VOLUME 8/ISSUE 3 - FEBRUARY 2021

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

To find out why Juvéderm® could work for your clinic on every level, visit juvederm.co.uk

2020 Allergan. All rights reserved. Model treated with Juvéderm. Individual patient results may vary. Produced and Funded by Allergan Aesthetics. UK-JUV-2050344 October 2020 Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/. Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.

Juvederm_AnyLevel_MagazineCover_Aesthetics Key Visual_V2.0.indd 1

Toxin and The Lower Third CPD Mr Ali Juma explores botulinum toxin A in the lower third of the face

Getting Started with Marketing An introduction to the basic marketing strategies which can grow your practice

Instagram Engagement

Heather Terveen on how to increase patient engagement via Instagram

14/10/2020 14:29

Incorporating Blogging Rick O’Neill explains why blogging is an important marketing tactic for business

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

To find out why Juvéderm® could work for your clinic on every level, visit juvederm.co.uk

Produced and Funded by Allergan Aesthetics. UK-JUV-2050405 October 2020 ©2020 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 https://yellowcard.mhra.gov.uk/. Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.

Contents • February 2021 06 News The latest product and industry news 13 Advertorial: Restylane Kysse The clinically-proven filler of choice for ‘kissability’ 18 News Special: Needles vs. Cannulas Aesthetics looks into the considerations for choosing cannula over needle 20 Advertorial: Combination Lifting Dr Huw Jones shares his approach to facial ageing

News Special: Needles vs. Cannulas Page 18

CLINICAL PRACTICE 21 Special Feature: Getting Started with Marketing Aesthetic marketers provide an introduction to enhancing engagement 26 CPD: Toxin and the Lower Third Mr Ali Juma explores the use of BoNT-A in the lower third 33 Case Study: Treating the Profile Dr Linea Strachan details her approach to profiloplasty 39 Understanding Skincare Preservatives Miss Jennifer Doyle discusses commonly used preservatives in skincare 43 Case Study: Male Facial Rejuvenation Dr Manav Bawa shares his approach to staged injectable treatments 46 Reducing Viruses in Clinic Air Physicist Mike Murphy explains how to reduce viruses in your clinic 50 Advertorial: Grow Your Business with Thermage FLX A real opportunity to grow your business during this unprecedented time 51 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 52 Marketing to Skin-of-Colour Patients The Black Aesthetics Advisory Board share their advice 54 Utilising Waitlist Marketing PR consultant Julia Kendrick discusses waitlist marketing 57 Improving Instagram Engagement Marketing consultant Heather Terveen explores how to increase engagement 60 Using Illustrations in Marketing Lauren Rogers-Martin shares how illustrations can captivate your audience 63 Enhancing Email Marketing Miriam Shaviv explains how clinics can use emails to their advantage

In Practice Getting Started with Marketing Page 21

Clinical Contributors Mr Ali Juma is a consultant plastic and reconstructive surgeon, and the proprietor of the Clinic @51 in Liverpool. Mr Juma’s experience includes teaching on the safe use of non-surgical treatments through cadaver courses, as well as participating in scientific research and writing. Dr Linea Strachan is the owner/founder of Dr Linea Medical providing non-surgical aesthetic, skin and laser treatments with established clinics throughout East Anglia. She is also the founder of Dr Linea Training Academy. Miss Jennifer Doyle a Fellow of the Royal College of Ophthalmologists and a lead trainer at Harley Academy. She currently works as an NHS registrar in ophthalmology, as well as leading her clinic, Oxford Aesthetics. Dr Manav Bawa is an aesthetic practitioner and GP with a surgical background. He is the medical director of Time Clinic in London, an injectables trainer, and has completed a Diploma in Aesthetic Injectable Therapies. Mike Murphy is currently the General Secretary of the UK Council for Surgical Plumes and General Secretary of the Association of Laser Safety Professionals, is a Certificated Laser Protection Adviser and registered as an LPA with Healthcare Improvement Scotland.

66 Incorporating Blogging Digital consultant Rick O’Neill describes why blogging is an important

marketing tool

68 Advertorial: In the Life Of Dr Paula Mann The Merz innovation partner talks hosting webinars 69 In Profile: Dr Paul Nassif Dr Paul Nassif explains why Botched is more than just a TV show 70 The Last Word: Harley Street Training Dr Steven Land debates the phrase ‘Harley Street trained’ in marketing NEXT MONTH In Focus: Injectables • Addressing Filler Complications • Treating the Deep Pyriform Space

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1. TEOSYAL® PureSense Redensity 2 – instructions for use — 2. Berguiga M, Galatoire O. Tear trough rejuvenation: a safety evaluation of the treatment by a semi-crosslinked Hyaluronic Acid filler. Orbit, 2017; 36 (1):22-26. — 3. Teoxane Post Marketing Surveillance from 2016 to 2020-Q3 — 4. Data on File. Torsion and compression tests assessed on a rheometer. The measurement of the rheological parameter Delta index represents the balance between gel viscosity and elasticity. Physical analysis of HA fillers intended for infraorbital uses. RDRE 2023. — 5. TEOXANE Post Marketing Surveillance Survey. September 2020. 1504 respondents — 6. Teoxane internal data source. TEOSYAL® PureSense Redensity 2 deliveries from 2012 to 2020: 1’011’774 boxes. TEOSYAL® PureSense Redensity 2 is a trademark of the firm TEOXANE SA. This product is a gel that contains 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 Redensity 2 is a class III medical device and is regulated health product bearing the CE marking (CE2797) under this regulation. For professional use only. Please refer to instructions for use. This product availability depends on registration, please contact your local distributor. Please inform the manufacturer TEOXANE of any side effects or any complaint as soon as possible to the following address: medical@teoxane.com.

Editor’s letter Welcome to our February issue. Despite a difficult start to the year with strict lockdowns and clinics closed, it’s been heartening to see many aesthetic practitioners using their time to support the vaccine rollout, bringing us ever closer to the day we get to meet in person again!

Chloé Gronow Editor & Content Manager

And if you’re not busy home-schooling or volunteering, now is an excellent time to review your marketing strategies for 2021 to ensure you’re raring to go when clinics can safely reopen. That’s why all the business content in this issue is entirely focused on marketing! If you’re new to aesthetics you can read our introductory overview on p.21, featuring top tips from three excellent marketers – including our very own marketing manager, Katie! They share hugely valuable advice, taking you through the marketing journey from start to finish, so it’s well worth a read. If you’re looking for more specific topics, check out p.52 onwards. @chloe_aestheticseditor

One of the key messages all contributors have highlighted is that knowing your audience is essential. For example, it’s not enough to say you simply want to target every woman over the age of 30 – to build long-lasting relationships with loyal patients you need to really understand their concerns, challenges and interests to know exactly how to best communicate with them. Each of our articles have lots of tips and tricks to do this successfully, so let us know what you found most useful! How many of you use the phrase ‘Harley Street trained’ in your marketing? It seems to be a popular way to demonstrate your expertise to prospective patients, with the general UK public recognising the prestige of the central London location. But what does it actually tell patients about your level of training? Dr Steven Land puts forward a strong argument for revising its use in our Last Word on p.70 – we’d love your feedback on this, so do share your thoughts! You can email us via editorial@aestheticsjournal.com or tag us on Instagram @aestheticsjournaluk

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

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

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 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 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 | alison.willis@easyfairs.com EDITORIAL Chloé Gronow Editor & Content Manager T: 0203 196 4350 | M: 07788 712 615 chloe@aestheticsjournal.com Shannon Kilgariff Deputy Editor T: 0203 196 4351 | M: 07557 359 257 shannon@aestheticsjournal.com Holly Carver Journalist | T: 0203 196 4427 holly.carver@easyfairs.com

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ADVERTISING & SPONSORSHIP Courtney Baldwin • Event Manager T: 0203 196 4300 | M: 07818 118 741 courtney.baldwin@easyfairs.com Judith Nowell • Business Development Manager T: 0203 196 4352 | M: 07494 179535 judith@aestheticsjournal.com Chloe Carville • Sales Executive T: 0203 196 4367 | chloe.carville@aestheticsjournal.com MARKETING Aleiya Lonsdale Head of Marketing T: 0203 196 4375 | aleiya.lonsdale@easyfairs.com Katie Gray • Marketing Manager T: 0203 1964 366 | katie.gray@easyfairs.com

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

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Safety

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

#COVID-19 Cosmetic Courses @cosmeticcourses Wow! Our expert trainers and nurses @alchemyaestheticsskinclinic and @ekaesthetics helping out at their local vaccination centres today! We are incredibly proud of our faculty who have all done their bit to support the current situation. #Consultation Cadogan Clinic @cadoganclinic Cadogan Clinic’s Director of Surgery @realplastics, logging in for a remote consultation list today. We’ve found these an excellent alternative to face-toface interactions during Covid.

#Webinar Dr Rita Rakus @drritarakus Dr Rakus was delighted to be part of last night’s webinar with @the_beauty_triangle!

New aesthetic qualifications introduced The Royal Society for Public Health (RSPH) has partnered with the newly-established Qualification Council for Cosmetic Procedures (QCCP) to launch new aesthetic qualifications for healthcare professionals. The QCCP concept was initiated by government-approved register Save Face, with the intention to develop competency-based qualifications in aesthetic medicine that are regulated and awarded by the RSPH. The first two qualifications launched by the QCCP are the Medical Aesthetics Certificate in Understanding the Safe Use of Botulinum Toxin in Cosmetic Procedures and the Medical Aesthetics Certificate in Understanding the Safe Use of Dermal Fillers in Cosmetic Procedures. To gain the qualification, healthcare professionals must pass a two-hour online exam to assess their knowledge and understanding of safe practice fundamentals. They may take a free online self-assessment prior to their exam to identify their learning needs and choose to access relevant further training from a list of RSPH-approved training centres should they need. Practitioners on the QCCP council include pharmacist Gillian Murray, who is the council lead, and council members Dr Lee Walker and Dr Cormac Convey, and nurse prescriber Emma Davies. Murray said, “We are excited to be working with The Royal Society for Public Health in bringing a suite of RSPH-regulated qualifications together for the cosmetic procedure industry. Current levels of education and training are not standardised across the UK among aesthetic practitioners. This gives rise to different practice standards and allows misleading claims of competence.” Duncan Stephenson, deputy chief executive of the RSPH, said, “We are pleased to have partnered with the QCCP in developing this qualification, to both support healthcare professionals who administer these treatments and provide reassurance to the public.” Dermal filler

#Education Dr Pradnya Apte @drpradnyaapte Essential reading to keep abreast of my knowledge of all things Aesthetics! #Aestheticsjournal

#Vaccine Dr MJ Rowland-Warmann @dr_mj_smileworks There is light at the end of the tunnel. As key medical workers, we were able to get the @pfizerinc Covid vaccine today! The process was quick, easy, and painless.

New study indicates improved attractiveness with lip filler A new marketing study has indicated a high level of patient satisfaction following lip enhancements. The phase 4 ‘Kissability’ study, conducted by global pharmaceutical company Galderma, evaluated 59 patients using a subject-assessed Global Aesthetic Improvement Scale eight weeks after the procedure, as well as photographic review of naturalness of expression, age and lip texture. After being treated with dermal filler Restylane Kysse, 96% of patients said that their lips had a natural look after treatment, 87% felt more attractive and 100% rated their lip fullness as improved. Dr Priyanka Chadha, director of training provider Acquisition Aesthetics, commented, “This is a really novel study as it’s showing that patients were satisfied with the look and feel of their lips, posttreatment. The study will act as a valuable tool for practitioners to help educate and inform their patients, helping reassure them about the natural look and feel that can be achieved with Restylane Kysse!”

