr unnatural. The panel suggested there were Brian Franks (Dr Brian Franks Training two distinct patient groups – those who want School) entitled “Lips Kept Simple”. to fit in with the Instagram crowd and those They explored the trend for larger who simply want to restore and maintain lips discussing safety, personal their natural lip shape. However, while the preference, and patient satisfaction panellists were championing the natural look, and whether or not this trend has they were keenmature to stresswomen that, it came down given more a skewed toperception individual choice and preference and that lip fillers are always that well tolerated treatment always remains unnatural. the central priority. Another interesting topic discussed was how and when towere confidently The panel suggested there two say no to a patient’s desired treatment, if distinct patient groups – those who this was deemed as unsafe or aesthetically want to fit in with the Instagram crowd impossible of the and thosepostwhoassessment simply want to patient. restore “It’s allmaintain about the their biological variability of the and natural lip shape. individual. different, and all However,Everybody while theispanellists were treatments shouldthe benatural tailor-made to they each championing look, were keen to stress that, it came down patient.” Dr Franks stated.

to individual choice and preference and that well tolerated treatment always remains the central priority.

The lips kept simple concept The concept of lips kept simple is to reshape and enhance the lips look in a different, andthe allway treatments should beautiful and natural way. patient”, be tailor-made to each Dr Franks Franks came up with the idea in response Dr stated. to concerns being raised by women he was The lips kept simple concept speaking to while recruiting training models The concept simple is to for his courses.of Helips waskept looking for female reshape andbetween enhance thefound models aged 35the andway 60 and lips look in a beautiful and 'unnatural natural lips'. nearly all patients did not want way. He said, “It’s the practitioner’s duty of care to educate the public that there are many Dr Franks came up with the idea who highly skilled practitioners out there in response to concerns being can deliver natural looking lips and natural raised women safely. he wasThey speaking lookingby treatments don’t have to while recruiting training models to be over-done. You can make lips look for his courses. He was looking younger, not just bigger.” for female models aged between Dr Franks added, “We found there were 35 and 60 and found nearly all many people not having their lips done patients specifying they did not want because they thought there was only that “unnatural lips”. alternative. The message needs to be there aresaid, alternatives. one of thoseduty is that He “It’s theAnd practitioner’s of you can have less as well as more.” care to educate the public that there

are many highly skilled practitioners Reframing the way we talk about out there who can deliver natural lip treatments looking lips and natural looking Emma Davies highlighted don’t that many treatments safely. They haveof her patients prefer the idea of restoring to be over-done. You can make lips the lips to a natural youthful appearance. look younger, not just bigger. The consensus was that we should be

talking less there about were just filling lipspeople and “We found many more abouttheir the shape and contour as not having lips done because they thought there waswrongly only that the term ‘lip filler’ could imply alternative. The message needs to be there are alternatives. And one of those is that you can have less as well as more.”

The concept of lips kept simple is to Another interesting topic discussed was how and when to confidently say Reframing way wethe talk about reshape and enhance thetheway lips no to a patient’s desired treatment, lip treatments if this was deemed as unsafe or Emma Davies highlighted that many look in a beautiful and natural way aesthetically impossible postof her patients prefer the idea of assessment of the patient.

“It’s all about the biological variability of the individual. Everybody is

restoring the lips to a natural youthful appearance. The consensus was that we should be talking less about just filling lips and more about the Aesthetics | December 2021

that enhancement always equals more volume and this could be preventing someand patients fromas wanting to explore the shape contour the term benefit lip treatments “lip filler”ofcould wrongly further. imply that

enhancement always equals more volume andagreed this could The panel that be the preventing way forward some wanting to was patients an artisticfrom and holistic approach from explore the benefit of lip and treatments healthcare professionals to educate further. the public about what they’re buying, why they’re buying it, and who they’re buying

The panel agreed thattowards the way it from, moving them going to forward was anpractitioners artistic andwho can look at experienced holistic approach from healthcare them from an anatomical perspective. “It’s professionals and to educate the that beautiful enhancement that everyone public about what they’re buying, really wants and what every practitioner why they’re buying it, and who wants to provide,” said Ron Myers. they’re buying it from, moving them towards going to experienced Medical aesthetic training practitioners who can look at them Dr Franks has been providing non-surgical from an anatomical perspective.

medical aesthetic training courses since 2010 and has co-produced an MSc in “It’s that beautiful enhancement that Specialistreally Practice of Clinical Aesthetics everyone wants and what every Non-Surgical Intervention, University practitioner wants to provide”, said of Bolton Ron Myers.of which he is currently the Programme Clinical Director. Having been a medico-legal expertTraining witness for more than Medical Aesthetic 20 years, Brian’s central focus is to ensure Dr Brian Franks has been providing students are trained to consider non-surgical medical aesthetic safety and risk management from 2010 the outset any training courses since and of has consultation or co-produced antreatment. MSc in Specialist

Practice of Clinical Aesthetics NonSurgical Intervention, University of Bolton of which he is currently the advertorial is sponsored by ProgrammeThis Clinical Director. Merz Aesthetics UK & Ireland

Having been a Medico-Legal Expert Witness for over 20 years, Brian’s central focus is to ensure students are trained to consider safety and risk management from the outset of any M-MA-UKI-1745 consultation Dateor of treatment. Preparation October 2021




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

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

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


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


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

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at Reporting forms and information for Republic of Ireland can be found at Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to or on +44 (0) 333 200 4143.

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




Case Study: Treating M-Shaped Lips Dr Sarah Hart presents a case study of a challenging lip that uses simple assessment and treatment techniques Even though lips are a commonly treated area, many injectors find them to be technically demanding. This challenging case study of an M-shaped, inverted, retruded lip with a long philtrum and perioral volume loss demonstrates how simple assessment and treatment techniques can be perfectly adequate for complex cases. I find assessment at animation (kiss and smile) to be especially useful.

Patient presentation A 44-year-old Caucasian female requested augmentation of her lips. She had always felt they were small and had noticed their size decreasing further in recent years. She requested a natural result where no one would suspect she’d had filler. Previously, she had undergone botulinum toxin treatment to her upper facial lines, but she had never had filler before. Her budget was limited to 2ml of dermal filler per treatment.

Assessment of the lips The patient’s lips appeared small and inverted, her medical tubercle protuberant, and her lateral tubercles undersized, giving an M-lip shape appearance. Her upper lip was smaller than ideal compared to the lower lip and there was a prominent Before




Figure 1: Patient before and after treatment with 4ml of Juvéderm Ultra over two sessions, spaced six months apart

Figure 2: The medial section of the vermilion border before and after treatment with 4ml of Juvéderm Ultra

medial section of the vermilion border, which jutted out over the lower lip giving a slightly beaky appearance on oblique view (Figure 1). Profile view revealed that both lips were retruded – the lower more so than the upper. I find assessment on animation very useful as it reveals underlying deficiencies that are not visible at rest, allowing them to be addressed with filler for best results. The patient’s smile revealed a narrow dental arch with crowded teeth angling posteriorly, showing there was a lack of bony support and therefore filler should be placed at periosteal level beside the piriform aperture. The kiss position (Figure 3) revealed lip lines and creasing at the oral commissures, indicating a need for filler to support these areas. More useful information was revealed at kiss on profile view, with multiple creases showing a marked lack of soft tissue support at the chin and a flattened, lengthened philtrum. The assessment revealed multiple needs. The patient’s M-shaped lips needed to be everted without augmenting the medial tubercle or the upper vermilion border, as it could jut out and look unnatural. The lower lip needed to be brought forwards more than the upper lip. The surrounding volume loss also needed addressing. Doing all these things with the patient’s budget restriction of 2ml of filler posed a challenge. If I treated only the surrounding areas, she would be disappointed with the lack of lip augmentation, but if I put all the filler in her lips, it would look unnatural. I needed to share the 2ml between lips and the surrounding areas. However, 2ml wasn’t enough for full correction. As a solution, I suggested two treatments of 2ml of Juvéderm Ultra spaced six months apart to build the result. The patient agreed to this plan which fitted her budget and wish for a discreet treatment.



Figure 3: Lips in the ‘kiss’ position before and after treatment with 4ml of Juvéderm Ultra

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021






Zealand disrupted an in-person follow up so a phone appointment was arranged. The patient indicted she would like to continue treatment to maintain her result.

Case study results

Figure 4: The distribution of 4ml of Juvéderm Ultra over six months in the lips

Figure 5: Lips before and after eversion of the upper lip with 4ml of Juvéderm Ultra

The treatment

compared to the vermilion border, and the lignocaine from the horizontal threads also offers some anaesthesia to the entry point. To evert and project the lower lip, I placed two boluses at mid-depth with a constantly moving needle on either side of the midline, lined up with the GK (Glogau-Klein) points of the upper lip.1 Overlying this I placed superficial submucosal linear threads to add extra eversion. It is theorised that keeping the needle constantly moving minimises the chance of depositing a large volume of filler into an artery.1,2 I treated volume loss at the marionettes and mental crease using multiple mini boluses, as shown in Figure 4. I find this a very useful technique that is ideal for beginners, as the result can be built little by little. I decanted the filler into a 0.3ml Becton Dickinson syringe with a 31 gauge 8mm needle. This is the ideal length for reaching the subcutaneous fat layer3 and the small needle size minimises pain and bruising. It should be noted that decanting filler in this way is off-label. To determine exactly where to place the small boluses, I asked the patient to purse her lips periodically during treatment, pinching with my fingers to help me find the areas requiring support. It was a simple task to gradually fill the creases, injecting the filler in multiple mini boluses. I used micromovements of the needle tip as it is theorised this can minimise the chance of depositing a significant volume of filler intravascularly.2 In my experience, this technique works best with fillers that lift with their cohesivity rather than hardness, such as Juvéderm Ultra or Belotero Balance.

Firstly, I applied numbing cream to her lips. Next, I placed 0.25ml of Juvéderm Ultra per side, both deep on periosteum and subcutaneously, near the piriform aperture. I chose a 25 gauge 38mm cannula to allow me to distribute filler in both planes using one entry point. This reduced the nasolabial fold and provided a foundation to help evert the lips. The lignocaine in the filler also supplied anaesthesia to the nerve fibres travelling to the sensitive upper lip. To evert her M-shaped lip, I did not place any filler at the prominent medial tubercle. I augmented the lateral tubercles only, using first horizontal threads and then vertical threads in a crosshatched pattern, placed very superficially in the submucosal plane. I believe each tiny linear thread acts like a prop to evert the lip. I did not inject directly into the vermilion border. I prefer to enhance the vermilion border by injecting the red vermilion just below the border, massaging the filler upwards to create a crisp edge. In my experience, this reduces the possibility of a wide, bulky border that can occur with direct injection into the vermilion border, especially when treatments are repeated a few times a year. My entry point for the vertical threads in the upper lip differs from other injectors. I enter from the wet dry border and move the needle upwards towards the vermilion border before placing a retrograde thread of filler. To my mind this has several advantages; I find it easier to stay in the correct submucosal plane, avoiding the deeper plane where the superior labial artery typically lies. I prefer not to inject through the vermilion border as it may encourage injectors to deposit a significant amount in the border which can spread over time, giving the border an unnaturally bulky appearance. I also find patients tolerate it better as numbing cream is absorbed more effectively by the lip tissue

Post treatment The patient was provided with written postcare advice which included education about the symptoms of vascular occlusion. Happily, she experienced no side effects and was delighted with treatment. Unfortunately, the unexpected COVID-19 lockdown in New