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Body sculpting

Cutera releases new concept featuring two devices Aesthetic device manufacturer Cutera has introduced the new truBody concept to the UK, combining its body sculpting platforms truSculpt iD and truSculpt flex. The device aims to achieve an average of 24% fat reduction and 30% muscle mass, according to the company. Cutera explains that the protocol focuses first on removing the excess fat using truSculpt iD, a monopolar radiofrequency technology used for lipolysis and deep tissue heating. It then introduces the truSculpt flex, which uses an electrical muscle stimulation technology, that aims to strengthen and tone the body. Dr Nestor Demosthenous, aesthetic practitioner and owner of Dr Nestor’s Medical Cosmetic Centre, commented, “truBody allows me to target the most common body concerns I see in clinic such us stubborn areas of fat, a lack of definition and general skin laxity. This protocol allows me to now tap into another demographic altogether; people who aren’t necessarily coming for injectable treatments, but they are looking to improve their body. It is also encouraging a lot more men to come into my practice. So, there is a great cross sell because we are offering a more holistic approach to patients.” Light

Celluma to present exclusive LED webinar LED device manufacturer Celluma will present a webinar exclusively on the Aesthetics website, discussing everything you need to know about light emitting diode (LED) devices. The talk will be hosted by CEO Patrick Johnson, and will cover the differences between near-infrared, red and blue light, the importance of wavelengths, monochromatic vs polychromatic and much more. The webinar will take place on February 18 at 2pm. Denise Ryan, vice president of brand management at Celluma Light Therapy, commented, “We are thrilled to be a part of this opportunity to share more about the benefits of light therapy and how Celluma’s unique shape-taking design combined with our marketing and educational assets can help transform practices. Our low-touch treatments, rental and retail opportunities and commitment to the safety of your patients is second to none. We look forward to sharing more about all we have to offer and answering practitioner questions at our upcoming webinar. We hope to meet many of you there!” Delegates can register via the Aesthetics website.

Vital Statistics 57% of 1,000 respondents said they invested in skincare to bring positivity into their lives (VSCO, 2021)

On average, nursing staﬀ are washing their hands around 81 times a day, double the amount from before the pandemic (NursingNotes and Nursem, 2020)

44% of 1,000 respondents picked healthcare professionals as the group showing the greatest levels of positive leadership (LIFT Ireland, 2020)

38% of 2,017 people in Britain think that 2020 aged them more than any other year (Uvence, 2020)

81% of 1,200 participants said they were motivated to make a health goal in 2021 (Life Time, 2020)

16% of 8,205 adults aged 16 and over screened positive for a possible eating disorder (NHS, 2020)

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Events Diary

2MAY 8 & 28 9 & M2 A 9, Y 2 2 1 |/ LOND L O N DON ON 20 02 AESTHETICSCONFERENCE.COM

Vaccinaction

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Skincare

AestheticSource introduces new online education Aesthetic distributor AestheticSource will host CPD-accredited webinars and live training throughout February and March. Aesthetic nurse Anna Baker and aesthetic practitioner Dr Amiee Vyas will host separate training sessions on skincare brand NeoStrata, discussing the science, technologies, products, regimens, and techniques. Baker and Dr Vyas will also join medical director Dr Jeanett Segal to discuss pigment correcting treatment Cyspera. AestheticSource training and key account manager Nikki Jones will explore the skincare brand Exuviance, talking about the science behind its products and its training protocols. There will also be various Skinbetter Science product webinars and AlphaRet Peel trainings with Tracy May-Harriott, head of international education and development at Skinbetter Science. Expansion

BCAM encourages members to volunteer The British College of Aesthetic Medicine (BCAM) has encouraged its members to sign up for the NHS COVID-19 Vaccination Programme to help with the mass roll-out of the vaccines across the UK. Practitioners can sign up via the NHS website or by contacting their local GP surgeries to offer their assistance to become vaccinators. BCAM president Dr Uliana Gout, who has also applied to the Vaccination Programme, said, “Our members have a wealth of medical experience and expertise that is of great value during this unprecedented national emergency and we’re delighted how many members have promoted the vaccination campaign and have applied to be vaccinators. The ultimate aim is to achieve mass vaccination as quickly as possible. BCAM is committed to supporting the national effort and assisting the NHS in delivering the programme.” Aesthetic clinic chain teams from the Private Clinic and Cosmetics Skin Clinic are also volunteering to administer the AstraZeneca vaccine. The clinics have 16 sites across the country, employing approximately 100 surgeons, doctors and nurses.

BTL expands business to Ireland Device manufacturer BTL Aesthetics has opened a new office in Dublin, Ireland. The company explains that the BTL Ireland office will cover both the Republic of Ireland and Northern Ireland and will be headed up by country manager Dee MacMahon. MacMahon has worked in the industry for 15 years, having launched the UK aesthetic branches for Johnson & Johnson and Merz Aesthetics, as well as heading up the Med-fx Irish business launch. She said, “BTL Ireland will offer leading expert service, training, and support to all our valued customers whilst introducing them to transformational technology platforms to enhance their business. Ireland has been long awaiting a heavyweight device manufacturer as exciting as BTL to arrive and land permanently on Irish soil, offering a fully dedicated best-in-class business opportunity based in Ireland, for Ireland!” Eddie Campbell-Adams, BTL business development director UK and Ireland, commented, “Opening an Ireland-focused BTL office with Mahon at the helm is a significant milestone for BTL Industries. We intend to support the Irish medical aesthetic expert clinics to successfully grow their business with BTL’s industry leading systems.” Learning

Acquisition Aesthetics launches complications course Aesthetic training provider Acquisition Aesthetics has launched an online masterclass to help practitioners prevent, recognise and treat complications. According to the company, the course comprises an anatomy-orientated programme of lectures and videos led by the faculty’s core instructors, Dr Lara Watson and Dr Priyanka Chadha. Delegates will be navigated through the recognition and diagnosis of complications in toxin and dermal fillers, and provided with protocols for their management. Acquisition Aesthetics explains that delegates will be able to move through the course in their own time and at their own pace.

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Education

First ICAN conference to take place this month The International College of Aesthetic Nurses (ICAN) has released the agenda for its first virtual conference, which will take place on February 23 and 24 at 6pm. The Tuesday event will feature talks from aesthetic practitioner Dr Nestor Demosthenous on consultation skills for beginners, sales and marketing manager John Campbell on the Allergan Spark Programme, business development manager Hannah Vincent on PCA Skin, nurse prescriber Lisa Whiting on starting in aesthetics, and nurse prescriber Emma Davies on aesthetic complications. The Wednesday event will include presentations from aesthetic practitioner Dr John Curran discussing medical VAT in aesthetics, Dr Demosthenous on periorbital rejuvenation and aesthetic nurse Patricia Goodwin on dermal filler Ellansé. Amanda Wilson, founder of ICAN and aesthetic nurse prescriber, commented, “The conference has been designed and tailored to meet the needs of both beginners and advanced nurses in aesthetics. It has been designed by nurses thinking of the requirements of these two groups of delegates and aims to equip them with more knowledge to advance in this wonderful field of aesthetics. We have industry leaders giving the talks for the group and we are inclusive of nurses internationally.”

28 & 29 MAY 2021 / LONDON

T WO F UL L DAYS O F EDUCAT IO N F RO M T EOXAN E During the exhibition, Teoxane will share their upcoming consumer campaign that promotes positive thinking and inclusivity. Their aim is to enable fillers to feel more accessible for everyone, so that anyone can choose a Teoxane filler and feel good.

Skincare

HydraFacial launches two new skin boosters

“As well as placing emphasis on our hyaluronic acid formulas and natural looking results, the campaign will introduce our brand-new consumer platform. Through personalised assessment techniques alongside directories of useful articles and content to refer to, the platform will support and educate the consumer through the complexities and unanswered questions regarding their dermal filler treatment. The virtual platform, alongside the campaign message and approach aims to take consumers on a wellinformed journey, enable a better understanding of our treatment possibilities and offer a sample of the personalised experience that we call the Teoxane Approach. All of our treatments are tailored to each person individually; we know that every person is different and so their treatment should be too.”

Skincare treatment brand HydraFacial has partnered with skincare brand Circadia to release two new topical skin serums aimed at boosting the skin. According to HydraFacial, the Protec Plus Booster delivers six different forms of hyaluronic acid and natural botanicals, designed to increase skin hydration, reduce signs of redness and provide protection against internal and external free radical damage. The Chrono Peptide Booster is designed to energise the skin and reduce the appearance of fine lines and wrinkles, explains the company. HydraFacial UK country manager, Martyn Roe, commented, “We’re pleased to be collaborating with Circadia and its unrivalled chronobiology skincare. These new boosters offer personalisation opportunities for clinics, harnessing name-recognition skincare pioneers with scientificallyvalidated ingredients.”

During ACE, Teoxane will host two days of educational content on the Teoxane Approach, embracing patients individuality through assessment of the A-T-P approach (assessment, ageing, anatomy, technique and product) during every personalised treatment. The educational content includes symposiums in partnership with their international faculty. HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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

EVENT RECAP In January, the BACN started its new monthly event format, with the theme Aesthetic Nursing in 2021 running throughout each event. BACN Chair Sharon Bennett and BACN event manager Tara Glover took to Instagram Live for the first In Conversation With series to discuss the past, present, and future of what the BACN is offering members. BACN members were also invited to a live webinar featuring board member Anna Baker, treasurer Jonathan Bardolph, and honorary member Constance Campion who discussed a wide range of issues including the role of the specialist nurse, the new BACN Professional Code of Conduct, and other concerns for nurses working in the specialty of aesthetics. Over 140 members watched the webinar live, which has been made available on demand in the members’ area of the BACN website. At the end of the month, members also engaged in a national peer review and social led by BACN board member Lisa Feliz, who offered insight and encouragement to newer members.

This column is written and supported by the BACN

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Patient safety

International complications group launches A new not-for-profit organisation called the Complications in Medical Aesthetics Collaborative (CMAC) has been formed to support practitioners worldwide in diagnosing and managing complications in medical aesthetics. The organisation aims to provide healthcare professionals with clinical support, develop and progress their ability to assess, diagnose and manage their patients with greater clinical independence and confidence. The CMAC board includes aesthetic practitioner Dr Lee Walker, CMAC chair, aesthetic practitioner Dr Cormac Convery, CMAC vice chair, nurse prescriber Emma Davies, CMAC treasurer, and prescribing pharmacist Gillian Murray, CMAC secretary. The organisation also has a multidisciplinary specialist advisory board with representations from plastic surgery, dermatology and ophthalmology. Dr Walker said, “We are pleased to have assembled the CMAC to provide invaluable resources for members when it comes to complication management. It’s a chance for practitioners to be involved in a more holistic learning approach to understand the complication process and become more responsible and safe injectors. We have an amazing faculty on board and we are excited to start this new community and welcome new members.” Retinal

Medik8 releases new serum UK skincare manufacturer Medik8 has launched the Crystal Retinal 20 serum as part of its Crystal Retinal range. According to the company, Crystal Retinal 20 is formulated with stabilised retinal, hyaluronic acid, glycerin and vitamin E. The serum aims to minimise fine lines and wrinkles, resurface skin texture and provide hydration. Medik8 explains that patients need to have used two full tubes of Crystal Retinal 10 or used it continuously for three months (whichever is sooner) in order to use Crystal Retinal 20, due to its strength.

FEBRUARY EVENTS Following the success of the new In Focus monthly series, February’s theme will be Trends in Complications. The second In Conversation With Instagram Live will be feature BACN Vice Chair and ACE Group World founder Sharon King who will be speaking with Dr Ewa Skrzypek, a professor at the University of Warsaw who is a consultant in histopathology, alongside working in aesthetic medicine. Sharon and Dr Skrzypek will be discussing soft tissue inflammation and implications in regards to COVID-19. Members also have access to the live webinar on Monday February 22, chaired by Sharon King, which will include a roundtable discussion on complications related to COVID-19 along with considerations over vaccines and any implications they may have in aesthetic practice. On Thursday February 25, BACN regional leader and honorary member Lou Sommereux will be leading the peer review and social, bringing along a clinical paper to review with other members. Members are now able to book all events via the BACN website.

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Industry

JCCP partners with the Royal Society for Public Health The Joint Council for Cosmetic Practitioners (JCCP) and the Royal Society for Public Health (RSPH) have formed a Memorandum of Understanding (MoU). The JCCP explains that the MoU has been set up to encourage public protection and consumer safety in the aesthetic industry by publicising and promoting the work and aims of both organisations, in order to raise public and professional awareness of best practice across the sector. According to the JCCP, the two organisations will collect and share information and will work in association with relevant advice from members of the aesthetic specialty in the UK. Professor David Sines, chair of the JCCP, said, “The JCCP is delighted to be working with such a renowned and prestigious organisation at the Royal Society for Public Health. Both organisations are aligned in their commitment to promote and disseminate best practice with regard to public safety and health protection in the aesthetics industry in the UK. By working together with the best interest of members of the public as the number one priority this partnership will be to the benefit of all.”

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Photography’s Role in your Marketing Plan

Photographer Hannah McClune’s monthly tips on how to strengthen your business through branding Imagery is an integral part of your marketing. A marketing roadmap is a must, although in this current COVID climate it seems hard to predict too far ahead. A plan that you can review each month – then adapt if needed – will keep your business being seen.

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Aesthetics

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Training

DHAT launches online cannula course Dalvi Humzah Aesthetic Training (DHAT) has launched an online version of its cannula training course. The company explains that the Cannula Core Knowledge course has been designed to help practitioners develop their skills for the safe use of blunt cannula for dermal filler placement. Concepts of cannula design, indications and recommended sizes in relation to anatomical areas will be explored throughout the training. In order to take the course, DHAT requires practitioners to have an in-depth knowledge of anatomy and injection techniques with needles, due to the emphasis on facial anatomy throughout. Skincare

mesoestetic releases new cleansing products As you look at marketing in this issue and outline your marketing activities for 2021 – whether that is launches, promotions, trade shows, press releases, networking, email series, advertising, social media, websites – you also need to consider what images you use for each of these. Being seen the right way is crucial. Professional images of you, your work and your clinic (rather than generic stock options), help grow your ‘like and trust’ factor with future patients. The more people feel they get to know you and your product or services, the more likely they are to buy from you.

When you review your current images visit each place you have imagery and check: 1. Is it in line with your branding? 2. Would it appeal to your dream patient? 3. Does it show your business the way you want to be seen? If you need any help I have a free downloadable workbook with a checklist to audit your images. Email for your copy, hello@visiblebyhannah.com

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

Pharmaceutical company mesoestetic has launched five new cleansing solutions. The company explains that the hydracream fusion is a facial cleanser formulated using squalane, a plant-derived oil, designed to provide nourishment and elasticity. The new brightening foam is a water cleanser formulated using AHAs, glycolic acid and lactic acid, designed to improve skin texture. According to mesoestetic, the new purifying mousse is made using chlorhexidine, salicylic acid and lactic acid, and is designed to unclog pores and improve skin texture. The hydratonic mist is designed to moisturise the skin, formulated using rose water and panthenol. The micellar biphasic is a new makeup remover which combines micelles with an omega 6 plant oil, designed to remove dirtiness and makeup. Industry

Lynton recruits new brand ambassador Laser manufacturer Lynton has appointed aesthetic practitioner Dr Ahmed El Houssieny as a new brand ambassador for the company. Dr Houssieny is the founder and lead medical practitioner at Bank MediSpa in Hale, which he opened in 2019. Lynton explains that as a brand ambassador, Dr El Houssieny will be providing other practitioners with promotional and educational support on the Lynton LUMINA device. Hayley Jones, sales and marketing director at Lynton, said, “We are delighted to have Dr El Houssieny on board as a Lynton brand ambassador for our LUMINA multi-platform device and dynamic reflex technology. With the LUMINA, he will draw upon his wealth of clinical experience and his passion for giving patients renewed confidence in their appearance to achieve outstanding results. Dr El Houssieny is driven by his strong values of natural, safe and effective enhancements, which mirror our own. We strongly feel that his knowledge, values and experience will help to support the continuous growth of the Lynton brand.”

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

100%

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Advertorial Galderma

aestheticsjournal.com

66 %100% of subjects rated their lip fullness as ’improved’, ’much improved’ or 61 % ’very much improved’ on the GAIS 8 weeks following their last treatment.

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REFERENCES 1. Nikolis A., Bertucci V., Solish N.; Post-marketing study to evaluate lip enhancement, naturalness and both PARTNER SATISFACTION (KISSABILITY) partner and subject satisfaction after treatment with HARK; Poster presented at IMCAS, France, Feb 2020.

PARTNERS WERE SATISFIED WITH

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SAFETY

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Aesthetics | February 2021

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93 %

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Aesthetic nurses

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Digital

BACN appoints new committee members

The British Association of Cosmetic Nurses (BACN) has co-opted aesthetic nurse prescribers Rachel Goddard and Adrian Baker onto the BACN Management Committee. Goddard is clinical director of Totally Aesthetics Training academy, as well as a country expert for the Teoxane Medical Faculty and she has previously been a member of the Allergan Medical Faculty. Baker is the founder of Lumiere Medispa and was a coauthor for the last BACN Aesthetic Nursing Competency Framework. Sharon Bennett, nurse prescriber and BACN chair, said, “I am so enthused with these new appointments. Goddard brings a host of skill sets to the board and we value her drive, knowledge, professionalism and her dedication in driving standards within aesthetic nursing. Baker is a highly respected, ethical and talented practitioner, with a particular passion for dermal fillers and soft tissue augmentation, focussing on patient centred care and evidence-based practice. He has clear insight into the key issues and professional development in medical aesthetic nursing. Having worked with him in the past we are delighted to welcome him back and draw from the host of skills he brings to the BACN.” Skincare

Skinbetter Science releases Refresh Cleansing Gel Skincare company Skinbetter Science has introduced the Refresh Cleansing Gel to its portfolio. The company explains that the cleanser is a foaming gel which is suitable for all skin types. Vikki Baker, marketing manager of Skinbetter Science distributor AestheticSource, commented, “We are delighted to introduce the latest addition to the Skinbetter Science range. With the increased awareness and focus on combatting PPE and face covering-induced skin conditions it is beneficial to be able to offer a product that is suitable for daily usage on compromised and sensitive skin.”

Harper Grace launches consultation service UK aesthetic product distributor Harpar Grace International has created a digital platform to hold consultations on behalf of clinics. The Consult and Concierge service will allow Harpar Grace skin specialists to give virtual skincare consultations on behalf of a practitioner/clinic and create a bespoke regime for each patient. Transactions can be processed through the team and products will be posted to the patient with next day delivery. Kimberley Saunders, key account manager at Harpar Grace, commented, “We have developed the Consult and Concierge service as part of the allencompassing e-commerce solutions that we offered our partners during recent uncertain times. We realised that many of our practitioners are too busy, or without resource to offer virtual consultations. This is where the Harpar Grace skin specialists step in as they are able to offer in-depth ingredient expertise to build a personalised regime for patients, whilst integrating as an extension of the practitioner or their clinic expert team.” Marketing

mesoestetic reveals new brand identity Pharmaceutical company mesoestetic has launched a new brand image, which features the motto, ‘the element for skincare experts’. Fernando González, marketing director of mesoestetic, said, “With the new motto we become the essential element for skincare, adding value to our research and medical expertise as the future of beauty. We exist to provide scientific rigour to the industry of professional cosmetics and cosmetic medicine, and to meet the needs of the most demanding professionals and consumers. Therefore, we redefine our world image, through which we can show the world all that we are.” Weight loss

Allurion reaches 40,000 weight loss balloon milestone Medical technology manufacturer Allurion has now produced 40,000 Elipse balloons worldwide, with a 50% increase in sales year on year. The Elipse balloon was designed to suppress patient appetite and teach portion control. Dr David Eccleston, clinical director of MediZen clinic, commented, “Offering a full lifestyle approach to long term weight loss, the Elipse balloon has become extremely popular with my patients over the last few months, as a proven method for sustained weight loss. The non-surgical balloon is fitted as a 20-minute outpatient procedure and supported by expert dietitians. With obesity being a risk factor for heart disease, kidney problems, diabetes and cancer, but also as a predictive factor in the potential severity and outcome of COVID-19 infection, now is time for patients to make the change.”

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Training

Interface launches graduate scheme in aesthetics Training provider Interface Aesthetics has launched a Junior Graduate Trainee Scheme in Facial Aesthetics. The course is directed towards undergraduate (penultimate and final year) medical, dental and nursing/midwifery students, and will comprise monthly webinars. According to Interface, the course has been designed to offer opportunities for students interested in aesthetics with the aim of educating these future registered health professionals in regulation, training and cosmetic injectables practice. Dr James Olding, director of Interface Aesthetics, commented, “As a training provider myself I am inundated with the same questions and concerns from young trainees across the key professions. Many concerns are common to doctors, dentists and nurses, and addressing these requires a joint approach from the undergraduate through to postgraduate stages. As well as webinars, there will also be face-to-face days which will be rolled out once the situation with COVID-19 becomes more under control. This is something we anticipate from May 2021 onwards.” Glycolic acid

NeoStrata releases new serum Skincare company NeoStrata has launched the NeoStrata Glycolic Renewal Serum as part of its RESURFACE range. The company explains that the new serum is formulated using glycolic acid, lactobionic acid, 10% alpha hydroxy acid, and green tea antioxidants. The serum is designed to help prevent uneven skin, enlarged pores, acne scars and hyperpigmentation. Vikki Baker, marketing manager of UK distributor AestheticSource, said, “This is the perfect product to recommend to patients during the slugging winter/spring months to increase skin cell turnover and improve skin luminosity and radiance. It provides an ideal at-home solution and at present we are able to drop-ship directly from our COVID-compliant warehouse.” Sun exposure

UV rays may not increase melanoma in skin of colour A study published in JAMA Dermatology has indicated that melanoma development in skin of colour may not be increased as a result of UV exposure. The systematic review was conducted by the division of dermatology at Dell Medical School using PubMed, Cochrane and Web of Science databases. The authors analysed UV exposure as a risk factor for cutaneous melanoma in people with skin of colour. Of the 13 studies, 11 indicated no association between UV exposure and melanoma in skin of colour. One showed a small positive relationship between UV exposure and cutaneous melanoma in black male subjects, while one suggested a weak association in Hispanic male subjects. The authors of the study commented, “In this systematic review, the evidence suggests that UV exposure may not be an important risk factor for melanoma development in people with skin of colour. Current recommendations promoting UV protection for melanoma prevention in skin of colour are not supported by most current studies. However, evidence is of moderate to low quality, and further research is required to fully elucidate this association.”

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News in Brief BDD support service launches The Body Dysmorphic Disorder Foundation has launched an email support service for sufferers or friends and family of those with body dysmorphic disorder (BDD). The foundation explains that the service will offer a confidential place for people to be understood and be provided with high-quality information about recommended treatments and how to access them. Volunteers for the service, most of whom have suffered from BDD themselves, have received and completed training on how to help those with BDD. Level 7 course to begin in Newcastle Training academy Acquisition Aesthetics is now offering mentoring for the OTHM Level 7 Diploma in Clinical Injectable Therapies in Newcastle. Mentoring for the qualification previously only took place at the London training facility. Directors of Acquisition Aesthetics, Dr Priyanka Chadha and Dr Lara Watson, commented, “We’re dedicated to continual learning and development, and we’re thrilled that the Newcastle team now comprises accredited Level 7 trainers and assessors, able to mentor learners enrolled on our Level 7 Diploma.” The mentoring will begin after current lockdown restrictions are lifted. Clarius to host ultrasound webinar Portable ultrasound manufacturer Clarius is hosting a webinar titled Ultrasound in Facial Aesthetics: Vascular Mapping, Evaluating Fillers and Complications. Board certified plastic surgeon, trainer and researcher Dr Steven F. Weiner will discuss how ultrasound can eliminate the risk of intravascular injections, explore vascular mapping to confirm the location, size and depth of arteries, and show delegates how to locate previously placed fillers and visualise their composition. The webinar will take place at 1pm on February 4. Lynton starts online masterclasses Laser manufacturer Lynton has launched a new online learning initiative, taking place throughout February. According to the company, the new Lockdown Learning Initiative will feature virtual classrooms in which delegates can learn about the science behind laser and IPL. Delegates will be able to attend masterclasses for specific treatments, such as skin rejuvenation, vascular and pigmented lesions, skin tightening, cellulite reduction, fat loss, fungal nail, warts and verrucae.

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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better results, so for us it’s a win-win!” While Mr Humzah agrees that cannulas have less chance of bruising and causing an occlusion, he emphasises that they still cannot be considered 100% safe. He comments, “It isn’t just about the instrument, but about how the practitioner uses it. I run a training course for cannulas and I’ve had even experienced doctors come in and be completely unaware of how to use them correctly. For example, I’ve seen them forget all about aseptic techniques which can cause infection.” He continues, “People also need to bear in mind that there is no evidence to say that a cannula will NEVER cause a vascular occlusion – it’s just less likely.”

Why are needles more prevalent?