I treated this case using simple techniques: injecting filler superficially into the lips to evert them and observing where creases appeared in the chin and oral commissures on kiss animation, filling those creases directly with small boluses of filler. Just these two techniques were able to improve a variety of issues. Placing filler in the lips everted them, increased their size and projected them anteriorly. The eversion of the upper lip also improved the philtrum, changing it from a flat, long shape to a concave curve (Figure 5). This can be seen best at kiss on profile view. The philtrum lengthens and flattens with ageing and restoring the youthful concave curve has a powerful effect on the appearance of the entire perioral area. To me, it was one of the most satisfying effects of treatment.4,5 Treating the mental crease and oral commissures with multiple small subcutaneous boluses appears to have helped project the lower lip into a better position relative to the top lip. It may also have reduced the muscular action of orbicularis oris and mentalis muscles, further improving the appearance of the area. I believe complex cases such as this one can be well managed with careful assessment, especially on animation, and simple techniques. Dr Sarah Hart graduated from Otago University, New Zealand in 1994. After initial training in psychiatry, she started practicing in cosmetic medicine in 2002. She has been an Allergan Advisory Board member since 2007 and is censor and senior Education Faculty member for the New Zealand Society of Cosmetic Medicine. Qual: MBChB, NZSCM REFERENCES 1. Sito, G., Consolini, L., & Trévidic, P., Proposed Guide to Lip Treatment in Caucasian Women Using Objective and Measurable Parameters, Aesthetic Surgery Journal, 2019 2. Greg J. Goodman, Mark R. Magnusson, Peter Callan, Stefania Roberts, Sarah Hart et al. Aspiration Before Tissue Filler—An Exercise in Futility and Unsafe Practice, Aesthetic Surgery Journal, 2021 3. Kim YS, Lee KW, Kim JS, et al. Regional thickness of facial skin and superficial fat: Application to the minimally-invasive procedures. Clin Anat. 2019, 32(8) 4. Lisa Ramaut, Patrick Tonnard, et al. Aging of the Upper Lip: Part I: A Retrospective Analysis of Metric Changes in Soft Tissue on Magnetic Resonance Imaging, Plast. Reconstr. Surg 2019 143: 440 5. Patrick L. Tonnard, Alexis M. Verpaele et al. Aging of the Upper Lip: Part II. Evidence-Based Rejuvenation of the Upper Lip—A Review of 500 Consecutive Cases Plast. Reconstr. Surg, 2019

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021



Exploring the Physiology of Black Skin Dr Yalda Jamali and Dr Shahd Twijiri detail the differences between Caucasian and black skin Colour may be the most immediate and noticeable difference between black and Caucasian skin. However, there are other differences that have significant clinical dermatological implications that clinicians must recognise to properly and appropriately treat black skin tones. Although previously identified differences included thicker skin and glandular activity, it is important to note that much of the literature around black skin physiology used pseudoscientific data to justify some of the political doctrines during that era. In this article, we highlight some of the key structural differences in black skin to help further the education of aesthetic practitioners.

Stratum corneum thickness The stratum corneum, the uppermost layer of the epidermis, can be best described using the brick-and-mortar analogy. It consists of corneocytes (brick) interspersed with intercellular lipid bilayers (mortar). The function of the stratum corneum is to protect


from external injury, UV radiation and microorganisms. The stratum corneum also has biological functions, as research has shown that this layer prevents transepidermal water loss (TEWL).1 The stratum corneum is approximately 10UM in thickness.2 Contrary to popular belief, black skin does not have a thicker stratum corneum than Caucasian skin. A 1955 study comparing 29 black and 22 Caucasian individuals did not show a significant difference in the mean thickness of the stratum corneum.3 However, a 1974 study by Weigand et al. using tape strippings to remove the stratum corneum on 46 participants showed that more strippings were required to remove the top layer in black skin compared to Caucasian skin. Thus concluding that black skin has more layers which are more compact and dense with potential stronger intercellular cohesion.4,5 This was further substantiated by Reed et al. who demonstrated that darker skin types had a more resistant barrier after tape strippings compared to individuals with lighter skin.6

Ceramide levels and transepidermal water loss

The intercellular lipids between the corneocytes are 15% fatty acids, 25% cholesterol and 50% sphingolipids (ceramides).7 Sugino et al. compared the ceramide levels in Asian, Hispanic, Caucasian and black skin.8 The ceramide levels in black skin were found to be 50% lower than in Caucasian or Hispanic skin. Another study confirmed these findings in 2010, showcasing that black skin has the lowest level of ceramides.9 The general consensus is that black skin has a stronger barrier despite the lower ceramide levels, owing to the stratum corneum structure, which has greater intracellular cohesion.10 TEWL is the amount of water lost through the epidermis passively. Findings by Sugino et al. on ceramide content indicated that black skin has the highest TEWL and the opposite for east Asians.8 However, there have also been some studies to show contradicting racial differences, or no differences at all.11 When analysing these studies, the number of subjects was small, and further research in this field is needed.12

Skin pH

Figure 1: The epidermal layers of the skin

The stratum corneum is known to have an acidic pH essential for maintaining homeostasis and optimal lipid barrier. The acidic pH is the perfect environment for the resident skin micro-flora and protects against the unwanted growth of S. aureus bacteria that is the leading cause of skin and soft tissue infections.13,14 Many studies have determined whether there may be a contrast in skin surface pH between Caucasian and black skin. Some studies have found black skin to have a lower pH than Caucasian skin; however, the aetiology of this is to be further explored.15,16 During the skin-stripping process within one study of 18 participants, black skin was shown to have a higher TEWL after three strippings compared to Caucasian skin which also subsequently resulted in lower pH in the stratum corneum.17

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021




to Caucasian skin. This results in more fibres, including collagen and glycoproteins. Additionally, the collagenous fibres are smaller and more densely packed. They run nearly parallel to the epidermis with small proteoglycans between the fibres.27

When it comes to protection against UVA and UVB rays, black skin is twice as more effective

Pigmentation Melanocytes are a component of the basement membrane in the epidermis. The number of melanocytes in Caucasian and black skin is found to be equal.18,19 The differences lie in the activity of the melanocytes, size of melanosomes and the melanin produced.20 Furthermore, melanosomes in Caucasian skin often form clusters and do not reach the stratum corneum.21 Black skin has more active melanocytes producing more eumelanin, which give rise to brown and black pigment, whilst Caucasian skin produces more pheomelanin, producing red and yellow pigment. Furthermore, the melanosomes are more extensive and are individually dispersed, reaching the stratum corneum.15,18,22

UV protection Black skin contains more eumelanin, which has greater photoprotective properties than pheomelanin. When it comes to protection against UVA and UVB rays, black skin is twice as more effective.23 In addition to this, melanosomes in black skin remain intact in the epidermal layer and not easily degraded by lysosomal enzymes, which contribute to the photoprotection.22 Despite the natural photoprotection, it is important to emphasise that black skin is still susceptible to skin cancer including: squamous cell carcinoma, basal cell carcinoma and melanomas.23 It is therefore, imperative that practitioners continue to educate patients on the importance of regular sun protection to prevent cancer and photoageing signs.

Vitamin D synthesis Melanin absorbs UVB and, in essence competes with 7-dehydrocholesterol. Ultraviolet- mediated (UVR) synthesis of vitamin D in individuals with black skin requires a UVR dose that is six times greater than white skin.24 However, there have been some concerns about vitamin D in relation to bone health and density amongst darker skin types. Existing data shows that although vitamin D deficiency is more likely to exist in black skin individuals, it doesn’t necessarily lead to compromised bone health.25 As the effect of melanin on vitamin D synthesis is still not accurately understood, the current recommendations for black skin is to use SPF 30 and consider the use of supplements.26

Glands There are many documented studies on the difference in the glands (eccrine, apocrine, mixed and sebaceous) between different races (28–34) African Americans, African Caribbeans, Chinese and Japanese, Native American Navajo Indians, and certain groups of fair-skinned persons (for example, Indians, Pakistanis, Arabs). However, many of these studies can be criticised for having small sample sizes. Reviewing the literature shows that there are no differences in the number of eccrine glands. However, in one study by McCance et al. suggested that Caucasian skin has a higher sweating rate compared to black skin. Furthermore, black skin seems to resorb less sodium chloride, so there may be a lower sodium concentration in sweat. There were no other compositional differences found.12,28,35 The mixed glands are known to have a secretory rate 10 times more than an eccrine gland. Most studies on the racial difference in these types of glands had a small population size, so definitive conclusions cannot be made. One study has shown that black skin has an increased number of mixed glands despite significant individual variability in these glands.27

Understanding the difference Physiological differences do exist. However, there appears to be a lack of research in some aspects, and a definitive answer still awaits. With the contradictory, outdated evidence and small sample sizes, further research needs to be conducted before firm conclusions can be made. Understanding the unique physiological variables between different skin colours will improve our patient care and service provision as medical aesthetic practitioners. Dr Yalda Jamali is a UK-trained medical and cosmetic doctor. She holds a Level 7 postgraduate qualification in Aesthetic Medicine and is currently completing a Master’s in Clinical Dermatology. She is an experienced aesthetics trainer and is the owner of Dr Yalda Clinics in the UK. She has recently relocated to Sydney to continue her practice. Qual: MBChB, PGDip, PGCert Dr Shahd Twijiri is a UK-trained qualified dental surgeon, holds a Master’s qualification in Medical Visualisation and Human Anatomy from the University of Glasgow and a postgraduate qualification in Aesthetic Medicine. She works as a cosmetic doctor in London and Bicester and is passionate about teaching and training. She is the lead trainer for Aesthetic Intelligence, a training academy focused on advanced aesthetics. Qual: BDS, PGCert, MSc


Fibroblasts One study by Montagna and Carlisle examined the dermis in 38 participants (19 black and 19 Caucasian). Researchers reported black skin has numerous, multinucleated and larger fibroblasts compared

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021

Advertorial Merz Aesthetics




Large Volume Treatment Plans Using the Merz Portfolio Dr Euan Mackinnon explores if we can achieve surgical outcomes using a non-surgical approach Advances in dermal filler properties and handling means we can achieve pleasing results for many of our patients with relatively small volumes of product. However, sometimes small volumes simply will not be able to produce the desired results that patient and practitioner may be wishing to achieve. In these cases, a frank and honest consultation with patients is required to avoid disappointment. I have long been fascinated by large volume treatment plans and in essence trying to effect surgical results for my patients using non-surgical modalities. In this case I will discuss my approach to a pan-facial treatment of a 30-year-old male using the Merz portfolio of dermal fillers. These fillers are my perfect armamentarium for pan-facial treatments. There truly is a product for every purpose that I require for my diverse range of patients. Naturally, when I inject higher volumes of products, I assume a higher level of risk both intra-operatively and post-procedurally. Therefore, it is imperative that I feel confident in the safety profile of my chosen injectables. I choose BELOTERO® as it has demonstrated a lower risk of inflammation compared to some other leading HA fillers whilst delivering exceptional results.4 Due to its ‘Cohesive Poly-densified Matrix (CPM)®’ technology, it offers the most homogeneous biointegration compared to other HA fillers and it really is a joy for me to

inject due to its flowing qualities.4 The range allows for exceptional threedimensional tissue expansion whilst maintaining natural facial appearances both at rest and on animation.

Patient concerns Primary Concern: Retrognathic (retruded) mandible. Secondary Concerns: Tired appearance when not feeling tired. Flattening of the midface. Does not want to look overdone.

Treatment desires To have a stronger chin and jawline. To look more rested. To look more attractive.

Objective Upper Third – Temple hollowing. No static upper face lines. Middle Third – Deplete medial cheek fat pads with early evidence of malar split. Limited anterior cheek projection in profile. Limited zygomatic arch projection. Mild tear trough deformity. Lower Third – Class 2 skeletal base. Retrognathic (retruded) mandible and overjet of upper incisors. Poor definition of mandibular body and angle. Long philtrum, narrow horizontal dimension of upper lip and scope to balance vertical proportions of both lips.

The exceptional integration of the Merz products into the tissues enables the patient to express and emote in a completely natural manner


Aesthetics | December 2021

Surgical options This patient certainly could be treated with surgery in a combined maxillofacial and orthodontic approach to correct his skeletal discrepancies. This may include a Le Fort 1 maxillary osteotomy, bilateral sagittal split mandibular osteotomy +/sliding genioplasty. Facial fat transfer or customised implants may also be considered. However, this would come at the price of extensive orthodontic treatment, surgical risks, and prolonged recovery time. In this case we decided to use dermal fillers to mimic the effects of surgery. 16.5ml of dermal filler was injected during one treatment session. Post-procedural pictures were taken at two weeks.

Treatment Scan the QR code to watch me perform this pan-facial treatment Temples: 2ml total. 1ml of BELOTERO® Volume1 per side using a supra-periosteal technique over two injection sites. Care is taken to identify the superficial temporal artery prior to injection. Cheeks: 2ml total. BELOTERO® Volume.1 Cannula entry point at the zygomatic prominence. Product fanned sub-SMAS into the deep cheek fat compartments indirectly providing support to the SOOF. Cannula flipped posteriorly through the same insertion point along the inferior aspect of the zygomatic arch to produce a masculine cheekbone vector. N.B. for female patients, follow the superior aspect of the arch towards the temple. Chin: 4ml total. BELOTERO® Volume.1 Dualplane technique. First, bone is simulated with supra-periosteal bolus placement to achieve better anterior projection and width. Secondly, a cannula is used subdermally to further enhance the anterior projection. Jawline: 7.5ml total of RADIESSE®.2 I use two cannula entry points for a full jawline augmentation allowing me to reach from the chin to the mandibular ramus. The

ethe liplip border. border. The The tubercles tubercles were were Advertorial en enhanced enhanced based based on on clinical clinical Lips:Lips: 1mlAesthetics 1ml BELOTERO® BELOTERO® vector. vector. N.B. N.B. for female for patients, patients, @aestheticsgroup @aestheticsjournaluk Merz Aesthetics Lips: 1ml total. BELOTERO® vector. N.B. for female female patients, Balance Balance Sub-vermillion Sub-vermillion placement placement follow follow the superior the superior aspect aspect of the of the Balance Sub-vermillion placement follow the superior aspect of the perience rience with with superficial superficial injection injection of product of is myis my for men for archarch towards towards the temple. the of product product ispreference my preference preference for men men arch towards the temple. temple. Lips: 1ml total. BELOTERO® vector. N.B. for female patients, to allow to allow for enhanced for enhanced definition definition Chin: Chin: 4ml 4ml total. total. BELOTERO® BELOTERO® elotero®, Belotero®, no no Tyndall Tyndall effect effect has tohas allow for enhanced definition Chin: 4ml total. BELOTERO® Balance Sub-vermillion placement follow the superior aspect of the without without creating creating an unnatural an ledge ledge Volume Volume . Dual-plane .. Dual-plane technique. technique. without creating an unnatural unnatural ledge Volume Dual-plane technique. 4 4 of product is my preference for men arch towards the temple. een nt observed. observed. at the at lip the border. lip border. The The tubercles tubercles were were First,First, bone bone is simulated is simulated with with suprasupraat the lip border. The tubercles were First, bone is simulated with suprato allow for enhanced definition Chin: 4ml total. 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RADIESSE® 3.3.IFU BELOTERO® Balance Ref 4. Micheels, P.,al. etP., “Superficial dermaldermal injection of hyaluronic acid soft tissue fillers: comparative ultrasound References: References: 1. BELOTERO® 1. BELOTERO® Volume Volume 2. RADIESSE® 2. RADIESSE® 3. IFU BELOTERO® IFU BELOTERO® Balance Balance Ref 4. Micheels, Ref 4. Micheels, P., et (2012). al. (2012). „Superficial „Superficial dermal injection injection of hyaluronic of hyaluronic acid soft acid tissue soft fillers: tissue comparative fillers: comparative 16.5ml dermal filler was injected surgical modalities. RADIESSE®2 and patients should References: 1. BELOTERO® Volume 2.Reporting RADIESSE® 3. IFU BELOTERO® Balance Ref 4. Micheels, P.,found et al. at (2012). „Superficial dermal injection of hyaluronic acid soft tissue fillers: comparative Adverse events should be reported. forms and information for United Kingdom can be Reporting forms and information for Republic of Ireland can be study.“ Dermatol Surg 38(7 Pt 2): 1162-1169. ultrasound ultrasound study.“ study.“ Dermatol Dermatol Surg 38(7 Surg Pt 38(7 2): 1162-1169. Pt during one treatment session. PostTreatment desires: In this case I will discuss my be reassured and counselled on ultrasound study.“ Dermatol Surg 38(7 Pt 2): 2): 1162-1169. 1162-1169. found at Adverse events should also be reported to Merz Pharma UK Ltd by email to or on +44 (0) 333 200 4143. procedural pictures were taken at 2 To have a stronger chin and jawline. approach to a pan-facial treatment this pre-procedurally. This produc weeks. of a 30-year-old male using the Merz To look more rested. To look more is not hyaluronic acid based and attractive. portfolio of dermal fillers. These should only be used by experienc References: 1. BELOTERO® Volume 2. RADIESSE® 3. IFU BELOTERO® Balance Ref 4. Micheels, P., et al. (2012). „Superficial dermal injection of hyaluronic acid soft tissue fillers: comparative Treatment fillers are my perfect armamentarium injectors. ultrasound study.“ Dermatol Surg 38(7 Pt 2): 1162-1169. M-BEL-UKI-1282 M-BEL-UKI-1282 Date of Date Preparation of Otcober Otcober 2021 M-BEL-UKI-1296 Date of Preparation October 2021 2021 Scan the QR code to watch M-BEL-UKI-1282 me Objective Facial Assessment for pan-facial treatments. There Date of Preparation Preparation Otcober 2021 perform this pan-facial treatment Upper Third – Temple hollowing. truly is a product for every purpose Temples: 2ml total. 1ml of No static upper face lines. that I require for my diverse BELOTERO® Volume1 per side Middle Third – Deplete medial range of patients. Naturally, cheek fat pads with early evidence when I inject higher volumes of using a supra-periosteal technique M-BEL-UKI-1282 Date of Preparation Otcober 2021 TO REGISTER SCAN THE QR CODE of malar split. Limited anterior products, I assume a higher level over two injection sites. Care is cheek projection in profile. Limited of risk both intra-operatively and taken to identify the superficial zygomatic arch projection. Mild tear post-procedurally. Therefore, it temporal artery prior to injection. trough deformity. is imperative that I feel confident Cheeks: 2ml total. BELOTERO® Adverse events should be reported. Reporting forms and found at Lower Third – Class 2 skeletal base. in the safety profile of my chosen Volume1. Cannula entry point at the Retrognathic (retruded) mandible injectables. I choose BELOTERO® zygomatic prominence. Product References: 1. BELOTERO® Volume 2. RADIESSE® 3. IFU ultrasound study.“ Dermatol Surg 38(7 Pt 2): 1162-1169. and overjet of upper incisors. Poor as it has demonstrated a lower fanned sub-SMAS into the deep definition of mandibular body risk of inflammation compared to cheek fat compartments indirectly 2

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How AWT works

Applying Acoustic Wave Therapy to Aesthetics Dr Ashwin Soni explores the use of acoustic wave therapy in aesthetic medicine Acoustic wave therapy is gaining global popularity and momentum within aesthetic medicine. Acoustic wave therapy (AWT), otherwise known as extracorporeal shock wave therapy (ESWT), refers to a mechanical stimulation that encourages natural healing processes in the body, and is a non-invasive treatment method. AWT has been demonstrated to help with facial tightening, provide a facial lift, and to help with wrinkles and fine lines.1 It has also been shown to benefit the body, such as for sculpting, tightening, and improving cellulite.1,2 This article aims to explore the science and mechanism behind this technology, and whether this type of treatment has utility in the world of facial and body aesthetics.

an established treatment for certain musculoskeletal disorders, such as plantar fasciitis of the heel, lateral epicondylitis of the elbow, and tendonitis of the shoulder, and patella. It was then introduced into the field of andrology and sexual medicine, where it was used to treat erectile dysfunction.4,5 The safety and utility of AWT in the human body has been established over the last few decades given its use in multiple specialties. In the past few years, the technology has leapt into the aesthetics space.

Acoustic waves are pulses that are characterised by their short lengths, high-pressure amplitudes, and rapid increases in pressure.6 The transmission of acoustic waves into the tissues has shown to stimulate vasodilation, increase cell metabolism and angiogenesis, and have anti-inflammatory properties by the release of nitric oxide.7 An increased release of growth factors, the reduction of subcutaneous fat, and the stimulation of blood and lymphatic flow have all been demonstrated, which can allow for safe facial and body tightening and rejuvenation.8 Given that there is an increase in circulation and blood flow, remodelling of collagen and elastin within the skin, and change in cell metabolism, there is a potential for a positive impact on facial rejuvenation. In a clinic setting, AWT is administered through a handpiece, which generates focused and deep acoustic pulses electromechanically. The provider is able to set the energy level, the pulse frequency, and the number of pulses. Depending on what area you are treating, and the goal of the treatment, these can all be modified to suit the particular area. Ultrasound gel is applied during each treatment to ensure that the energy is transmitted efficiently and smoothly.8

AWT and aesthetics Animal studies have shown promising results regarding the effects of shockwave therapy on skin and tissues.9,10 Alshihri et al. designed a study in goats to examine the potential of shockwave therapy application to enhance several soft tissue parameters in skin. It was observed that the treatment significantly

Compressed air line from main unit

A background on AWT AWT was first discovered through aerospace technology in the 1960s when the effects of shockwaves on tissues were noticed in Germany, leading the government to research their further use.3 Shockwave therapy was introduced to treat kidney stones in the 1970s, when experiments began, and clinical application started in the 1980s.3 AWT was then utilised for the treatment of gallbladder stones and was then introduced in the field of orthopaedics where it became


Radial shockwaves

Figure 1: The transmission of acoustic waves into the skin

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021




AWT may also have a role to play in body sculpting technology too, given that it can improve skin elasticity and enhance connective tissue firmness

stimulated dermal thickness, angiogenesis, and collagen production after only four days.9 In addition, the study also found AWT stimulates cell proliferation of collagen and elastin. Both human and animal studies have shown that detectable changes in tissue structure have been observed, specifically related to the network of collagen and elastin fibres, resulting in a denser and firmer tissue as a result.9,11 In addition, a 2021 study by Kimura et al. evaluated a total of 333 patients, demonstrating the volumetric changes of the whole face, which were calculated using Vectra software. Only mild erythema, which resolved within 24 hours, was observed in three patients. No other side effects were observed in this study.8 A few high-profile US brands, such as Shani Darden, have started to design their own ‘at-home’ acoustic wave vibration devices, which claim to result in facial tightening and sculpting.12 Although the current data out there suggests that AWT may have a role to play in non-invasive facial tightening and rejuvenation, there are a few variables. It depends on the specification of the power of the acoustic waves, the pulse wave frequency, and how many pulses the machine gives off, and so the specifications of at-home devices would need to be known in order to understand its effectiveness, compared to the in-clinic devices that these scientific studies have been based on. It has been suggested that AWT may also have a role to play in body sculpting technology too, given that it can improve skin elasticity and enhance connective tissue

firmness, and can also be effective in patients with cellulite.11,1 Many global device companies have developed acoustic wave therapy technology for face and body sculpting including BTL Aesthetics (X-Wave), a range of devices from Storz Medical, Bio-Med Inc (Shock Med), Inceler Medikal (Modus ESWT), and MTS Medical (urogold100) to name a few. Studies have shown that the BTL X-Wave device stimulates regenerative processes in the dermal layers of the skin and can result in positive effects on skin elasticity and an improvement in cellulite.1,8,11 These effects have been shown clinically in studies conducted specifically for BTL, which involved 52 patients assessing the efficacy of this treatment by measuring skin elasticity and having a professional and self-evaluation of skin improvement. The results of these studies showed an improvement in skin elasticity and skin upon evaluation.13,14 Another study of 30 patients, conducted by Hexsel et al, used different AWT devices from Storz Medical. The results demonstrated a significant reduction in hip circumference, an improvement in thigh circumference, a significant reduction in adipose tissue thickness, and an improvement in cellulite.15

Side effects and complications Theoretically, this non-invasive modality can be applied to any skin type given the type of technology that is being used. This is due to the safety profile associated with this non-thermal ultrasound device, and the fact that these acoustic waves are targeting the subcutis, which means that the side effects are reduced to a minimum; at most

some mild discomfort and reddening of the skin during the treatment.7 Theoretically, it is possible to develop epidermal burns, adipose atrophy, and contractures, but these have not been observed in any of the studies mentioned in this article.8

The future of AWT The future of aesthetics has shifted towards non-invasive or minimally invasive procedures that are able to provide a significant benefit for our patients. Based on current research, AWT certainly has a potential role in facial and body aesthetics, but more long-term data needs to be collected before recommending this as an alternative to other current and well-known treatment methods. In addition, training courses in the UK are also starting to launch teaching on AWT, which means that the clinical application of this in the field of aesthetics is growing and its use will become more widespread over the next year.16 It should be considered that several studies do not have formal objective three-dimensional assessments in order to evaluate the effectiveness of AWT. Larger patient cohorts with longer follow-ups are required to improve our knowledge in this particular treatment method. So far, the side effects of this treatment method have been shown to be negligible, and we know that this technology is safe given decades of use in other medical and surgical specialties. However, further long-term studies will prove the true safety profile of this therapy for the indications within aesthetic medicine. Dr Ashwin Soni is a US and UK-trained plastic surgeon and the owner of The Soni Clinic, located in Surrey and Berkshire. After attending Imperial College London for medical school, he then relocated to the US completing his plastic surgery training at Cornell, Johns Hopkins, and the University of Washington. Qual: MBBS, MD, BSc


Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021




a sharps injury. The reason for the high incidence of events was difficult to ascertain in the UK; however, it was deemed to be likely related to COVID-19 workloads.7

Minimising the risk Vaccination HBV infection can be effectively avoided by vaccination, but there is currently no vaccine available for HCV or HIV. Vaccination must be offered free of charge by their employer to all workers and students delivering healthcare with exposure to blood or body fluids.8 In the event of a sharps or splash injury, it is useful if the healthcare worker can provide their most recent HBV antibody titer.