Cannulas vs. Needles Following a recent study, Aesthetics looks into the considerations for choosing cannulas over needles The needle versus cannula debate is frequently discussed in aesthetic medicine, particularly in regards to safety. A recent study published by the Department of Dermatology at the Feinberg School of Medicine, Northwestern University, has suggested that cannulas are less likely to cause a vascular occlusion than needles when injecting filler. The study evaluated injection practices, injection volumes and prior intravascular occlusion events of 370 US-based dermatologists, with a total of 1.7 million injections. Results showed that one occlusion occurred per 6,410 injections via needles, compared to one occlusion per 40,882 injections with cannulas.1 With evidence indicating that cannulas are a safer method, aesthetic practitioner Dr James Shilvock and consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah consider whether the industry should be replacing needles as the main instrument for aesthetic injections.

Minimising complications Dr Shilvock is the clinical lead for the Dubai and Birmingham Consultant Clinic branches, a brand which has adopted the cannula as its default method of injection. He comments, “The reason the brand first started using cannulas was for safety, as they’re much less likely to cause vascular occlusions and other complications. This is because, when used correctly, the cannula should move the vessel out of the way rather than hitting it like a needle, also lessening the incidence of bruising. Now, 90% of the treatments we perform are with a cannula, although we do still use needles for noses as we wouldn’t achieve the necessary accuracy otherwise.” Dr Shilvock also notes that as patients are becoming more educated on injection techniques, they are having more people present to the Consultant Clinic purely to be treated with a cannula. He says, “As there is more information emerging about aesthetics, patients are more aware of what the safest options are. We find that a lot of our patients choose us specifically because they know we always use cannulas, and often people come to us having just experienced a complication from a needle injection administered by a different practitioner. I think if we continue to put out content that informs people of the dangers of aesthetic procedures, and the ways they can be made safer, then patients will make choices which reflect that. We’ve also found that cannulas give our patients

Dr Shilvock believes that some practitioners may be prioritising cost over safety by choosing to use needles. He comments, “When you buy filler you often get a needle included in the box as part of the price, whereas you have to buy cannulas separately, which aren’t cheap. Because of the expense, I worry that practitioners would rather save money than invest in something which is a lower-risk for their patients. Similarly, in terms of competitive pricing, a cannula treatment will be more expensive and so clinics may prefer to use needles in order to keep the prices down and attract more business. However, I urge my colleagues to remember that just because something is cheaper, it doesn’t mean it’s the best option, and it may end up

"It isn’t just about the instrument, but about how the practitioner uses it" Mr Dalvi Humzah

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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“In order for practitioners to be more confident and comfortable when using a cannula, they need to have received the correct training" Dr James Shilvock

being worse for your reputation in the long run. It’s something that the practitioner needs to weigh up for themselves.” Dr Shilvock also advises more training providers to incorporate cannulas into their curriculum, as currently he believes the specialty is focused primarily on needles. He comments, “In order for practitioners to be more confident and comfortable when using a cannula, they need to have received the correct training. Unfortunately, there aren’t as many courses out there that focus on cannulas, and practitioners begin in the industry solely using a needle. Many then continue to use them as their main instrument throughout their career, as it’s what they know and are comfortable

with. I would recommend that new practitioners seek out a course on cannulas for themselves, because otherwise we have a large number of inexperienced injectors performing what I believe to be the more dangerous method.” Mr Humzah agrees, commenting, “Using a cannula is not something people should just be picking up on the job, which at the moment it mostly is. It’s important that the industry provides educational courses for both old and new practitioners to supply them with vital knowledge, for example how to choose the right cannula for the treatment/patient. Without the right training, even the safer methods can cause the patient harm.”

A combination approach Mr Humzah believes that while cannulas have their benefits, practitioners should not limit themselves to just one instrument. He comments, “In my experience, there are pros and cons to both methods. Cannulas can be beneficial for certain procedures, for example when injecting a large surface area, however I believe that needles are still needed for things like contouring and fine adjustments. To me, you aren’t a good aesthetic practitioner if you can only use a needle, and you aren’t a good aesthetic practitioner if you can only use a cannula. What’s important is having a good knowledge of both techniques and being able to recognise when one is more beneficial to the patient than the other.” REFERENCES 1. Holly Carver, Study indicates that vascular occlusion less likely with cannulas 2020, <https://aestheticsjournal.com/news/study-indicates-that-vascular-occlusion-less-likely-with-cannulas?authed>

LED Facts, Fiction & Fake News: Light Therapy Evidence in a Post-Truth World

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Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

Advertorial Intraline

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Combination Lifting Dr Huw Jones shares his approach to facial ageing using dermal fillers, platelet-rich fibrin and PDO threads Morphological changes to the facial skeletal structure, soft tissue, retaining ligaments, fat compartments, and skin interact to give the ageing facial appearance. For best results, the different elements should be considered together. Skin rejuvenation techniques promoted without consideration of volume loss or muscle/ligament laxity will not be optimal. Volumising perceived facial fat loss in the lower third of the face without addressing upper and middle facial loss will produce sub-optimal results. We now have a greater appreciation of the multifactorial causes of the gravitational and centripetal movement of the facial tissues that result in the inverted ‘Triangle of Youth’. Fat pads get thinner and descend. We lose fullness. Hollows form at the temples and beneath the eyes, drooping skin can cause deeper lines around the nose and mouth, loose skin can result in a sagging jawline.

supraorbital and infraorbital regions. They also provide support for the mid-cheek and the jawline. I found that addressing these areas whilst applying tension with PDO Cog Threads provided a more harmonious result, which were both instantaneous and relatively long lasting (15-18 months). Now I start by addressing the temples. Volume loss in this area is one of the earlier signs of ageing. Volume replacement will reverse this and help elevate the lateral brow and reduce periorbital rhytids. Intraline M4 Plus has a high concentration of HA (24mg/ml) with a high G-prime, resulting in an impressive lifting effect. I approach this region with respect due to the vascularity and the potential side effects that can result from injudicious filling. I inject deeply using a single injection with a 27 gauge needle placed vertically 1cm above the temporal fusion line and 1cm laterally. The needle tip is placed deeply onto periosteum. A bolus My combination lifting approach injection is made and digitally massaged I realised that for a great part of my career I inferiorly to spread the filler. Next, I treat the had failed to address the ageing temples and superficial aspect of the temples and the lateral temporal fat (LTF) pads appropriately inferior continuation of the lateral temporal fat and the effect this had on my results. Volume pad. The skin in this region is thin and using loss from these two regions not only results a high G-prime filler may result in lumpiness in a hollowed/aged appearance but also and filler visibility. Numerous published removes vital lifting support for the lateral papers reference HA filler ‘hydrated’ with normal saline +/- lidocaine to provide a greater volume and smoother injection. It has been my practice to ‘hydrate’ the Intraline M4 Plus with injectable platelet-rich fibrin (PRF). The PRF is obtained using a one-step centrifugation process without the use of anticoagulants and is totally autologous. The M4 Plus HA filler is mixed with the PRF which 52-year-old women before and after 1ml of Intraline M4 Plus, 2ml of PRF and Intraline PDO Threads. is stable for 15-20 minutes. 20

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I prepare the skin and inject 0.1% lidocaine at the insertion point. Using a 25 gauge 70mm cannula I proceed to fill the temple and lower LTF with a fanning retrograde filling technique. The injected area is then gently massaged to achieve a smooth result. The multitude of growth factors in the PRF will also help to address some of the ageing skin issues including collagen and elastin content, lentigines etc. The first two stages described above will address some of the volume issues and at the same time will start to lift sagging in the mid and lower third of the face. Using a cannula in the LTF will also help to reduce some of the tethering of the skin caused by free radical induced sub dermal fibrosis. The use of absorbable barbed PDO threads produces an initial mechanical tensile lift enhanced by a delayed fibrosis induced lift seen at three to six months after treatment. This is supported by histopathological studies indicating dermal and subcutaneous foreign body reaction in the form of lymphocyte infiltration, collagen deposition, and fibrosis. I use the Intraline 19 gauge 100mm Dimension 360/720 Cogs, which produces great results. Using a single entry point high on the zygoma I insert three sub-dermal threads bilaterally down to the angle of the jaw and the jawline. Gentle traction and upward placing of the skin on the threads will then give the desired lifting effect. Another benefit of treating the LTF with the HA/PRF combination is that it makes insertion of the cogs easier and less painful.

A solution to facial ageing I have found that addressing the issues of mid and lower facial ageing by managing temples and lateral temporal fat pads is very effective and also reduces the issue of hollowed temples. I address the lower face laxity issues simultaneously with PDO Cog Threads that give an immediate and a delayed lift. The procedure can be repeated as required to achieve optimal results, which are showing an acceptable longevity of 12-18 months. Dr Huw Jones qualified from Sheffield University Medical School in 1986 and worked full time as a GP for 10 years. Dr Jones started using dermal fillers in 1989 and has since developed extensive experience in non-surgical treatments. This advertorial was written and supplied by

(e) info@intraline.com

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Getting Started with Marketing Aesthetic marketers share an introduction to the key tools to grow your practice

Strategy formation “The first thing to know about marketing is that its purpose is to get people interested and keep them engaged in your service – it is not selling,” says Alex Bugg, head of content and digital marketing strategist at Web Marketing Clinic. But how do you get people interested? And how do you reach the right people? Alongside Bugg, we chat to Fiona Comport, UK marketing and international communications manager at Cynosure, and Katie Gray, who manages the marketing strategies for the Aesthetics journal, ACE, CCR and the new consumer magazine Beyond Beauty, to get their advice on running a successful campaign. SET MEASURABLE OBJECTIVES AND KPIs The first thing to do is set clear objectives and key performance indicators (KPIs) so you can track how successful your marketing efforts have been. Comport says you should ask yourself, “What’s the desired outcome of your marketing? How am I going to measure its success?” She explains, “Sometimes the goal will be education or awareness, sometimes it’s lead generation or it can be customer engagement. Often you’ll have multiple objectives so you will need consider methods to achieve each.” She adds that for objectives to be effective, they should be SMART, so ensure they are: • • • • •

Specific Measurable Assignable Realistic Time-related

they were in the market for your particular product or service? Would they look at reviews for example, or ask advice from the experts? Bugg agrees that you should learn about your ideal patients to build an image of a person but warns you can’t be everyone’s cup of tea. “Casting your net too wide can dilute your messaging – aim to be as specific as possible,” she advises, recommending that practitioners create three to five personas of each of their ideal patients and write them down to share with the team and refer back to. CHECK OUT YOUR COMPETITORS The next step is to conduct a SWOT analysis. This involves considering the strengths, weaknesses, opportunities and threats that may lay ahead for both you and your competitors. “This will help you nail your unique selling points to make you stand out from the crowd when you begin communicating with your target audience,” says Gray. CONFIRM YOUR BUDGET The final part of your marketing strategy formation should be to set your total budget. For some just starting out, this could be minimal. There’s lots you can do for free or with very little spend, but the professionals say it’s essential you stay on track to ensure you’re not spending money aimlessly. Don’t forget there are well-established marketing theories and strategies you can refer to before you get started, which include Marketing Management by Kotler et al.,1 the SOSTAC planning model2 and Porter’s Five Forces3 to help you understand competition and maximise profitability.

If you’re longer established…

CREATE AUDIENCE PERSONAS Comport advises practitioners to next think about the audience you want to reach. As well as considering the basics such as age, sex and location, she recommends asking yourself: what do they read? What websites do they use? Where and how would they be looking if

If you’ve being running your clinic for a couple of years but are still struggling to nail your marketing strategy, Gray suggests now is the time to review it. “Particularly since COVID, I’d recommend refreshing yourself with your marketing analysis and insights. Look at your objectives and consider whether they are still relevant, and think about new strategies and KPIs,” she says, adding, “These pathways and end goals may have changed drastically since 2019; for example, you may want to increase your weekly consultation target now that virtual appointments free up more of your time, or you may need to consider a new goal for revenue generation if we go into more lockdowns.”