Managing Sharps Injuries and Splash Incidents Nurse prescriber Sharon King and Dr Martyn King outline how practitioners can minimise the risk of contracting blood-borne viruses Blood-borne viruses (BBV) are those that are transmitted from the blood of one person to the blood of another person. Of particular concern are hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). A sharps injury can be defined as exposure to blood or body fluids caused by laceration or puncture of the skin (these can include bites or scratches by sharps). Sharps include needles, scalpels, broken glass, or any items that may lacerate or puncture the skin. A splash incident can be defined as where blood or body fluids come into contact with the eyes, mouth, broken skin or mucous membranes.1 Although the number of sharps injuries each year is relatively high, only a small number have caused infections that have led to serious disease.2 Healthcare workers are particularly at risk from exposure to BBV. Accidental exposure to blood or other body fluids from patients can lead to infection if the patient is infected with a blood-borne virus such as HIV, HBV or HCV. Infection is not only damaging for health, but it could also prevent certain work within the healthcare setting.

Incidence A survey carried out in 2008 of 4,407 nurses found that just under half (48%) had been injured with a needle or sharp previously used on a patient, and that 52% of those surveyed feared an injury. In addition, a significant number felt that they had received no or little training from their employer.3 A similar survey carried out among a group of UK surgeons in 1991 showed that 44% anonymously admitted to having a needle-stick injury. Only three of the 33 (9%) who sustained a needle-stick injury said that they followed the agreed local policy.4 Data compiled by Public Health England in December 2014 warned that healthcare workers remain at risk from BBV.5 A government report examined 8,765 BBV exposures from healthcare workers between 1997 and 2018, which suggested a risk of transmission (Table 1).6 A new survey, carried out on behalf of the Royal College of Nurses and published in May 2021, stated that out of 7,500 members, 96% had experienced a blood or body fluid exposure and 63% had experienced

General measures Policies and procedures must be in place and available for all healthcare workers, and employers must organise and provide mandatory training to workers on a regular basis considering monitoring, modernisation and improvements. These policies should include:8 • Washing hands before and after contact with each patient and before putting on and after removing gloves. • Changing gloves between patients. • Cover any existing wounds, skin lesions and all breaks in exposed skin with waterproof plasters or dressings. Always wear gloves if hands are extensively affected. • Wear gloves when contact with blood can be anticipated. • Avoid sharps usage where possible. • Where sharps usage is essential, exercise care in handling and disposal. • Avoid wearing open footwear in situations where blood may be spilt or where sharp instruments or needles are handled. • Clear up spillage of blood promptly and disinfect surfaces. • Pre-employment occupational health assessment should identify those with damaged skin (e.g. fissured hand eczema) who may be at higher risk of occupational Blood-borne virus

Risk of transmission

Hepatitis B (HBV)

1 in 3

Hepatitis C (HCV)

1 in 30


1 in 300

Table 1: Risk of BBV transmission amongst healthcare workers following a percutaneous injury from a known infected patient6

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021



Identifying whether a patient is in a high-risk group for BBV

to make sure that hands are being washed with soap and water before and after 2 If you are male, have you ever had sex (even safe sex) with another man? procedures, that all clinicians 3 Have you ever injected yourself with drugs (including bodyuse protective barriers such building drugs)? as gloves, gowns, aprons, 4 Have you ever received hospital treatment in Africa or any Far masks, and goggles for Eastern country? direct contact with blood and 5 Have you ever received a blood transfusion from anywhere other body fluids, and that outside of the UK? they disinfect instruments 6 Have you ever had sex with someone for drugs or money? and other contaminated 7 Have you had sex with anyone in any of the above groups? equipment.8 Practitioners Table 2: Questions to help identify if your patient is high-risk. Table should wear gloves and adapted from NHS Blood and Transplant screening questions.1 a disposable apron when handling soiled linen and acquired infection and ensure that advice keep contact to a minimum. Soiled linen is given about minimising any occupational should be transported in a suitable leak health risk to which they may be exposed. proof bag. Cleaning should occur outside • Wear gloves when cleaning equipment patient areas, using detergent and hot prior to sterilisation or disinfection, when water. Use sharps with safety-engineered handling chemical disinfectant and when protection mechanisms if a risk assessment cleaning up spillages. has indicated that they will provide safer • Follow safe procedures for disposal of systems of working for healthcare workers, contaminated waste. carers, and patients.8 • All sharps or splash injuries need to be More detailed advice, including use of reported to the employer/designated blunt-tipped needles, and ‘neutral zones’ person. for passing of sharps during surgery, are available in the Department of Health’s Specific measures ‘Guidance for Clinical Health Care Workers’.9 The use of new, single-use disposable equipment for all injections is highly NICE recommendations recommended, and reusable equipment should only be considered if single use The National Institute for Health and is not available and if the sterility can be Clinical Excellence (NICE) has several documented according to the manufacturer’s recommendations for keeping practitioners instructions with appropriate audit (e.g. time and patients safe in its clinical guidance and temperature indicators). Practitioners titled ‘Healthcare-associated infections: should ensure to discard contaminated prevention and control in primary and sharps immediately and without re-capping in community care’.10 puncture and liquid proof sharps containers, as well as documenting the quality of the Safe use and disposal of sharps sterilisation for all medical equipment used Handling of sharps should be kept to a for percutaneous procedures.8 It’s important minimum and they should not be passed 1

Have you ever tested positive for HIV/AIDS, HBV or HCV?

Policies and procedures must be in place and available for all healthcare workers, and employers must organise and provide mandatory training to workers on a regular basis


directly from hand to hand. Used needles must not be bent or broken before disposal and must not be recapped. Used sharps must be discarded immediately by the person generating the sharps waste into a sharps container conforming to current standards.10,11 Sharps containers Sharps containers must be in a safe position that avoids spillage, at a height that allows the safe disposal of sharps. They must be kept away from public access areas, out of the reach of children, and must not be used for any other purpose than the disposal of sharps. Containers should not be filled above the fill line and should be disposed of when the fill line is reached. When not in use, sharps containers should be temporarily closed, and they should be disposed of every three months even if not full by the licensed route in accordance with local policy.10 Management of a sharps injury If a sharps injury occurs, practitioners should encourage the wound to gently bleed, ideally placing it beneath running water – applying pressure above the wound may induce further bleeding from the wound.11 You should then wash the wound with running water and plenty of soap, as disinfectant agents may provide greater risk reduction (such as 10% iodine, 70% alcohol or hypochlorite solutions). You should not scrub or suck the wound. After washing, dry the wound and cover it with a waterproof plaster or dressing.6 We advise that you seek urgent medical advice as you may need post-exposure prophylaxis in a private healthcare setting. This may mean contacting your local infectious disease consultant or an Accident and Emergency department or genitourinary medicine department. There should be no delay as ideally, prophylaxis should be commenced within an hour of injury.11 The final step is to report the incident to your employer, manager, or occupational health department. In certain situations, a sharps injury may need to be reported to HSE (Health and Safety Executive) under the Reporting of Injuries, Disease and Dangerous Occurrences Regulations 1995.12 Following exposure to blood or body fluids contaminated with a BBV, it may take six months for seroconversion to occur, and the healthcare worker should be tested at six weeks, three months and six months.11 The practitioner does not need to refrain

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021

from work during this time as the risk of seroconversion and passing on the infection from occupational exposure is too low to consider. However, they should practice safe-sex and refrain from blood donation.9

Identify patients at high-risk In the event of a sharps or splash injury, the healthcare worker should ascertain the level of risk associated with the injury. There are some very personal and confidential questions that can be asked to identify high-risk patients; these are often best asked by a senior and separate practitioner (Table 2). Ideally a sample of blood is taken from the patient to test for BBVs. However, the patient is not obliged to answer any questions or to provide a sample and undue pressure should not be applied.

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Take care of yourself and your staff BBVs are a particular concern to healthcare professionals, and those working in aesthetics should take the necessary precautions to minimise the risk of infection. Employers should ensure to implement the appropriate measures to protect both members of staff and patients, and in the event of a sharps injury practitioners should follow the above guidelines.

Designed for • Skin rejuvenation and conditioning • Oily skin • Ageing skin • Skin hydration • Reducing pore size

This article was written based on the newest ACE Group World guidelines on managing sharps injuries and splash incidents.

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Sharon King is a registered nurse, an independent prescriber and has a MSc in Non-Surgical Aesthetic Practice. She has worked within aesthetic practice for almost 20 years and runs a successful clinic as well as Cosmedic Training Academy. King was a co-founder of the ACE Group World and is the current vice chair of the British Association of Cosmetic Nurses. Qual: RN, NIP Dr Martyn King is a GMC registered doctor and the director of Cosmedic Skin Clinic, Cosmedic Online and Cosmedic Pharmacy. He is medical director of the ACE Group World, vice chair of the Joint Council of Cosmetic Practitioners, a member of the British College of Aesthetic Medicine and board member for the British Association of Sclerotherapists. He has completed a Master’s Degree with distinction in non-surgical aesthetic practice. Qual: MBChB, MSc, PGDip, PGCert

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Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021



feel like being asked to drive my car Over the last decade, medical with my eyes closed! At Aesthetic ultrasound imaging technology Accessible high definition ultrasound could Health we now increasingly use has improved dramatically, now be theasked reach of and I feel like being to drive my feel likewithin being asked tomany driveclinics, my car car Over the the last last decade, decade, medical medical ultrasound imaging throughout Over creating clearer and more defined with my eyes closed! At Aesthetic believe this will herald a revolution in care. with my eyes closed! At Aesthetic ultrasound imaging technology our patient journeys, and so far the ultrasound technology pictures. 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Ultrasound Imaging

For all enquiries, please contactLucy Lucy Dowling: For For all all enquiries, enquiries, please please contact contact Lucy Dowling: Dowling: Adverse events should forUnited UnitedKingdom Kingdomcan canbebefound found Reporting forms and information for Republic of Ireland Adverse events shouldbebereported. reported.Reporting Reporting forms forms and and information information for at at Reporting forms and information for Republic of Ireland can becan be Adverse events should be reported. Reporting forms and information forAdverse United Kingdom can bealso found reported at Reporting forms and information for Republic of Ireland can be4143. found at eventsshould should Merz Pharma by email to on(0)+44 333 200 found at Adverse events also bebe reported to to Merz Pharma UK UK Ltd Ltd by email to or on or +44 333(0) 200 4143. found at Adverse events should also be reported to Merz Pharma UK Ltd by email to or on +44 (0) 333 200 4143.

Merz Pharma UK Ltd,Ground Ground Floor,Breakspear Breakspear Breakspear Way Merz Pharma UK BreakspearWay Way Merz Pharma UKLtd, Ltd, GroundFloor, Floor, Breakspear Park, Park, Breakspear Hemel Hempstead, Herts,HP2 HP2 4TZTel: Tel: +44 (0) (0) 200 4140 Hemel Hempstead, 200 4140 4140 Hemel Hempstead,Herts, Herts, HP24TZ 4TZ Tel:+44 +44 (0) 333 333 200

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Aesthetics | December 2021

M-MA-UKI-1721 Date of PreparationNovember November2021 2021 M-MA-UKI-1746 Date ofDate Preparation M-MA-UKI-1721 Date of Preparation November 2021 2021 M-MA-UKI-1721 of Preparation November




A summary of the latest clinical studies Title: A Study of Combined Microfocused Ultrasound and Hyaluronic Acid Dermal Filler in the Treatment of Enlarged Facial Pores in Asians Authors: Vachiramon V, et al. Published: Journal of Cosmetic Dermatology, November 2021 Keywords: Energy-based device, ultrasound, dermal fillers, rejuvenation Abstract: Microfocused ultrasound with visualization (MFU-V) and low-degree crosslinked hyaluronic acid filler (L-HA) injection has recently become a popular procedure for skin rejuvenation. The effectiveness of the combined MFU-V and L-HA injection in the treatment of enlarged pores has not been evaluated. The objective was to compare the efficacy of MFU-V monotherapy (single technique) and MFU-V combined with L-HA injection (combined technique) for the treatment of enlarged facial pores in Asians through a randomized, single-blinded, split-face study on 46 participants with enlarged facial pores. Each side of the face was randomly assigned to treatment with one session of single technique or combined technique and pore volume was measured by an Antera 3D system. Assessment was evaluated by one-blinded physician using a pore grading score (0-4). Patients rated the improvement in terms of satisfaction using the visual analog scale (VAS, 0-10). Mean pore volume of both sides declined with statistical significance at every visit compared to baseline, with the lowest mean at 4 months post-treatment. The combined technique showed a lower mean pore volume than single technique throughout the follow-ups and there was no significant difference between the two techniques. The patient satisfaction score showed a similar trend to the mean pore volume, with a statistically significant difference at 4- and 6-months post-treatment.

Title: Effects of Topical Retinoids on Acne and Post-inflammatory Hyperpigmentation in Patients with Skin of Color: A Clinical Review and Implications for Practice Authors: Callender V.D, et al. Published: The American Journal of Clinical Dermatology, November 2021 Keywords: Skin of colour, acne, retinoids, hyperpigmentation Abstract: Acne is a common cause for post-inflammatory hyperpigmentation (PIH), particularly in patients with skin of color (SOC), and PIH is often more distressing to patients than the acne itself. Topical retinoids are approved for the treatment of acne and for pigmentation disorders such as melasma or mottled hyperpigmentation associated with photodamage; moreover, they have been shown to reduce hyperpigmentation in patients with SOC. Therefore, treatment with topical retinoids should be started as early as possible unless contraindicated. Use of novel formulations or application of commonly recommended moisturizers may help reduce irritation. Combining retinoids with other topical agents and procedures such as superficial chemical peels can help to improve hyperpigmentation. Primary acne lesions are likely to improve weeks before PIH resolves and helping patients manage their expectations maytoreduce confidence be frustration. Providing clinicians and researchers with more education about the presentation and management of dermatologic conditions in patients with SOC is also recommended.

Title: The Potential of Platelet-Rich Plasma Injections and Stem Cell Therapy for Penile Rejuvenation Authors: Israeli J.M, et al. Published: International Journal of Impotence Research, November 2021 Keywords: Impotence, PRP, stem cell therapy, penile rejuvenation Abstract: Penile concerns include erectile dysfunction (ED) and Peyronie disease (PD). Restorative therapies including Stem Cell Therapy (SCT) and Platelet Rich Plasma (PRP) injections are proposed to treat these concerns. SCT encompasses the harvesting and injection of mesenchymal stem cells or stromal vascular fractions from various tissue sources. PRP is derived autologously from a patient’s plasma and is then injected into the penile tissue. These therapies repair damaged penile tissue and promote both new cellular and vascular growth, as demonstrated in basic science studies. Human trials on SCT and PRP for both ED and PD and have yielded promising results with few side effects. While encouraging, small cohort size and lack of blinding or placebo control limit these studies’ external validity. Recently, the first double-blinded randomized controlled trial on PRP for ED was published, providing significant evidence of efficacy. With the rapid commercial availability of SCT and PRP for ED and PD, it is imperative to perform more randomized and placebo-controlled trials with standardized procedures and preparations to evaluate efficacy and safety. This narrative review will summarize the available literature on these penile restorative therapies to date. Title: A Critical Review of Complications in Non-Surgical Rhinoplasty and Their Management Authors: Babu S.H, et al. Published: Journal of Cosmetic Dermatology, November 2021 Keywords: Non-surgical rhinoplasty, complications, hyaluronic acid, vascular occlusion Abstract: In recent years, there has been a rise in non-surgical rhinoplasty (NSR) due to its minimally invasive approach. As with all procedures, NSR can result in complications. Although rare, the consequences of complications can result in a devastating outcome and therefore an evidence-based approach to enable the recognition and management of NSR complications is required. This paper aims to review and appraise current literature to determine the evidence base for complications experienced with NSR including their causes and management. A systematic review was conducted using a PRISMA methodology. The PubMed and WebofScience databases were queried. Papers relating to the three most used filler materials; hyaluronic acid (HA), calcium hydroxyapatite and collagen were collated. 490 studies were identified in the initial literature search and after applying an inclusion and exclusion criteria, 12 papers were included. The results showed a paucity of high-level evidence which may indicate underreporting of NSR complications. Although treatment is not always effective, early recognition and treatment favors better outcomes with the potential for complete resolution in some cases. Immediate availability of hyaluronidase is important when undertaking NSR with HA as this review showed early use was critical in the management of serious complications such as vascular occlusion.

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021




employees or job applicants differently because of their vaccination status, should be mindful of the legal risks.5 The Health and Safety at Work Act 1974 requires employers to take reasonable steps to reduce any workplace risks, and this duty does give employers justification for encouraging their employees to be vaccinated to protect both themselves and everyone else at the workplace.5

Exploring Mandatory Vaccination Policies Employment associate Catherine Hawkes explains the legal hurdles of mandatory vaccinations and some alternative approaches that employers can take Medical aesthetic businesses, like many others, are assessing how they can move forward, working safely and securely alongside the risks of COVID-19, protecting both staff and customers. There is currently no legislative power for the UK government to mandate COVID-19 vaccination across the board. However, there are sectors in which existing primary legislation enables the government to bring in regulations on mandatory vaccination. From November 11, 2021, getting a COVID-19 vaccination will be made compulsory for those working in care homes in England. The legislation will apply to all Care Quality Commission (CQC) regulated service providers of nursing and personal care, in care homes.1 The duty applies not only to employees, but will also extend to all agency workers, volunteers, healthcare workers and tradespeople that might be engaged by the home. The new regulations are being challenged on the grounds that it contravenes section 45E of the Public Health (Control of Disease Act) 1984.2 This Act says that whilst regulations can be made to stop the threat of infection or contamination, they may not include provision requiring a person to undergo medical treatment, including vaccination. Further, following a government consultation on mandatory vaccination for frontline NHS staff, it was recently announced that from April 2022, all NHS staff in England will have to get both COVID-19 vaccines or risk dismissal from their employment.3 This is likely to cause difficulties amongst staff who may choose to raise grievances against their employer. It is likely that the NHS will focus on redeployment opportunities to avoid widespread dismissals and resignations. There are also some non-frontline businesses who are introducing mandatory vaccination for their workers. For example, Pimlico Plumbers caused media controversy earlier this year when it announced its new policy as being, ‘no jab, no job’.4 However, whilst it may appear tempting for businesses to insist on mandatory vaccination, it is important to understand the legal obligations before embarking on any such approach.

Discrimination However, the key risk to employers of introducing a blanket policy on mandatory vaccination would be a challenge by employees on discrimination grounds. There are several valid reasons why an employee might refuse the vaccine, and this could be related to a protected characteristic under the Equality Act 2010, such as religion or philosophical belief, race, age, pregnancy, or disability.6 Therefore, introducing a policy or seeking to treat individuals unfavourably for not taking the vaccine such as subjecting them disciplinary action, reducing pay, or refusing their attendance at the workplace could expose an employer to discrimination claims. Reasonable management instruction There is scope for employers to claim that requiring staff to get the vaccine is a reasonable management instruction and could in theory initiate disciplinary (or even dismissal) proceedings for a failure to follow a reasonable instruction. However, the courts and tribunals have not yet commented on whether mandatory vaccination would be considered a ‘reasonable instruction’ in the circumstances and so to adopt this approach runs significant legal risks. Constructive unfair dismissal Further, there is an implied duty of trust and confidence which is incorporated into every contract of employment, which exists between an employer and an employee. Adopting a policy which applies pressure on employees to take the vaccine without justification, could result in a breach of the trust of confidence, entitling employees to resign and bring claims for constructive unfair dismissal if over two years’ service.7

Legal position

Consider alternatives

In the absence of vaccination becoming a legal requirement, an employer cannot force an employee to be vaccinated without their consent. Vaccination without consent could amount to the criminal offences of assault and battery. Therefore, an employer outside of the regulations that is considering imposing a mandatory vaccination requirement or treating

Employers should remember that vaccination is just one measure of protection and the extent to which the virus will further mutate is still unknown. Employers still need to consider

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021



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other measures that can be taken and should stay up-to-date with the latest government advice, adjusting their plans accordingly. High vaccine uptake is a way in which both staff and customers can be protected in the workplace. However, employers have many options to protect and reassure staff and customers whilst encouraging vaccine uptake, without resorting to a mandatory policy. Positive approach to vaccination A positive approach to vaccination can increase the level of uptake amongst staff without the requirement being mandatory (and thus raising the issues detailed above). This includes ensuring staff have access to clear information about the risks of vaccination and how to overcome or manage those risks, as well as information about the value and benefits of vaccination. Further, employers can provide confidential support to staff who have any vaccine related concerns and consider allowing paid time off to obtain the vaccine if necessary. Update/create your vaccine policy An alternative approach without the risks of a mandatory vaccination programme is for employers to introduce a policy which encourages the workforce to get vaccinated against COVID-19. With a COVID-19 vaccine policy, it is easier to keep your staff fully informed of your company’s position, increasing trust amongst staff. Within the policy, it is advisable to include the following: • Who the policy applies to, e.g. employees, consultants, casual workers and agency workers • Information about the COVID-19 vaccination and educating employees about the vaccine’s safety, health benefits and addressing their concerns • Whether you will keep track of who has had the vaccine and, if so, how you will record and store this data confidentially • How you will maintain a COVID-19 secure workplace • Allowing paid time off to attend any vaccination appointment • Any incentives which will be provided for vaccination Sharing vaccination status Employers should be mindful of their obligations under the General Data Protection Regulation (GDPR). Personal data about an employee’s health will amount to ‘special category data’ under the GDPR and therefore, is personal data which is afforded additional protection because it is sensitive.8 To process special category data, employers will need to have a lawful basis for doing so under Article 6 of the GDPR.9 Employers are entitled to ask employees whether they have been vaccinated, however, they will need a legitimate reason for processing this information, because processing any data about health is sensitive. For example, a legitimate reason could be to assist employers with policies such as which staff should self-isolate and when, therefore helping reduce the risks of transmission throughout the business. Employers will therefore need to consider their reason for insisting on and collecting data on vaccinations and be clear about what they intend to do with that data, otherwise they could be in breach of the GDPR. The Information Commissioner’s Office (ICO) has published advice to organisations who are collecting vaccination status data confirming that collection of this data must be necessary and relevant for a specific purpose.10 However, it also confirms that if there is a good reason for collecting the information, then there will be a lawful basis to process the data.