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Essential tools BUILD A WEBSITE If you don’t have one already, the professionals highlight the importance of a clinic website. It might sound obvious, but Comport says, “You would be surprised how many doctor-led start-up clinics or small aesthetic businesses have no digital footprint. In this era, your website is your shop window.” She notes, “There are multiple low-cost and even free website builders that are simple to use and have hundreds of pre-built templates that you can populate with your pictures and information. These can provide you with a professional-looking digital space to send your prospective customers and, depending on the functionality you require, can even manage payments and bookings.” Bugg agrees, “Your number one essential is a website. Some people say they’ve started their clinic just on Instagram and have loads of patients, but when you dig deeper you realise they spend hours on it. Having a website with all your information on would save a great deal of time and will look more professional.” She adds, “Something else to note about only using social media is you don’t own Instagram – if it decided to shut down tomorrow, your digital presence is gone.” While you can create a website fairly easily, Bugg says it’s essential to make certain it displays well on mobile and that you have basic search engine optimisation (SEO) in place, explaining, “You need to ensure you at least rank well in your local area for your name and standard treatment offerings.” Setting up a Google My Business (GMB) page will help with your SEO ranking, advises Bugg, noting that this is free, quick and easy to set up. For more information on how to master local SEO and make the most of GMB, check out Bugg’s article on Enhancing Your Digital Reach via the Aesthetics website.4 CHOOSE YOUR SOCIAL MEDIA PLATFORMS Statistics released last year indicated that 51% of the world’s population is now on social media, and that number grew by 10.5% from 2019 to 2020.5 So where should you be sharing your content? Gray says you should have a purpose to every action in your marketing. “Always base your marketing efforts on analysis. Look at the personas you’ve created and consider what social media platforms they use and start there,” she advises. Generally, the professionals agree that Facebook and Instagram can be regarded as the most effective platforms to reach those interested in aesthetic treatment. She notes that Facebook has the largest number of users and the demographic is usually older – statistics indicate that it is used by 72% of 30-49-year olds. For Instagram, this is only 40%, whereas 64% of those aged 18-29 use it.6 Gray highlights that if you do have Twitter and LinkedIn accounts but they aren’t performing well for you, it’s ok to stop using them. “Only invest time in what’s working for you. You can either close the account completely, or post and pin a final message that redirects users to your other platforms, so if people do stumble across you they don’t think your clinic is closed because they have seen your dormant account. You can keep it colloquial and chatty and make sure you include the link to your preferred channel.”

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INVEST IN DIGITAL ADVERTISING Social media is free-of-charge to use, however if you do have budget available then you can really scale up your reach. “The targeting you can do on Facebook and Instagram is excellent,” says Gray, adding, “You can just about target anyone you want through setting age ranges, geographical radiuses, lookalike audiences, behaviours and general interests.” If you already have a a database of your most loyal of patients, she recommends making use of Facebook’s ‘lookalike audience’ tool, which allows you to target people who are similar to your existing database. Marketing and PR professional James Dempster wrote an informative article on this topic called Understanding Facebook Advert Audiences, which is available on the Aesthetics website for those who’d like to learn more.7 As well as advertising on social media, you can utilise pay-per-click (PPC) marketing. “It may sound terrifying and intimidating, but there are lots of online tutorials that will help you easily get started,” says Comport. Multiple PPC approaches are available, allowing you to gain prominent positions on Google search engine results, rank highly for keywords associated with your brand, as well as appearing in Google Play, Images, Shopping and Maps. For a more in-depth guide to PPC marketing, read digital marketer Bradley Hall’s article Using Pay-perclick Marketing on the Aesthetics website.8 To help manage your advertising spend, Comport explains that you can set budgets at a daily rate very easily, which can be from as little as £5 a day, so you can test and learn to see what does and doesn’t work. “The great things about digital marketing is that it is often the quickest way to get new leads. You can ensure you’re putting your messages in front of the right people, which is huge. You won’t be wasting money on advertising to people who aren’t interested,” she says. EMAIL YOUR DATABASE As you build your patient database, Bugg emphasises the value of email marketing. “Your website and SEO will be attracting mostly new patients, your social media should be engaging with new and existing patients, but your email lists should really focus on retaining the patients you already have,” she says. She recommends investing in an email builder, which are generally low cost, so you can easily manage your email lists and create engaging content. “If just one person takes action from reading your email, you could be generating hundreds of pounds for very little investment,” she says.

Setting up a Google My Business page will help with your SEO ranking

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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CONSIDER PRINT ADVERTISING Book adverts in local newspapers or magazines or put up posters in places your target audience will frequent to inform them of the services you provide and how you can help them. However, be aware that print advertising can be expensive, and it can be difficult to track results. “Print adverts may be great if you want to make people aware of what you do or to tell them you’ve launched a new product. But if you’re looking for leads to your website, getting them to type in a URL from a print advert is going to be much more difficult,” says Comport. There is the option of adding a QR Code to your advert, allowing viewers to scan the code with their phone and reach a specific URL. Comport adds, “Whatever you do, it’s got to make taking action as easy as possible for your audience. In today’s day and age, everyone has such short attention spans that you have to choose the right channels and messaging for your marketing to ensure you don’t waste time or money.”

Content creation You should now know who you want to target and the platforms you’ll use to reach them, but what should you say? What will drive their interests in your products and services? MAKE EVERYTHING ACTIONABLE The professionals emphasise that all content should have a call to action (CTA) – an instruction for your audience to carry out. Gray advises planning your CTAs first, before you start writing copy, to ensure every message you send has a purpose. “Ideally you want one hard CTA per message, but you can include some soft CTAs in the same message that will demand less from your patient, so they’re not so ‘sales-focused’ which can put people off,” notes Gray. Hard CTAs are things like ‘Buy this vitamin C now,’ whereas softer CTAs could be, ‘Read more about the benefits of vitamin C here’. She also highlights that for CTAs to be effective, research has suggested that they should not be generic messages such as ‘click here’ or ‘book now’. Analysis of more than 330,000 CTAs found that personalised CTAs perform 202% better, so get creative!9

“FAB stands for feature, advantage, benefits – if you cover each of these you’re on the right track” Katie Gray, marketing manager

FOCUS ON THE BENEFITS “Always keep your content benefit focused,” says Gray, suggesting practitioners bear in mind the FAB method. “FAB stands for feature, advantage, benefits – if you cover each of these in your message you’re on the right track,” she says. Comport agrees, adding, “You could say, ‘This product contains retinol’, which covers what it features, but why is using retinol an advantage over something else and how can it benefit that person?” ENSURE YOUR MESSAGES ARE CLEAR Another important point to consider is the terminology you use. Perhaps ‘topicals’ is not a word your prospective patients are familiar with, suggests Comport, emphasising that practitioners should always use layman’s terms. “I think engaging content is written how you speak – make it sound chatty and explain anything an average patient would be unfamiliar with, as you would do in a consultation,” adds Bugg. Gray recommends the use of sensory words, describing how patients will feel and look after they’ve had a treatment with you. DON’T FORGET WORD OF MOUTH The professionals are all in agreement that positive reviews from past patients are some of the best forms of marketing available and it’s completely free! They advise always asking for permission to use testimonials that you can display in your marketing material, as well as encouraging patients to share their own social media posts about their experience with you. Gray says, “Research has suggested that people are more likely to buy from someone they know than an influencer. Even if the person only has a few hundred followers, they’re likely to be people who know and trust them, as well as of a similar demographic to the audience you’re trying to reach.” Even if people don’t want to share their before and after photographs, Gray recommends asking them to ‘check in’ to your clinic on social media or simply to post a picture of the waiting room and comment on the service they received. “Anything to show you’ve got loyal advocates can really help,” she says, adding, “Being able to share this user-generated content also means less work for you, so it’s a win-win!” Of

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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course, if anyone shares any negative reviews, the professionals advise that these are best dealt with out of the public eye, so give the person a call to discuss and resolve. IMAGERY AND DESIGN Ensuring your marketing looks good is essential for engagement, so how do you do this with limited design skills and a small budget? Bugg suggests that if you have any budget at all, spend it on a professional logo. “In my opinion, big jobs like a logo should be done by a graphic designer so you don’t end up looking like everyone else. Once you’ve got the general colour theme and fonts decided, you can then create imagery pretty well on your own.” The professionals all recommend tools such as Canva and Adobe Creative Suite, Spark and Lightroom to help you build graphics and create branded templates. There are free versions available and you can upgrade to get the best tools. “Canva is amazing and very easy to use,” says Gray, adding, “You can also find so much inspiration there – it’s good to just have a browse and get ideas!” You can also use stock imagery, with many paid-for website available and some free. Bugg recommends Unsplash, which is free, explaining imagery is donated by photographers so are a little bit different and seen in less places. Comport emphasises the need to always ensure that you have the rights to use the images – she says celebrity images for example are a real no-no without permissions and you risk opening yourselves up to legal action if you use them. Comport also advises, “Don’t be afraid to take your own photos and videos; with phones today, the quality can be very good!” She adds that Cynosure provides device and treatment imagery, as well as other marketing assets for its customers, so it’s worth speaking to your suppliers to see how they can help. As well as images, the professionals recommend integrating video into your content. While you can get great results with your phone alone, to further enhance them Gray suggests investing in some basic equipment such as a ring light, tripod and portable camera stabiliser. “Videos can really stand out in a sea of images on Instagram,” she says, adding that they can help your audience get a taster for who you are as a practitioner, as well as their expected clinic experience which can really assist them in determining what clinic to choose.

Tracking results “How do you know how to improve if you don’t track results?”, asks Comport, emphasising how important it is to measure your success. If your social media is set up as a business page, it will allow you to view insights on the demographics your posts reach, as well as their engagement in comparison to others. You can also track your website through Google Analytics (GA), which provides you with a wealth of insight. Comport recommends focusing on the Acquisition tab to see where users are coming from, as well as Behaviour which shows what pages they visit and where they leave. Monitoring these aspects allows you to consider what you may need to tweak if it’s not working as well as you’d hope, or to ramp up anything that’s doing well to enhance success further.

Gray advises creating a spreadsheet where you can input all tracking results, allowing you to easily review and compare. “I put time in my diary once every two weeks to review and adjust my plan as necessary,” she explains. Bugg, on the other hand, reviews social media once a week and GA each month. “You should aim to review regularly, but don’t set unrealistic expectations on yourself if you don’t have time to look at it weekly – it’s better to do it properly when you can really focus,” she says.

Always consider your audience The key to any successful marketing campaign is to really know your audience. “No matter how much you spend or how much marketing activity you do, you’ll never get good results if you’re not reaching the right people,” emphasises Gray. Once you’ve nailed your strategy, review and adapt it regularly. “Be agile – swap things around, test and learn,” says Comport, concluding, “And always think like your customer – what would they like to know?” REFERENCES 1. Philip Kotler et al., ‘Marketing Management’, Pearson, 4th Edition, 2019. 2. Dave Chaffrey, SOSTAC (US: Smart Insights, 2020) <https://www.smartinsights.com/digitalmarketing-strategy/sostac-model/> 3. Porter’s 5 (US: MindTools, 2021) <https://www.mindtools.com/pages/article/newTMC_08.htm> 4. Alex Bugg, Enhancing Your Digital Reach (UK: Aesthetics, 2020) <https://aestheticsjournal.com/ feature/enhancing-your-digital-reach?authed> 5. Simon Kemp, More Than Half of the People on Earth Now Use Social Media (US: Hootsuite, 2020) <https://blog.hootsuite.com/simon-kemp-social-media/> 6. Dominque Jackson, Instagram vs. Facebook: which is best for your brand’s strategy? (US: SproutSocial, 2019) <https://sproutsocial.com/insights/instagram-vs-facebook/> 7. James Dempster, Understanding Facebook Advert Audiences (UK: Aesthetics, 2020) <https:// aestheticsjournal.com/feature/understanding-facebook-advert-audiences> 8. Bradley Hall, Using Pay-per-click Marketing (UK: Aesthetics, 2020) <https://aestheticsjournal.com/ feature/using-pay-per-click-marketing> 9. Jeffrey Vocell, Personalised Calls to Action Perform 202% Better Than Basic CTAs (US: Hubspot,2020) <https://blog.hubspot.com/marketing/personalized-calls-to-action-convert-betterdata>