The safest legal basis will be compliance with your legal obligations and ‘substantial public interest’. This means that preventing the spread of the virus and complying with your duty of care to employees needs to be at the root of your justification rather than, for example, customer or staff preference or boosting confidence. Asking employees to tell you about their vaccination status is less risky than insisting that they do so, because individuals who are happy to share the information are less likely to make a data protection complaint. Further, the ICO would be more likely to regard your policy as proportionate if there is no mandatory element to it. It may therefore be sensible to start by asking if employees will volunteer this information before you escalate to insisting upon it. The information should only be used in a way that the employee would reasonably expect and should not result in any unfair or unjustified treatment of the employee. It is very difficult, for example, to envisage a circumstance where an employer could justify sharing a specific individual’s vaccine status with other employees. Recruitment Requiring new starters to have the vaccine is less risky than mandating vaccination for existing employees because there will be no risk of unfair dismissal claims from potential new recruits. This is because new starters will not have the requisite two years’ service to bring this type of claim. However, they still have the right not to be discriminated against because of a protected characteristic under the Equality Act (such as age, sex, race, religion or belief, disability etc).6 Therefore, employers will need to carefully word their recruitment policy so that applicants with valid reasons for refusing the vaccine are not prevented from applying for the role.

Weigh up your options Whilst many businesses, particularly in customer facing and healthcare roles, will want to ensure that their staff and customers are as protected as possible, the potential legal repercussions of mandatory vaccination policies should not be overlooked. As above, there are many ways in which businesses can protect themselves without introducing mandatory vaccination policies, and these should be considered where appropriate. While currently, mandatory vaccination only applies to care workers from November 11 2021 and NHS staff from April 2022, employers should ensure that they keep themselves up-to-date with any government guidance which may impact their business. Catherine Hawkes is an associate at Royds Withy King LLP, specialising in employment and HR law. Hawkes qualified in September 2015 and her experience includes advising on a variety of employment law related issues including unfair dismissal, discrimination, redundancy/ restructure and whistleblowing.


Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021

Accelerate your Aesthetic Business

Scan Me Promotional meetings organised and funded by Merz Aesthetics UK and Ireland M-MA-UKI-1617 Date of preparation October 2021




missions in developing nations and animal rescue – to name but a few! Looking outside of medical aesthetics, many of the highestgrowth brands are committed to achieving equitable outcomes across all areas of influence – workforce, marketplace, and society. Based on research from global consulting firm Deloitte, 57% of consumers are more loyal to brands that commit to addressing social inequities in their actions.5

Short form video is the new selfie

Evolving Your Platform for the New Year Brand marketing strategist Adam Haroun explores the ways in which you can leverage the hottest trends heading into 2022 to set your clinic apart For many aesthetic clinics, the last year and a half have felt much like a juggling act to consistently keep pace as marketing trends, pandemic restrictions, and consumer sentiment have been in a constant state of flux. As the modern patient navigates a world that shifts from digital to physical on a moment’s notice, to say ‘evolution’ is a key theme in many clinics’ marketing plans for the year ahead would be an understatement. Among marketers, we have found ourselves moving faster than ever whilst keeping a sharp eye on the ever complex and rapidly changing trends within marketing to keep one step ahead. Looking forward to 2022, here are several of the most important trends your clinic can evolve into your platform to see better results from your promotional efforts in the new year.

Authenticity reigns supreme Based on findings from Deloitte’s 2022 Global Marketing Trends research report, we are beginning to see an encouraging trend brand marketers have been increasingly aware of – authenticity is playing a more important role than ever before. Gone are the days of perfectly airbrushed, culturally homogenous models and messaging.1 As you begin to look at your social channels, in-clinic collateral, and online presence, be sure to authentically reflect a range of backgrounds and experiences in your messaging to effectively connect with future patients. As a starting point, explore different skin types, gender identities, age demographics and body types in your imagery. This is especially important for clinics who target a younger patient demographic, as these consumers take greater notice of inclusive advertising when making purchase decisions than older patients (ages 46 and older).1 Building on this trend, 94% of Gen Zs expect companies and brands to take a stand on important societal issues, with 90% saying they are more willing to purchase products they deem beneficial to society.1 A key question to ask yourself is what matters to your community? Are there causes that your patients really care about? If so, align your clinic with these and become an ally and advocate – from a simple Instagram post to matching donations your patients make; the opportunities to become a catalyst for change are abundant. Consider what causes and groups your clinic can advocate for. Some of the causes I have supported are breast cancer awareness, supporting those experiencing homelessness, Alzheimer’s disease research, supporting women escaping domestic violence, medical

Short-form video (a video between 15 to 60 seconds in length) rose to prominence in marketing in 2020 with the rapid growth of TikTok; and has showed no signs of slowing down since. Although TikTok was the platform to pioneer this trend, and still leads as a short-form video platform, other social channels such as Instagram and YouTube were quick to adapt with their own shortform video features. While it certainly takes creativity and time, investing in short-form video content is an excellent use of your marketing resources, and the data supports it. From a quick product review, to a short video dispelling a common beauty or antiageing myth with several key talking points – this content can be quick to create, yet yield incredible results. According to marketing software publisher Hubspot, for B2C (business to consumer) brands across all industries, short-form video content offered the second highest ROI for B2C marketers in 2021 behind influencer marketing.2 Despite being second for ROI, it’s the trend marketers plan to invest the most in 2022. Roughly 33% of B2C marketers already invest in shortform content, while one-third of those who haven’t will do for the first time in 2022.2 The key is to begin with something as simple as a video with your top three to five recommendations for a particular condition (such as acne scars) with clever editing and trending music can prove to be an incredibly helpful starting point.

Take ownership of your audience Social media platforms play an important role in the marketing success of any clinic, however, the difficult reality is that they own your audience. Without the right safeguards, these audiences can be lost at a moment’s notice due to hackers or by having your profile shut down by a platform. By adding in the ever-changing algorithms of each social channel – you can get front and centre with your audience! Thankfully, the best way to own your

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021

OUR PRICE PROMISE Whilst we value providing our customers with competitive prices for aesthetics products and services, PRICE means so much more... Professionalism • Regulation • Integrity • Customer Focus • Ethics

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audience is simple: by creating an email database that draws your audience from social into your own ‘marketing ecosystem’. This being said, email marketing only achieves results when content is relevant, personalised and compelling. Segmenting your audience’s common questions and most in demand treatments by age group or type of concerns (preventing visible signs of ageing, restoring volume loss for example) can be far more beneficial than a traditional ‘one size fits all’ newsletter. Consumers have become increasingly selective about the data they consume, and their expectations for quality content are on the rise – gone are the days where emailing a scattered array of special offers and a featured product paragraph get attention. Instead, focus on timely topics (i.e. How to Set Your New Year’s Skin Resolution With an Effective Routine) that offer practical and tangible advice patients can take action on. As a starting point, consider creating email content for the broader age ranges you see coming through your clinic doors, such as millennials, patients over 40, and perhaps content catered towards your male patients. While this will take time and is far from an overnight process, even a small step to segment your audience can create substantial improvement in your click-through and email open rates. Aim to segment one audience per quarter as a starting point and build from there!

Embrace the transformation of digital analytics Until recently, tracking users across the web was essential to many advertisers and businesses – including medical aesthetic clinics. However, user privacy concerns have become more important to many internet users. With the implementation of General Data Protection Regulation (GDPR), consumers have become more aware of their online privacy. Currently, there is an option for consumers to opt-out of the third-party cookies and tracking, but digital advertisers are searching for ways to change their tactics. Concerns have been raised over tracking cookies, text files dropped on to browsers that are able to record data about the consumer, from their actions on the site and geographical location to what they buy, often without their consent or knowledge. This change in user preference is so dramatic, in fact, that Google announced that it would end all tracking cookies in 2023.3 Instead, zero-party data collection is transcending the loss of cookies and


traditional analytics for marketers to gather information about your audience and patients, and provide relevant advertising to facilitate conversion online. Zero-party data has been gaining more and more momentum. In brief, it refers to the data which is given directly by the consumer to a brand, and in this case, the information your patients provide directly to your clinic. It can be collected via a survey, a ‘gamified’ online experience that feels more like a game or fun quiz than an intake form, or a simple consumer/brand interaction online. To harness this evolution, take a close look at how your digital systems integrate – do your marketing tools integrate with your marketing and patient management tools? Aim to ensure you seamlessly use your platforms together to understand both your existing patients and those prospective patients who have come to your website. Having a CRM (customer relationship management) system that integrates with your patient records is an excellent start – and if these systems can integrate with your marketing tools, that is even better. A conversation with your software vendors can prove incredibly insightful and ensure you are making the most of the tools you invest in for your clinic.

Quiet is the new loud In line with the evolution towards authenticity, clinics (and brands across all sectors) look to stand out from crowded advertising channels. Subtle marketing tactics are playing an intriguing role in getting your message across. Low-key marketing strategies that are less interruptive and, ideally, more organic are being tested with exciting results. From a patient advocacy programme to ‘native’ content that appears more organic than a blatant advertisement (such as a guest blog series by an influencer, or a creator who does a mini-documentary series about their experience at your clinic) will capture patient attention in the months to come. While influencers continue to play a key role in your clinic marketing efforts, I invite you to consider a new term: the key opinion customer (KOCs) – highly engaged, everyday patients of your clinic. Following the other evolutions, this concept of subtle marketing is part of the continual shift away from a traditional approach of selling, towards so-called ‘stealth’ marketing, where advertising appears intuitive and enjoyable across platforms – rather than coming across as marketing. Stealth marketing is making more of an impact as people are becoming overloaded

with paid media. Screen fatigue is also increasing: 75% of respondents surveyed in January 2021 by the Out of Home Advertising Association of America (OAAA) said they were paying less attention to online ads.4 That’s not to say you should abandon your digital efforts – far from it – but instead lead with creativity and focus on what information and content your KOC is seeking and providing to their own network. The concept of the KOC first rose to prominence in China, and has now found rapidly-growing success in Western markets.4 Unlike traditional, sales-oriented billboards and sponsored social media posts, the primary objective of stealth marketing is patient advocacy and retention. True loyalty to your clinic is the end goal as it leads to customers believing they’re part of an exclusive group.

Kickstart your marketing! As with everything in today’s world, marketing is in a constant state of change – but rather than shy away from it, I urge you to embrace it. Indeed, being one step ahead with trends ‘levels the playing field’ for your clinic to harness patient attention and gain an advantage over clinics that may be more established or have a larger marketing budget. With so many exciting evolutions ahead in the new year, the opportunities are limitless. Adam Haroun is a marketing strategist, entrepreneur, and owner of BrandingMD. He has spoken for industry leading companies in the US and globally, including Allergan, Merz, Candela and BTL Aesthetics. He recently spoke at the American Society for Dermatologic Surgery annual meeting and the Global Aesthetics Conference. Haroun is also the author of Now The Patient Will See You which serves as a strategic guide to branding and positioning for aesthetic practices. REFERENCES 1., ‘2022 Global Marketing Trends’ (2021) < marketing-and-sales-operations/global-marketing-trends. html?id=us:2el:3dp:wsjspon:awa:WSJCMO:2022:WSJFY22> 2. Bretous, M. ‘The Top 5 B2C Marketing Trends of 2022’, Hubspot (2021) <> 3. Graham, M. ‘Ad Tech Stocks Surge as Google Delays Killing Third-Party Cookies until 2023’, CNBC (2021) <https://www.cnbc. com/2021/06/24/google-pushes-back-deadline-to-deprecatethird-party-cookies-to-2023.html> 4. Chitrakorn, K. ‘Out-of-Home Advertising: The Big Fashion Comeback?’, Vogue Business (2021) <https://www.> 5. Deloitte Insights. 2021. Authentically inclusive marketing. [online] Available at: < marketing-and-sales-operations/global-marketing-trends/2022/ diversity-and-inclusion-in-marketing.html>

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021

NEW REVENUE STREAM FOR YOUR CLINIC Are you a clinic or practitioner interested in stocking your practice with a higher volume of copies at a trade discount?








Advertorial BTL Aesthetics

Practice Building with EMSCULPT NEO Mr Matt James explains how the EMSCULPT NEO has benefitted his practice Pushing the leading edge in the aesthetic industry, EMSCULPT NEO® takes the ground-breaking EMSCULPT brand to the next level in building successful aesthetic practices. This innovative BTL platform brings together targeted emission of synchronised radiofrequency (RF) and the BTL’s signature High Intensity Focused Electromagnetic (HIFEM+) technologies in a single applicator. This targets both fat and muscle simultaneously in nine body areas including the abdomen, buttocks, arms, legs and inner thighs, thus expanding the treatment opportunities. “The introduction of the radiofrequency to the device has been a game changer,” shared Mr Matt James, founder of the Cavendish Clinic in London. “The EMSCULPT NEO provides exceptional results without surgery, downtime, in a short time frame. It’s the perfect lunchtime treatment,” he continued, “As such, it is a faster, more economical and more efficacious solution than any combination of multiple procedures.” Cavendish Clinic is recognised for its body sculpting expertise, and body treatments make up a significant part of its offering. “We had such amazing success with EMSCULPT that getting the EMSCULPT NEO was a natural progression. The Before

accomplishment of the EMSCULPT NEO in our clinics has been exceptional, so it made sense to add a third unit into our London clinics. We want our patients to experience EMSCULPT NEO no matter which clinic they visit, and I’m sure more will follow in the near future!” added Mr James. The course of the treatment typically consists of four 30-minute sessions, scheduled one week apart. “Patient feedback from EMSCULPT NEO has been fantastic – it really is a results-driven treatment with many patients seeing and feeling a difference after one session. With no downtime, it allows patients to continue with their usual day-to-day activities, which is very important to many of them. Since its introduction we have certainly seen an increase in patients who do not traditionally visit aesthetic clinics, including male patients,” Mr James continued, “The great thing about the device is that most patients are suitable for the treatment post initial medical consultation. It is not an age-specific treatment, and everyone can benefit from it.” Cavendish Clinic has used a lot of traditional marketing tools, such as emailing existing patients to create buzz about the treatment, but the most important aspect has been a knowledgeable team. Mr James explained, After

“We began with extensive training from BTL, so the team understands how the treatment works. The other marketing tools they have provided are very useful, and the business development team has made a huge difference in how we raise awareness with patients and ensure we treat safely.” The EMSCULPT brand is recognised by peers around the world as well as by various international awards, and it has quickly become one of the star products. It has recently reached one million treatments globally. “We are really proud of our partnership with BTL and how we have contributed to getting to the one million mark. It is a huge achievement and only helps our confidence when we are treating patients. There is no replacement for experience, and we are very focused on patient safety, so we only offer safe and effective treatments to patients,” Mr James commented. Mr Matt James has 20 years’ experience providing reconstructive services internationally. Previously clinical director of service at Guys and St Thomas’ NHS trust, he now leads hand trauma services. Having performed thousands of successful operations during his career, he founded Cavendish Clinic in 2011 with two other consultant doctors, Mr Jamil Sheikh and Dr Sanjay Gulati.

This advertorial was written and supplied by

Before and after treatment with EMSCULPT NEO. Images courtesy of Cavendish Clinic

Aesthetics | December 2021




Optimising Patient Satisfaction Psychologist Kimberley Cairns explores how using trauma-led practice can improve patient experience and practitioner performance Trauma-informed practice is an evidenced-based model that educates about the importance of a complete picture of a patient’s situation, past and present to assist care providers in formulating the best approach for desired outcomes.1 It is well documented and widely accepted that this holistic approach provides a superior service operation which promotes wellness or healing in its processes.2 Trauma-informed practice has military origins dating back to the Korean War (1950-1953) and The Vietnam war (1955-1975) where at the time medical science was not attuned to the needs of the soldier.3,4 Since then, trauma-informed insights have evolved and positively influenced many settings creating a substantial shift to the way in which we interact with those who have had higher rates of stress and trauma in environments such as schools, the NHS, social care, prisons and adults in the workplace and has become even more relevant since the COVID-19 pandemic.1,2,4-7 With the lack of empirical research in aesthetics, we must sensibly use validated and reliable data that is available from other formal disciplines to inform our best recommended practice. Therefore, trauma-informed practice should be considered an emerging concept within the industry that if adopted has the potential to increase patient engagement and retention, improve treatment outcomes, reduce avoidable redress costs and avoid costly business consequences due to the emotional fallout of the patient.8

Defining a trauma-based approach Historically, trauma was regarded as a purely physical notion that was used in the context of medicine to distinguish between a blunt force or penetration causing injury to the body.9 The definition of trauma has since been expanded to include the lasting emotional experience of three separate, but related components:10 1. 2. 3.

Acute trauma – a single event Chronic trauma – the exposure to repeated incidents Complex trauma – the experience of severe and sometimes pervasive adverse events that are often protracted (last for a long time) or are interpersonal (between people) in nature

How trauma affects the brain Biopsychology provides investigation into, and evidence of, lasting trauma through research into how the brain, its neurotransmitters, and other aspects of our biology influence our behaviours, thoughts, and feelings. The conclusive empirical evidence here demonstrates that trauma affects the brain by causing structural damage to the temporal lobes in the prefrontal cortex.11 This area of the brain is known for executive functioning and problem solving. There is also a further biological or chemical damage here that impacts the flow of dopamine to these brain structures.12 Dopamine is a type of neurotransmitter. Your body makes it, and your nervous system uses it to send messages between nerve cells. Why is this relevant to your aesthetic practice? Because dopamine is fundamental to the human motivation and reward systems, therefore it is essentially implicated in every one of your patients.10 Dopamine may be amongst the most important criteria for patient selection, given the near ubiquitous exposure of trauma within the developed population.13 It is of note that some people will be more at risk than others and we must take into account genetics, social factors, economic circumstances, existing mental health conditions and neurological conditions which can all play a contributory factor here.13


When released in large amounts, dopamine creates feelings of pleasure and reward, which motivates us to repeat a specific behaviour e.g. eating or sleeping.14 Dopamine is informing your patients constantly and subsequently motivating them to seek rewards through your aesthetic or cosmetic interventions. However, dopamine cell firing can encode errors in reward prediction, especially when trauma is indicated, and it can provide faulty learning signals.14,15 It is therefore essential to consider how this ‘plays out’ in the clinic and what this means for patient satisfaction and practitioner performance. Example scenario An excited patient comes into the clinic after seeing a promotion on social media and has a great consultation, loves the team and can’t wait to get started on their journey. They pay a deposit and book in their next appointment. They are thrilled with the treatments and love their new look but then, something shifts. They think they are experiencing an adverse event and they want to see you urgently – they want their money back and they want to look the way they looked before. This could go as far as a formal complaint, disparagement and an insurance company pay out. Whilst we may not be able to test for dopamine directly ahead of any treatment, we can extrapolate findings to confidently evidence base the relevance and argument for trauma-informed practice in your clinic. This therefore provides a unique opportunity for aesthetic providers to incorporate psychology and emotional aspects of aesthetic care and to make an important contribution to healing and growth.12

Implementing the trauma-informed approach It is important to understand that lasting effects of trauma can present in an individual as a loss of safety, a loss of or misinterpretation of danger cues, a loss of physical connection to the body, loss of trust, intimacy troubles, shame, dissociation, depleted self-worth, re-enactment, and a loss of sense of self.16 This can also be inflated or triggered by in-clinic experiences such as poorly constructed consultations, breaches of confidentiality, as well as adverse reactions. Therefore, the guiding principles for the implementation of a trauma-informed approach are safety, choice, collaboration, trustworthiness and empowerment.17

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021




We must accept that patients may be deceitful in order to protect or disguise their emotional vulnerabilities Trauma-informed care seeks to acknowledge the widespread impact of trauma and how it can affect people and groups through the four Rs: Realisation and Recognising the signs and symptoms of trauma in patients, families, and staff. In turn, this integrates knowledge about trauma into policies, procedures, and practices to implement a system that can Respond to trauma by actively Resisting or avoiding re-traumatisation.17 Below are some of the ways aesthetic practitioners can ensure their patients’ mental health is protected by using a trauma-informed approach. Expand your consultation skills beyond a ‘fix it’ transaction Offering an immediate solution to a patient’s problem positions you and the patient in a ‘fix it’ mentality which will be working against the four Rs. Avoid consulting and treating on the same day and implement a cooling-off period. Similarly, avoid fulfilling patient-led requests that rely on persuasive communication to do something you are not 100% comfortable with. Do not have another team member do a consultation for you if you intend on treating a patient, as being present in the consultation is essential to realise the impact of trauma and recognise the signs and symptoms that may be present, for example, an urgency for treatment. Increasing your consultation time to suitably explore the past and present to build a more accurate patient profile beyond the presenting concern is necessary to respond accordingly. Be sure to give yourself adequate time to make your notes too (e.g. 50min consultation + 10min write-up). Ask about previous treatments and satisfactions ranging from skincare to invasive surgery. Be curious with motivation and satisfaction – how does this perceived appearance flaw relate to quality of life factors, self-worth, work or education, cost and convenience, intimacy or social support, mental health or wellness function and the sense of safety, danger and connection? Educate and explain the risks Encouraging fast moving trends may inflate the risk of re-traumatisation in your

patient resulting in dissatisfaction, costly and time-consuming complaints, financial redress and complex case management issues. Promotional offers which encourage an urgency for treatment will also attract new risk-taking behaviours to your clinic. It is important to look at the proxy risks of treatment e.g. financial, and emotional risks too. Providing patients with written pre- and post-care advice with a fully explained and transparent treatment plan with prices, payment terms, your cancellation policy, satisfaction redress and your complaints policy demonstrates a clear system that is responding to trauma through procedural means. Support this with a mandatory cooling-off period to ensure time is taken to understand this fully with no financial penalty to the patient for doing so. Protect confidentiality but not secrecy Pay close attention to patients that only pay in cash, or don’t want to provide a next of kin or a GP contact, or those that are not on top of their regular health screening checks. Recognise that for some patients, aesthetics may be a secretive behaviour that may perpetuate self-neglectful behaviour because of trauma. We must accept that patients may be deceitful in order to protect or disguise their emotional vulnerabilities. In context, a patient may not have adequate meaningful social support despite being social and having lots of friends. This can prove difficult for downtime and treatment reflection for satisfaction as this space can be filled with isolation and negative appearance ruminations which can present a danger to the patient as they look for ways to cope with their maladaptive aesthetic treatment alone. It is important not to judge this, but to be confident to respond to such red flags and have a responsible policy that encourages openness and a supportive atmosphere within your clinic. Say ‘no’ from the outset This may seem counterintuitive but using blanket advertising and marketing that assumes everyone is a candidate or using gift vouchers for aesthetic or cosmetic

interventions is dangerous practice that can inflate insecurities or vulnerabilities in a patient. A symptom of trauma is a disconnection from the body which makes treatment satisfaction harder for these survivors.8 Implicated further is their understanding of what the body is seeking. This may be misunderstood despite every best effort to soothe the discomfort they are experiencing. Establishing strong referral links with experts to support your patient’s needs and clinical decisions is important for successful transition or multidisciplinary care. Saying ‘no’ doesn’t have to mean no treatment. Building trusted outcomes along a patient journey to promote authentic connection and patient retention is essential to identify, access, understand and respond to patterns of internal signals of the body appropriately. You may wish to introduce mindful breathing with your patients and reflect on reactions that give clues to what the patient is feeling.

Consider trauma-informed care Much has been published in recent years about trauma-informed care and the importance of healthcare providers to factor past trauma into their care approach. The main objective is to secure ethical practice and psychological safety to increase your business prospects through improved patient satisfaction and practitioner performance. To further your knowledge you can visit the Integrated Practitioners of Aesthetic Wellness website to learn more ways to ensure the mental health of your patients is protected when seeking aesthetic or non-cosmetic treatments. Kimberley Cairns is a published psychologist and member of the British Psychological Society with 16 years of acute mental health and aesthetic clinic management experience. Specialising in psycho-aesthetic solutions, Cairns has numerous key appointments including that of clinical advisory and fitness to practice within the JCCP.


Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021

Advertorial Prollenium




The doorstep technique Using the tacky texture of REVANESSE® CONTOUR™, Dr Swift performs what he calls the ‘Doorstop Technique’. Pulling the skin of the jawline back towards the upper ear, he injects a small bolus of the product to act as a doorstop, preventing the retaining ligaments from folding forward. While he proceeds to inject the other side, the patient is tasked with holding the face in place with a cold compress.

The double scoop

Mastering the Mid-face with Revanesse® REVANESSE® causes a stir within the aesthetics industry following its official launch at CCR A leading global voice in non-surgical aesthetics, Dr Arthur Swift, roused widespread anticipation when he took to the stage to reveal his world-renowned injection techniques at CCR in London on October 14 and 15. The aesthetics heavyweight spilled his secrets in a symposium on the OMGEE Curve: Mastering of the Mid-face with REVANESSE®. A play on the Ogee Curve, the name given to the double S-shaped curvature along the cheeks that gives the face contour and dimension, the symposium uncovered Dr Swift’s secrets to creating mid-face masterpieces, unveiling

the injection techniques he uses to counteract the downward protection that occurs with age. Citing the amazing rheology of REVANESSE®, Dr Swift explained how he uses SHAPE™ deep in the periosteal plane to project and lift, followed by CONTOUR™ deftly layered with a cannula to create the soft, S-shaped curves he’s famous for. He cast a spotlight on two of his most illustrious techniques, united in the idea that a systematic approach to cheek enhancement means using less product to achieve better results.

Have you tried REVANESSE® in clinic yet? Try one of each product Kiss, Ultra, Contour & Shape for a special offer price of £532. At just £66 per 1.2ml syringe, this equates to £55/1ml… that’s more fill for your ML! Redeem with code: JanAJ22 It’s simple, type the code into the search bar and your basket will load with the special offer! Offer valid for a limited time only at Healthxchange


Aesthetics | December 2021

Likening the product to a scoop of ice cream, Dr Swift layers two boluses on top of one another to project the cheek upwards. Using REVANESSE® SHAPE™, he injects a small bolus down onto the bone before lifting the skin up vertically and injecting a second bolus directly on top. The two balls of product sit on top of each other and push the mid-face up, as opposed to projecting it outwards.

The Swift seal of approval One of only five companies to receive FDA approval, REVANESSE® has already become a big player in the US and Canada,1 where it has revolutionised the aesthetics market with its unique formula, commitment to high-quality ingredients, and innovative manufacturing technique. The state-of-the-art dermal filler has spherical particles which give it its key selling points of safety and performance. The gel’s smooth integration can be linked to their particle shape and low levels of modification, which can reduce immune responses and inflammation.2,3 The spherical shape is designed to be accepted by the body and provide smooth, beautiful results that perform throughout the lifecycle of the skin. Smooth Spheres, Less Inflammation, More Volume. This advertorial was written and supplied by

For more information, please contact


Prollenium UK

REFERENCES 1. FDA Premarket Approval (PMA) Database (P040024/S072). Approval OrderStatement for Restylane® Silk™, 2014. Restylane® is a registered trademark of Nestlé Skin Health SA. 2. Edsman K, Nord LI, Ohrlund A, et al. Gel properties of hyaluronic acid dermal fillers. Dermatol Surg. 2012;38:1170–1179. 3. Laeschke K. Biocompatibility of microparticles into soft tissue fillers. Semin Cutan Med Surg. 2004 Dec;23(4):214-7. doi: 10.1016/j.sder.2004.09.005.




In The Life Of Dr Arthur Swift Canadian plastic surgeon Dr Arthur Swift outlines his typical working day and how he gained popularity across the globe A typical working day… My typical working day starts by waking up at 5-5:30am – my body doesn’t let me sleep any later! I do some stretching and have a shower. I don’t really eat breakfast – around three sips of orange juice is enough – and I head straight to my clinic in Montreal, Canada. Each day varies, and I have surgical days and non-surgical days. If it’s a surgical day, it begins at around 7:30am and I might conduct between three to eight surgical cases. I’m a full body surgeon so I perform a wide variety of surgeries throughout the day, from faces, noses and eyelids to breasts and abdominoplasties. If I could choose one surgery to perform for the rest of my life, it would definitely be face-related as I’m fascinated with facial beauty, so it would probably be rhinoplasty. I’ve brought a younger surgeon into my practice now to take on heavier cases, such as thigh and arm lifts, which has enabled me to narrow my focus down a bit and do more non-surgical procedures. My injectables day starts at around 8am – I like to give my injectable patients the extra half-hour to sleep in! I see quite a few patients, usually up to 45. Some appointments might be follow-ups to check results and ensure there are no complications, and others will be actual procedures. I feel like I’m a little bit too busy for someone who is mature, but for the next 10 years I’m going to concentrate more on education and teaching, whilst performing non-surgical treatments and injectables, and occasionally some surgery too. Once the day has finished, I’m off back home again. Usually in the summer months it means I can get into the pool and swim a couple of laps to keep somewhat in shape, or have a nice outdoor barbeque. However, during the winter months, I enjoy going skiing on the weekends or doing activities to try and stay active.

but it takes one moment in life to bounce you off that path and open other avenues. I wrote an article called BeautiPHIcation: A Global Approach to Facial Beauty, trying to explain how to use ratios and proportions on the face when performing dermal fillers and botulinum toxin injectables. I was soon invited to a scientific meeting to discuss it, and the next thing you know, my life turned upside down and I didn’t expect so many people to find it useful! I think the most fascinating thing is that the article was published in 2011 – 10

Career if you weren’t in aesthetics… I think I was destined to be a rockstar! I had a musical background and was taught classical piano when I was younger and loved it.

Favourite movie… I have two – Shawshank Redemption and Amadeus. I could watch them numerous times and still be entertained.

If you could live anywhere… The story behind the famous BeautiPHIcation paper… I was a home-grown, community plastic surgeon working at McGill University in Montreal and teaching residents. The direction of my career was on a singular path,

I was fascinated with Cape Town when I visited. I also love London, Paris, and Vienna, which are all beautiful and I would happily live in one of these cities.

years ago – and people are still reading it now. When is it that you find a physician or healthcare professional pick up an article which is 10 years old? I didn’t create the ‘golden ratio’ theory, it’s been around for thousands of years, but putting it into writing and applying it to injectables in the face seems to have had a longevity that I never expected. Soon, I was being invited to explain my thoughts and concepts all over the world, which it turned out I had a knack for! I try to make my talks educational but also with some entertainment, and so I became more in demand. My recent educational trip was to CCR London with Canadian dermal filler brand Prollenium to launch Revanesse dermal fillers to the UK market. I enjoyed two fantastic days of teaching and learning, whilst conducting symposiums on lips and tweaks with Revanesse and mastering the mid-face with Revanesse. I also had a dedicated ‘an audience with’ session in which I got to answer questions and explain my experiences to UK practitioners.

Most memorable day in my career… They say you never forget your first! In one of my first surgeries, I remember it was a reconstructive surgery on a woman who unfortunately was born with a cleft deformity and due to living in a rural province of Quebec, they didn’t understand how to deal with it. Instead, the medical team removed the part of the lip which was in the middle and closed her mouth. As a result, the patient ended up with a mouth that was going to split! She never had the chance to eat solid food and could only eat through straws, and she worked as a telephone operator in the basement of a building because she was so embarrassed to be seen in public. I met her when she was in her 40s and said we would try to rebuild and recreate the mouth. Within the surgery, we gave her more of a mouth as well as some very nice lips! The patient ended up getting her life back and left her job as a result. Aesthetics and surgery are all about having an impact and being able to restore confidence in people’s lives.

Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021



The Last Word Aesthetic nurse prescriber Lisa Waring argues the relevance of blended learning in aesthetic training The impact on education services over the last 18 months has become a subject of great interest for many researchers worldwide, particularly due to the exceptional situation generated by the COVID-19 crisis.1 Accelerating the transition from face-to-face learning to online has completely changed the shape of normal teaching practice.2 Many training academies and companies have been forced to adopt new methods of providing their courses and even redesigning their delivery process to actively adopt to and cope with the realities of the pandemic.3 As a whole, communities are accepting the changes and adapting – but I believe these changes need careful balancing! We must ensure we avoid the pitfall of ‘maintaining the distance’ and losing face-to-face learning altogether.

The benefits of e-learning The literature is flooded with the benefits of e-learning and how it may positively complement traditional medical teaching.4,5 Some pieces of literature are even suggesting that it may lead to a higher outcome regarding learning progress and competence acquisition.6 Literature provides results in favour of using online learning in terms of its usefulness and positive influence on delegate performance and the fact that it can be accessed from anywhere at any time, and it’s universal.5 This may make it a win-win for most training companies and the trainees. Aesthetics is rapidly changing, and therefore continuous professional development (CPD) remains vitally important, yet since the outbreak of COVID-19 large global companies (that have a strong focus on

education) may want to continue with distance learning due to the evident benefits it affords the company. There is no doubt that this format and its unique attributes provides an enormous flexibility in terms of time management and allows for widen access and increased diversity globally.2 I believe that for our specialty, one of the biggest advantages is that it allows for the possibility of using highly experienced professionals and experts who may not have the time to physically attend an event in person to deliver global training to vast audiences, saving time, money and resources. Although research to date has shown that e-learning is an excellent tool, there has been research recognising inhibiting factors affecting e-learning, such as distractions and time management, difficulty staying motivated, adapting to unfamiliar technology and technical issues.2 This is why I believe using solely e-learning may be detrimental to aesthetic practitioners, despite its benefits.

We cannot lose the human aspect The debate of traditional vs. distant learning will continue in the literature for years to come no doubt, and despite the evidence of e-learning’s effectiveness, I believe we still must strive for human contact. Working as a nurse lecturer and trainer, I’m of the opinion that face-to-face training is still the best experience a learner can have. Meaningful learning is experiential, it leads to understanding and the ability to make sense of things.8 Yes, we know that learning is an innate element of human development, and thus the delivery of the education should not


affect our ability, but training companies and facilitators have a significant contribution to make in enabling learners to learn effectively and efficiently through experience, especially in the field of aesthetics.5 Hands-on training is vital in our industry, as it provides the perfect simulation of the actual in-clinic treatment, where potentially delegates will be working unaided. The comprehensive measures of social distancing, restricted social connections, and loss of routine potentially also have a huge negative effect on our social networks and mental wellbeing. In an already lonely career where practitioners often work in isolation, the need for being face-to-face with other colleagues is critical.4

So, what should we do? At my training academy, as well as many others in the medical aesthetics field, blended learning has become the norm for us. Blended learning can be defined as combining faceto-face education and internet mobile-based learning.3 We choose this approach as we believe it provides a number of processes such as pre-learning and evaluation of the teaching process in the web environment with the opportunities offered by online environments, thus enabling this period to be directed to more efficient education/training processes by shortening the face-to-face learning process.3,4 By blending both e-learning and traditional teaching, research has shown that both tutors and students cope better as both have the opportunity and enough time to deepen their studies, activities and experiences.3,4,7 I believe that by combining what we already did with what we now must do, we can allow students to master knowledge and gain comprehension outside of class, and focus on application and synthesis in class. Lisa Waring graduated from the School of Nursing at Queen’s University Belfast in 2005 as a RGN. She opened her clinic, FacetherapyNI, in 2016. With her love of education, she set up her own training academy FT Academy. Qual: RGN, SCPHN, PGCE, INP


Reproduced from Aesthetics | Volume 9/Issue 1 - December 2021


12 March 2022 | Royal Lancaster Hotel, London

Each ticket includes A celebratory glass of prosecco on arrival | Professional photographs at the Aesthetics Awards press board | A delicious three-course meal with complimentary wine | A celebrity guest host | Dancing into the night S C AN T H E Q R CODE TO BO OK YOUR TICKE T NOW