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Building Your Brand Dr Marcus Mehta shares his journey of working with a marketing agency to establish a recognisable clinic brand My business partners, Dr Tristan Mehta and Dr Emily MacGregor, and I wanted to create a new clinic brand that was open and inclusive to all. Every injectable, wrinkle reduction injections and filler treatment, is performed by a professionally regulated medical practitioner who has a Level 7, or equivalent post-graduate qualification, in Aesthetic Medicine. We are the only clinic that can guarantee this. With a long-term goal of opening more clinics, brand consistency was extremely important, as was a professional and polished look. We therefore decided to work with a design and branding agency – Biles Hendry – to help us nail our strategy. We began by briefing them on what we wanted to create and the ideas we had in mind. These included a clinic that was honest, transparent and accessible to all skin types, sexes and ages. We also wanted the brand to reflect our high standards of thorough safety protocols and excellent results, reinforcing our practitioners’ medical qualifications and our passion for educating the public. The agency then put together a few different concepts, which included ideas for the clinics’ name, logo, colour palette and marketing material. It was a really fun process and great to see different ideas come to life! We chose STORY as our name as it reflects our patient-centric approach and highlights our belief that every patient should be treated as an individual, as they all have their own unique story to tell. We worked with the agency to create website copy that echoes this, while also choosing a colour palette of fresh and natural hues to convey a welcoming and non-intimating environment. Finally, the agency held a photoshoot for ‘hero’ shots for our website, with models reflecting the diverse patient base we hoped to attract. Once the project was complete, we were provided with the brand guidelines to follow to ensure we continue to uphold the STORY identity through our tone of voice and appearance in all our marketing collateral. I currently lead on our marketing activities and one of the biggest challenges I’ve faced is maintaining the brand consistency. Having the agency’s guidelines to refer back to really helps, as does reminding myself of what we wanted to achieve when we began. The other difficulty I’ve found is making all our content relatable, especially now that we have multiple practitioners working at our clinics. Sometimes, basic treatment explanations and imagery – especially if it’s stock imagery – can look quite generic and impersonable, which I want to avoid. Before STORY, I ran my own-branded clinic and found it a lot easier to market as it simply involved talking about my experiences and approaches to treatment. I therefore refer back to this and aim to show as much of the people behind the brand, and what makes them interesting, as I possibly can. Sometimes, this isn’t even aesthetics related – people connect with their characters and enjoy visiting us for a Figure 1: An example social catch up, just as much as they do for treatment. I think media post demonstrating STORY’s brand identity it’s important to remember the psychological element

I aim to show as much of the people behind the brand as I possibly can of aesthetics too; we boost people’s confidence through their whole experience with us, not just through an injection, which in turn builds long-lasting relationships and creates loyal patients. For those considering working with an agency on your clinic’s branding, I would emphasise that it’s not cheap and the cost really has to be justified. If you’re a sole practitioner starting up your clinic alongside NHS work, I would suggest now probably isn’t the best time. There are so many great tools available for free that can help build your brand, which I really benefitted from when I started out, so make use of them before establishing your long-term goals and deciding if working with an agency is right for you. If you do decide to go down the agency route, or choose to outsource any of your marketing material, I would remind you of the power of your own voice. As I’ve found, it’s so valuable for potential patients to hear from the person who’s going to be treating them, as well as to get an insight into their daily lives through photographs and videos, so do consider how you can best incorporate yourself into your brand!

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Toxin and The Lower Third Mr Ali Juma explores the use of botulinum toxin A in the lower third of the face Loss of facial contour and ageing is influenced by a number of factors. These factors include bony resorption, involution of the deep fat compartment, and hypertrophy of the superficial fat compartment.1 However, alterations in facial muscle length and lever arms also affect contour changes in the face, including the lower third.2 The defining features of the lower third of the face include a welldefined mandibular line, which is a key feature in youth, and a posterior balanced facial width which is impacted by the masseter muscle, in addition to the soft tissue position and thickness.3 Ageing leads to the jawline becoming less defined, contributed to by the depressor muscles, which pull on the skin, the ligamentous attachments, in addition to the fat compartments of the lower third of the face in a downward vector.3 Myomodulation, the mechanism/s of how injecting HA facial filler adjacent to mimetic muscle/s to influence the muscle/s activity, and/ or neuromodulation, can influence the behaviour of the facial muscles. Combining both techniques, in addition to lost volume replacement and tissue displacement, can achieve best outcomes in facial contouring and rejuvenation.2,4,5 Treating the lower third of the face with botulinum toxin A (neuromodulation) requires more expertise than in the upper third; yet when perfected, the outcomes can be more rewarding than in the upper third.3 Muscles to consider for neuromodulation in the lower third of the face include muscles affecting the lower lip, chin, cheeks and the neckjawline interface.3 Botulinum toxin A creates a crucial proportioning and dynamic harmony between these muscles and other structures in the face, achieving a more youthful look.

Ageing of the lower face The fibres of the muscles in the lower third are positioned in close proximity. In addition, they can also merge at different depths and levels with variable anatomy.3,6 Bony resorption of the mandible is a major contributing factor in its ageing due to the loss of mandibular vertical dimension. This leads to a weaker facial profile, less defined angle of the mandible and loss of jawline definition.7 The loss of fat in the malar and perioral area, along with the laxity of skin and mandibular ligament in the lower face, further contributes to the loss of contour and jowls developing.8 To contour the lower face, three main mimetic facial muscles must be targeted. These include the platysma, the depressor anguli oris (DAO), and mentalis. However, in some patients, treating the masseter, which is a mastication muscle, reduces its bulk. This morphs a square face into a more oval youthful face.3 Hence, combining masseteric muscle botulinum toxin injections with the three mimetic muscles can lead to a visually more sculpted jawline, improved facial proportioning and harmonisation, especially if patients are treated at an earlier stage in life and prior to developing significant

skin excess around the jowls, jawline and neck.3,10 The DAO muscle contraction pulls the oral commissure inferiorly, thus contributing to the appearance of marionette lines. The mentalis muscle raises the lower lip while creating dimpling on the skin and flattening of the chin.3,8,10 The platysma merges with the DAO, lower lip orbicularis oris, depressor labii inferioris, and risorius. It attaches into the superficial musculo-aponeurotic system (SMAS) and skin of the cheeks. Hence, platysma contraction leads not only to descent of tissue in the neck but also pulling down of the cheek and the corners of the mouth at the same time.3,10,11 Contraction of the anterior platysma reduces definition between the chin and neck. Contraction of the DAO worsens the melomental groove and increases the volume of the jowls.3,11 The active depressor muscles of the lower face and neck, including ptosis of the mid-face deep and superficial fat pads, add further to the ageing of the lower third of the face and prominence of the jowls.3 Other muscles’ activity that contributes to loss of the lower third facial contour and ageing include platysma lateral bands pulling down the entire mandibular area aggravating the ptosis of the jowls and submandibular fat. Submandibular glands ptosis can exaggerate the jowls and exacerbate ageing in the lower face; however, this is not within the scope of this article. Mentalis muscle contraction flattens the chin, adding to the DAO’s inversion of the mouth corners and the sad look. Hence, botulinum toxin A neuromodulation of any one of these muscles or muscle groups can alter the lower third facial contour.3 Nonetheless, the proximity of these muscles, the complexity of their interactions, in addition to the dynamics of how the facial fat compartments behave in ageing, influences the activity of the SMAS and surrounding soft tissue.3,11 This complex interaction between the muscles, the SMAS, soft tissue, fat pads, and the resorbed bony skeleton makes achieving good outcomes in neuromodulation of the lower third intricate.11 In my view, this task warrants a detailed knowledge and understanding of the elaborate anatomy of all the enlisted structures and a more refined application of expertise than in the upper third of the face.

Anatomical consideration and patient selection Appropriate patient selection is a crucial component in any treatment success. Botulinum toxin A injection into the muscles of the lower third of the face is no exception. The first principle of patient selection is to distinguish when nonsurgical treatment rather than surgical intervention is the first choice, be it on clinical grounds or due to patient preference. One important factor to consider in the lower third of the face is skin excess, as this could be exacerbated with neurotoxin injections in the inappropriately-selected individual.3,9,11 The second matter to contemplate is in patients with facial

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5 2

3 1

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1. Mentalis 2. Depressor anguli oris (DAO) 3. Depressor labii inferioris (DLI) 4. Zygomaticus major 5. Risorius

Figure 1: Anterior view of lower third facial muscles

asymmetry. These include asymmetries arising from imbalance in muscles’ activity secondary to facial nerve pathology. One such example is Bell’s palsy.12 The muscles in the lower third of the face are at close proximity; in addition to their merging at different depths and levels with variable anatomy,3,6 this adds another confounding factor in achieving consistency of outcomes in neurotoxin injection. Hence, it is of profound importance to assess the patient in detail, and to well inform them prior to any treatment. Giving the appropriate time for the patient to reflect prior to making the decision is a mandatory requirement. Alongside this, the importance of topographical anatomy, detailed knowledge including the variation of this anatomy prior to any treatment, cannot be emphasised enough. Nonetheless, aspiring to achieve a dynamic balance within the different groups of muscles creating improved symmetry can be challenging. The refinement of such outcomes will warrant a hybrid approach including the use of hyaluronic acid dermal fillers for myomodulation in addition to botulinum toxin A treatment.13 The surgical and other nonsurgical treatments are outside the scope of this article.

Considerations for injecting the lower third of the face Planning botulinum toxin A treatment of the lower third of the face must take the whole face into consideration including facial proportions, the distribution of rhytids, the severity of these rhytids and whether these are active or passive, volume loss, topographical anatomy of muscles and injection site location, in addition to racial background of the patient.3,10,11,12 It is of profound importance when treating the lower third of the face to use lower doses to reduce risks and potential complications,3 in addition to perhaps the use of a more concentrated botulinum toxin to avoid a larger circle of diffusion.14 Thus, this will reduce impact on adjacent muscles such as the DAO and depressor labii inferioris (DLI), masseter and risorius, which can cause an asymmetrical smile. An algorithmic approach to solving the ageing lower third of the face relies on a number of factors. One example is treating the marionette lines and the downward sad looking lip; the treatment involves mid-face volume loss replacement in both deep and superior

fat compartments, support of the soft tissue, and chin volume redistribution.14 The myomodulation effect on DAO and mentalis muscles can then be supplemented with a lesser dose of botulinum toxin A to the DAO and mentalis muscles, rather than a higher dose, which can lead to a less natural look with increased complications.2,4,5 Facial rejuvenation must treat the face as a whole as it ages globally. The skin, in the majority, must also be included in the treatment. Hence, it is my belief that botulinum toxin A must not be the only step of the treatment algorithm in the ageing face.

Topographical anatomy of mimetic facial muscles of the lower third for botulinum toxin A injection Depressor anguli oris The depressor anguli oris is a fan-shaped muscle originating with a broad attachment along the body of the mandible 1cm anterior to the masseter muscle. It inserts into the oral commissure and interdigitates with other muscles of the modiolus. Its main function is as a depressor of the oral commissure.3,10 As a result of the complex anatomy in this area, accurate placement of the neurotoxin is of profound importance to reduce complications of asymmetry, phonation and oral incompetence. The injection site of neurotoxin is 1cm medial to the masseter muscle and 2-3mm above the inferior border of the mandible, whilst ensuring the injection site is 1cm lateral to the modiolus. This targets the lateral fibres of the DAO and reduces risks of affecting other muscles in the area. A useful expression, which helps locate the muscle on the patient, is to ask them to show their lower teeth which helps contract the DAO.3,10 As discussed, patients can present with a sad look as a result of the downturned corners of their mouth. The dose of botulinum toxin A to improve this varies between 5-7.5 SU (Speywood units) per side of Botox or Bocouture, which is equivalent to 15-22 of Azzalure units.3,10

One important factor to consider in the lower third of the face is skin excess, as this could be exacerbated with neurotoxin injections in the inappropriatelyselected individual

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Mentalis Over activity of the mentalis muscle presents with dimpling of the chin and a deep melolabial fold.2,4 Asking the patient to raise and evert their lower lip with wrinkling their chin will identify the bulk of the muscle and where to inject.3,10 The mentalis muscle is the only elevator of the lower lip and serves to lift the chin skin. It lies deep to the orbicularis oris and interdigitates with it, in addition to the depressor labii inferioris.3,10 The mentalis muscle can be treated with 5-10 SU of Botox or Bocouture, equivalent to 15-30 units of Azzalure, in one injection site between the two muscle bellies or in two injections with one in each muscle belly. In the two-injections method the injections are located 2mm above the inferior margin of the mandible and 5mm to either side of the midline. The injection is deep into the muscle bulk.3,10 Platysma muscle The platysma muscle is a large, thin, broad muscle originating in the deltopectoral fascia. It inserts along the inferior border of the mandible and SMAS of the face. By its sheer size and insertion into the SMAS, the platysma is a strong depressor of the lower facial third exerting influence on the lower lip and the oral commissures. The muscle varies in its anatomy and is not always depicted as two distinct bands either side of the midline.3,10 The platysma muscle is a key muscle in the ageing of the neck and lower face. Treating this muscle non-surgically must be considered carefully and a detailed dynamic and static assessment made of the neck, the adipose tissue excess and distribution, skin quality and excess, submandibular glands and ptosis, in relation to the lower third of the face.3,10,11 Platysmal bands, if static, will not be amenable to neurotoxin injections; neither is excess skin, adiposity or, in my experience, submandibular gland ptosis.3,10,11 However, dynamic vertical platysmal bands are amenable to neurotoxin treatment. Treating the platysma can add improvement to the contour and definition of the jawline. Hence, combining lower third face and neck neurotoxin treatment can give cosmetically pleasing results in the appropriately selected individual.3,10 When treating dynamic platysmal bands, the patient is asked to contract the platysma by asking them to show their bottom teeth or get angry at maximal expression of their anger; as expressed by ‘The Incredible Hulk’. The injection points are then marked along the platysmal bands with a total of two to three points per band

• PINK: Injection site for mentalis • GREEN: Injection sites for DAO • ORANGE: Injection sites for platysma

Figure 2: Platysma topographical anatomy and injection sites. The injection sites for the platysma includes the lateral jawline where platysma contraction can be observed.

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depending on the how long and strong the muscle is.3,10 If aiming to improve jawline contour as part of contouring the lower face, then the posterior bands are treated. On occasion, the anterior bands are treated if they have a strong action on the jawline and only if there is no skin excess or laxity. The mandibular border of the platysma (observed during maximal contraction when examining the patient) is injected in two to three points, adding improvement to the jawline and lower third.3,10,11 The amount of neurotoxin injected in the platysma muscle per site is 5 SU of Botox or Bocouture; however, practitioners should limit the total to no more than 100 SU, the equivalent for 15 units of Azzalure for a total of 300 units. Injections must be kept superficial into the muscle. If unsure of the muscle depth and thickness, then superficial dermal injections to avoid diffusion of the toxin into the deeper strap muscles of the neck, which can cause undesirable complication including dysphagia, dysphonia, dysarthria, and breathing difficulties should be considered.3,10,11,15 The ‘Nefertiti lift’ is an effect reserved to the sharpening of the mandibular contour and elongating the appearance neck. The technique pioneered by Dr Phillip Levy in 2007,16 is named after the pharaoh queen Nefertiti, as she was thought to have had the ideal neck and jawline.10 Nefertiti neck neurotoxin lift injections are placed along the inferior border of mandible and strongest lateral platysmal band. The injections are deep into the muscle using 14-20 SU of Botox or Bocouture per side, equivalent to 42-60 SU of Azzalure.10 It is important to be aware that if the injections are extended medially to a line drawn down from the lateral extent of the nasolabial fold to the mandible, this can affect the DLI and lead to lower lip droop or an asymmetric smile. Over injection of the muscle in this area can lead to dysphagia and an irregular asymmetric smile with excessive pull downward of the lower face, which is cosmetically undesirable.3,10

Topographical anatomy of the mastication muscle of the lower third for botulinum toxin A injection Masseter mastication muscle hypertrophy is uncommon; however, it presents with a square, widened lower facial contour. This occurs in both genders and can be associated with functional problems of dentition and temporomandibular joint (TMJ) pathology in Caucasian patients. In patients of Asian origin the cause of this muscle hypertrophy is idiopathic. In Asian women, the resultant widening of the jawline and lower facial contour is seen as unfeminine.3,10,17 The masseter muscle superficial portion originates from the anterior two thirds of the zygomatic arch inferior border, including the zygomatic maxilla. The deep portion originates from the deep medial surface of the zygomatic arch. Both portions insert into the angle and ramus of the mandible.10 Injections of the masseter muscle has to be in the lower portion of the muscle to avoid affecting risorius and zygomaticus muscles, in addition to injuring the parotid duct.3,10 The patient is asked to clench the teeth, outlining the anterior and posterior borders of the muscle. A line connecting the tragus and midportion of the upper lip outline the approximate location of the parotid duct, which lies along the middle third of this line, thus reducing risks of injuring it. The injection points must be below this line and placed in the main bulk of the muscle.3,10 The injection is deep intramuscular, located over five to six points 1cm apart with 30-40 SU of Botox or Bocouture; 90-120 units of Azzalure. However, avoid a single injection point as this can lead to irregularity of facial contour secondary to discrepancy in the

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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4 3 2 5 1. Depressor anguli oris (DAO) 2. Masseter 3. Zygomaticus major 4. Zygomaticus minor 5. Orbicularis oris 6. Depressor labii inferioris (DLI)

Mr Ali Juma is a consultant plastic and reconstructive surgeon with 19 years’ experience. He is the proprietor of the Clinic @51 in Liverpool. Mr Juma served as an honorary lecturer at the University of Liverpool for nine years and as an examiner for the Royal College of Surgeons for seven years. Mr Juma’s experience includes teaching on the safe use of nonsurgical treatments through cadaver courses, as well as participating in scientific research and writing. Qual: MB BS (Lon), FRCS (Plast)

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

Figure 3: Side view of the lower third facial muscles

function of the muscle fibres.10 Pain is the main side effect at the injection sites, and patients may notice difficulty eating hard food, facial asymmetry, and reduction in the width of smile; the latter is due to neurotoxin diffusing in to the buccinator muscle. Damage to the parotid gland duct is also a recognised complication of this treatment, which can de difficult to treat. Masseter muscle atrophy occurs over three to six months, and is reversible over nine months.10,17

Questions

Possible Answers

What is the definition of neuromodulation?

2. The buccinator muscle…

Discussion The lower third of the face is not often seen as a major contributing factor in the aesthetic outcomes of non-surgical treatments; however, it is usually combined with other anatomical areas of the face.3 In addition, in Caucasians, masseteric hypertrophy is not often treated and certainly not as a part of improving the jawline contour and lower third of facial proportions. Neurotoxin in the lower third of the face, although effective in achieving excellent outcomes in the experienced practitioner’s hands, it is nonetheless important to add that the risks are higher than the upper third of the face due to the complex anatomy of the lower third facial muscles and their proximity to each other, including the merging of their fibres.3,14 All this warrants intricate and detailed knowledge of the deep and topographical anatomy of these muscles and the surrounding structures, in addition to the functions of these muscles and how they act in groups.17,14 When complications in the lower third of the face arise, they cause cosmetically and functionally undesirable outcomes. Unfortunately, these are difficult to treat and the course of action of the toxin has to be allowed to wear off. On occasions, more complex salvage of injections has to be implemented to improve an undesirable outcome. Combining myomodulation with neuromodulation is the way forward in many areas of the face.4,5 In combining the two treatments, lower doses of toxin are used, thus achieving more natural results with fewer secondary effects and complications related to the neurotoxins.2,4,5 One such example is the use of fillers to myomodulate the mentalis muscle and using a lower dose of neurotoxin to reduce the negative impact on the lower lip eversion, giving a more balanced natural look to the chin with least negative effect on the lower lip pout, and less impact on the competence of the lower lip. Last but not least, we must not forget that treatment of mid-facial ageing holds the key to facial rejuvenation not only in the periorbital areas but also of the jowls and neck-jawline interface, especially when combined with lower third facial treatment, making for cosmetically desirable and repeatable outcomes.3,10,14,18

a. Influencing a facial mimetic muscle by injecting botulinum toxin A & HA filler b. Influencing a facial mimetic muscle activity by injecting botulinum toxin A c. Influencing a facial mimetic muscle by injecting HA filler d. None of the above a. b. c. d.

Is a facial mimetic muscle Is a muscle of mastication Is one of the important smile initiation muscles Is located superficial to the masseter muscle

3. The masseter muscle…

a. Is a mimetic muscle without any impact on facial width b. Its hypertrophy is desirable in the Asian female population c. Is anatomically located superficial to the parotid duct d. Is a mastication muscle influencing the facial lower third width

4. The platysma muscle…

a. Is deep to the sternomastoid muscle in the neck b. Is supplied by the mandibular branch of the trigeminal nerve c. Has no action on the corners of the mouth d. Draws the corners of the mouth inferiorly and widens it

5. Each Botox and

Bocoture units are equivalent to…

a. b. c. d.

1 unit of Azzalure 1.6 units of Azzalure 3 units of Azzalure 5 units of Azzalure

1. b, 2. b, 3. d, 4. d, 5. c

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Note: The diagrams described only serve as an approximation to real-life anatomy.

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Case Study: Treating the Profile Dr Linea Strachan details her approach to profiloplasty and retreating a patient one year on When addressing the profile using dermal fillers (also known as profiloplasty) it is important to assess each patient individually, understand their expectations and treat appropriately. By using this approach rather than a ‘paint by numbers’ technique, each individual’s full potential can be achieved using their own natural features to harmonise their profile without a dramatic, obvious transformation.

Patient background A 26-year-old female patient first attended my clinic in November 2019, complaining of a retracted chin and unbalanced side profile. She works as a social media influencer/blogger and wanted to achieve a well-balanced, natural and refreshed look from every angle. I conducted a full medical consultation where there were no indications to determine she was not appropriate for non-surgical treatments. The patient had not undergone previous aesthetic treatments and I gained a full understanding of her goals and expectations for treatment. She presented with an angle class II bite, or overjet, where the maxilla lies ahead of the mandible and retrognatic (convex) profile with a mandibula that is too small, as it is underdeveloped.1 The zygomatic arch was quite flat and there was a grade 1 tear trough (TT) deformity with no significant pigmentation and good skin quality, making her a suitable candidate for tear trough filler.2 After assessment, I felt that this patient would benefit from mid-face correction, addressing the volume of her mid-cheek, enhancing definition of the zygomatic arch and correcting the TT. Also, augmenting the body of the mandibula and gonial angle would add definition to her lower face and result in a more balanced profile. I determined that chin augmentation aiming for anterior projection would correct the convex profile. Combining these treatments would create a balanced side profile and general beautification, resulting in a more defined and fresher look. Even though the non-surgical rhinoplasty (NSR) is normally a part of profiloplasty, the patient presented with an upwardturned nasal tip and sufficient nasolabial angle.3 She was happy with her nose, therefore NSR was not indicated.

First treatment With all patients, I carry out my routine of obtaining consent, photographs and prepping them for treatment. I choose to use a cannula technique for treating most indications as I find that patients experience less discomfort and have shorter recovery time.4 It also minimises the risk of serious complications such as vascular occlusion and blindness.5

As some research shows, using cannula doesn’t affect the precision of depth of the injections,6 and this has been my experience of treating many cases with consistently positive outcomes. I addressed the mid-face first as, in my experience, this indirectly helps improve and lift the lower face. I used a single insertion point for the cannula each side in the zygomatic region laterally to access and treat medial, lateral cheek and all aspects of the TT. A 25 gauge 50mm cannula was used, as smaller gauge cannulas could cause trauma to the blood vessels.7 To achieve definition of the zygomatic arch and to create a youthful and feminine convex ogee curve,7 I chose to use a hyaluronic acid (HA) filler with a high G prime with sufficient volumising capacity, but also high viscoelasticity, which allows the product to adapt to facial movements, yet remain at the site of injection.8 I used 1ml of Stylage XL in each cheek, augmenting the zygomatic arch by placing microboluses of 0.1ml along the cheek bone supraperiosteally. I also augmented the deep medial cheek fat compartment. This gave support to the lower lid-cheek junction, helping improve the appearance of the TT that would allow me to use less filler when directly treating it. For TT correction, a less hydrophilic filler with low viscosity and HA concentration was needed in order to prevent the likelihood of oedema and the Tyndall effect.9 I chose to use Stylage S and placed 0.4ml per TT, injecting filler under the orbicularis oculi muscle in the suborbicularis oculi fat (SOOF), using a retrograde linear threading technique. I found this was a sufficient amount as, in my experience, undertreating this area reduces the risk of oedema when filler attracts water following the treatment. I chose Stylage XXL to augment the chin, increase anterior projection and to create a defined, feminine facial shape to harmonise the features. It is a highly elastic product with high lift capacity. Women tend to have narrower faces with single point light reflection on the chin.11 I approached the chin augmentation via a single insertion point in the midline of the chin, placing 1ml of product on the periosteum under the mentalis muscle and adding anterior projection to the chin. I then added 0.6ml of Stylage XL over the mentalis in the fat tissue to further project the chin and shape it. I treated the whole jawline and gonial angle, using one insertion point for the cannula in the border of mandible each side, at least 1cm in front of anterior border of the masseter

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Before

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After

Before

Figure 1: Patient before and immediately after the first treatment. Patient was treated with 6.8ml of dermal filler in total.

to avoid the facial artery. I used 0.5ml of Stylage XL on each side to shape the gonial angle subdermally, placing micro boluses to mimic the triangle shape of the gonial angle. To further enhance and sharpen the jawline and correct the pre-jowl sulcus, I treated it with 1ml each side in a retrograde linear threading technique, creating a line of filler along the border of the mandible in posterior and anterior directions. The patient had good tissue quality, so there were no concerns of seeing product in the superficial plane after the placement. The patient was pleased with the result achieved, found the treatment comfortable and reported no bruising or swelling at her post-procedure review two weeks later.

Second treatment A year later, the patient contacted me again, seeking further treatment to address the profile and lips. On examination, the patient presented with a less-recessed chin than a year ago but would benefit from anterior projection. The jawline and gonial angle had lost most of the definition and would need augmentation again. We also decided to add some volume to the chin laterally to correct the pre-jowl sulcus for a more uniform jawline. The zygomatic arch was flatter, but she still had the ogee curve and sufficient malar volume, therefore less product would be needed to treat this. The TT did not need correction. My advice was that very light cheek enhancement would be beneficial, adding definition to the zygomatic arch. The patient also presented with a slightly thin upper lip with deficient and inverted lateral tubercules and a large median tubercule and flat side profile that was not a concern for the initial treatment, but she wanted to address this for her second treatment. I felt that creating slight

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After

Figure 2: Patient one year on, before her second treatment and immediately after. Patient treated with 6ml of dermal filler.

frontal projection, adding definition to the vermilion border and the vertical height to the upper lip, would benefit her profile harmonisation and beautification of the face as a whole. The treatment plan was to address the lateral portion of the cheek, defining the zygomatic arch, add anterior chin projection, correct the pre-jowl sulcus and the labiomental fold, repeat the jawline augmentation, and also gently enhance the lips. I discussed this in detail with the patient and she was happy and consented for the treatment. The cheeks were treated in exactly the same manner as before; this time I used 0.5ml of Stylage XL each side as it didn’t require as much volume as last time. In the chin, 1ml of Stylage XL was used supraperiosteally to add anterior projection. I used 1ml of Stylage XXL per side to augment the jawline and gonial angle in exactly the same manner as previous treatment, choosing this product as it is slightly more volumising. The pre-jowl sulcus and labiomental fold was treated with 1ml of Stylage L via an insertion point that I used laterally in the middle of the border of mandible, just changing the direction of the cannula. I chose Stylage SL for lip enhancement. This product is very soft yet, at 18.5mg/g concentration, provides natural, soft and hydrated-looking results with enough volume. It contains mannitol, which is an antioxidant and aims to reduce the swelling after injection.10 To augment the lips and correct their shape, I used a combined cannula and needle technique. I used a single insertion point for the 25 gauge 38mm cannula each side, lateral to the corners of the mouth, and placed 0.4ml in the upper and 0.3ml in the lower lip at a supramuscular depth using linear threads. I was careful to

avoid the median tubercle. To correct the inverted lateral tubercules and add vertical height, I used a 30 gauge needle, placing vertical threads through the vermillion border. There was quite a bit of swelling on the upper lip, due to reinjecting with the sharp needle, and I warned the patient she will likely present with a bruise following treatment. Again, the patient reported no downtime post procedure and felt that the treatment exceeded her expectations.

Summary Younger patients are becoming more aware of their profile so are seeking non-surgical profiloplasty options, which is becoming a more popular treatment. With appropriate assessment and correctly selected products and techniques, practitioners should be able to get consistently great results and returning patients. The results are long-lasting, and it is possible that less product can be used each time to achieve similar or better results. Dr Linea Strachan is the owner of Dr Linea Medical providing non-surgical aesthetic, skin and laser treatments with established clinics throughout East Anglia. She is also the founder of Dr Linea Training Academy, teaching other medical practitioners intermediate and advanced aesthetic treatments using cannulas. Qual: DMD

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Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

Introducing… EDUCATING AND INSPIRING THE PUBLIC TO MAKE SAFE AND ETHICAL CHOICES IN AESTHETIC MEDICINE

ith the medical aesthetic market set to be worth $15.9 billion by 2025, we know it is a fast-evolving specialty, booming with new products and treatments, life-changing procedures and revolutionary science. Yet, unfortunately, there is a lack of quality education on what’s available and media coverage can be largely negative; leaving patients and consumers misinformed, afraid of complications and hesitant to talk openly about aesthetic treatments and procedures. This is where Beyond Beauty comes in. The ground-breaking new magazine, with four issues a year, will be filled with educational content that is factual, informative and engaging. We’ll also be hosting an experiential event for consumers – Beyond Beauty Live – in early 2022, so stay tuned!

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Understanding Skincare Preservatives From parabens to essential oils, Miss Jennifer Doyle explores the commonly used preservatives in skincare, along with their evidence for safety Preservatives are natural or synthetic substances that are added to products such as foodstuffs, cosmetics and pharmaceuticals in order to increase their shelf-life and maintain their quality and safety by inhibiting microbial growth and contamination.1 Whilst the term ‘preservatives’ often provokes negative connotations with consumers, without preservatives the moist warm environment of a skin cream would be the perfect breeding ground for microbes.2 A variety of compounds have been used as preservatives in personal care products and, over the years, the safety of these products has been evaluated. We explore the commonly found preservatives used in personal care and explore the evidence for their safety.

How preservative works Preservatives are essential to prevent products from spoiling.3 Without them, the shelf-life of a product would be much shortened, as after contamination with microbes, there would be no active products

present to prevent the microbes from proliferating.3 Even if a cosmetic product was produced in sterile environments and sealed, once opened and exposed to the environment it would be contaminated with microbes and, without any preservatives, would become a breeding ground for microbes.3 Thus, unless our product is single use, all cosmetic products designed for reuse over a period of time need to contain some sort of preservative compound, natural or synthetic. In skincare products, this could

lead to skin problems such as infections or dermatitis.2,3 The European Commission maintains a list of scientifically-evaluated safe preservatives for their use in cosmetic products on the EU market.3 The efficacy of preservatives in cosmetic formulations is evaluated in a challenge test as per the European Pharmacopoeia guidelines.4 This test involves the artificial contamination of cosmetics with a predetermined amount of bacteria and fungi. This includes bacteria such as Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli and fungi including Aspergillus niger and Candida albicans.4 Samples are periodically removed at fixed times and the number of viable microorganisms are counted.4,5 Parabens are the most widely used preservative in cosmetics with previous estimates of 75-90% of cosmetics containing parabens.2,5,7 They have recently come under scrutiny and we will explore the reasons why along with the supporting evidence. With concerns regarding parabens and other artificial preservatives such as benzoates, butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT),1 due to hypersensitivity and carcinogenic effects, more interest has grown in natural preservatives. We will explore the natural preservative options that are being utilised, including organic acids and oils.1 Artificial preservatives Parabens including methylparaben, butylparaben and propylparaben are common preservatives found in cosmetics. They are alkyl esters of p-hydroxybenzoic acid, which are preserved by reacting the desired alcohol (methyl, ethyl etc) with p-hydroxybenzoic acid in the presence of an acid catalyst such as sulphuric acid.8 They have come under scrutiny in recent years due to health concerns, with many brands now advertising ‘paraben-free’. Parabens

All cosmetic products designed for reuse over a period of time need to contain some sort of preservative compound, natural or synthetic

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

BECAUSE BECAUSE SEEING SEEING EVERY EVERY DETAIL DETAIL MATTERS. MATTERS.

Dr Tracy Dr Tracy Mountford Mountford MBBS MBBS MBCAM MBCAM

REAL-TIME VISUALISATION. REAL-TIME VISUALISATION.

NEVER NEVER TREAT TREAT YOUR YOUR PATIENTS PATIENTS BLINDLY. BLINDLY.

® ® Ultherapy Ultherapy , also , known also known as Micro-Focused as Micro-Focused Ultrasound Ultrasound with with Real-Time Real-Time Visualisation Visualisation (MFU-V), (MFU-V), is theisonly the only US FDA-cleared US FDA-cleared skin lifting skin lifting procedure procedure that allows that allows clinicians clinicians to precisely to precisely deliver deliver micro-focused micro-focused ultrasound ultrasound energy energy at the atcorrect the correct layerlayer for safe for safe optimal optimal results. results.

VisitVisit ultherapy.co.uk ultherapy.co.uk for for more more information information REFERENCE: REFERENCE: 1. Fabi SG, 1. Fabi Joseph SG, Joseph J, Sevi J, Green Sevi J, JB, Green Peterson JB, Peterson JD. Optimizing JD. Optimizing patient patient outcomes outcomes by by customizing customizing treatment treatment with microfocused with microfocused ultrasound ultrasound with visualization: with visualization: gold standard gold standard consensus consensus guidelines guidelines from anfrom expert an panel. expertJpanel. DrugsJDermatol. Drugs Dermatol. 2019;18(5):426-432. 2019;18(5):426-432. Individual Individual results may results vary. may vary. M-ULT-UKI-0866 M-ULT-UKI-0866 Date of Date Preparation of Preparation JanuaryJanuary 2021 2021

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

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have an oestrogen-like structure, leading to concerns regarding hormonal interference2 and the effect of certain cancers that are oestrogen sensitive, such as breast cancer.9 The concern started after a review by Darbre published in the Journal of Applied Toxicology in 2003 attracted interest into the investigation of the possible effects and implications with regards to breast cancer of parabens being used as preservatives in underarm cosmetics.10 Since this time, there has been many in vitro and animal models which have demonstrated some hormone-like activity of parabens,11 however the activity was much weaker than that of the natural hormones. There is still more work required to elucidate the potential risk, but the current recommendation as per the European Union is that the use of parabens is allowed up to a certain concentration (8g of parabens per kg of cosmetic product), as it is felt to pose a low risk to health.11 BHA and BHT are synthetic antioxidants used as preservatives in skincare products such as moisturisers.4 Both can cause allergic reactions in the skin.12 An incidence of 13-15% for BHA/BHT reactions has been reported.13 BHA is also considered a possible carcinogen and been banned for use in cosmetics by the EU.5 There is a variety of other synthetic preservatives which have raised similar concerns regarding allergic reactions, interference with hormone function or carcinogenic effects, and include coal tar dyes, diethanolamine (DEA)-related ingredients, formaldehyde-releasing preservatives, polyethylene glycols (PEGs), siloxanes and triclosan.6 For many of these, further studies will be needed to elucidate their effect in vivo. Natural preservatives The consumer market is becoming more aware of the potential concerns regarding synthetic preservatives, and this is driving a growing demand for natural preservatives.4 Several essential oils including Lavandula officinalis (lavender), Melaleuca alternifolia (tea tree) and Cinnamomum zeylanicum (cinnamon) have shown comparable or even higher inhibitory activity against tested microorganisms compared to methylparaben.14 Plant extracts including Matricaria chamomilla (chamomile), Aloe barbadensis (aloe vera) and Calendula officinalis (marigold) have also shown to have near comparable antimicrobial action to methylparaben.15 Studies have also looked at combining such

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natural preservatives with synthetic ones, in order to reduce the required concentrations of synthetic preservatives.15 Whilst there are numerous in vitro antimicrobial studies into the use of pure essential oils and plant extracts as natural preservatives, there has been little research done demonstrating their antimicrobial activity when incorporated directly into cosmetic products.15-18 Further research will be needed in this area in order to demonstrate their effect once incorporated into cosmetic products. Other natural preservatives include organic acids such as salicylic acid, benzoic acid and sorbic acid.17 It has been demonstrated that these acids meet the required antimicrobial action as required by the European Pharmacopoeia.17 They are all categorised as preservatives in European Regulation No 1223/2009 on cosmetic products,19 and are accepted as natural preservatives. The main drawbacks limiting the use of natural preservatives include a lack of broad-spectrum activity and poor efficacy at low concentrations, irritation or potential for allergic reaction, poor compatibility with other ingredients, undesirable odour or colour and high cost.17,20,21 These factors will be taken into consideration as limiting factors by researchers and cosmetic manufacturers.

Preservatives are necessary Preservatives in skincare products are necessary in order to prevent microbial growth within the product and, hence, are found in every formulation. Preservatives can be synthetic or of natural origin. There are concerns regarding the effect on health of synthetic preservatives such as parabens, BHA and BHT. Natural preservatives, including plant extracts, essential oils and organic acids, have been investigated and show promising in vitro results for their antimicrobial action. Many are limited by factors such as cost or undesirable odour. Further research to evaluate their use within cosmetic preparations and their compatibility with other components found in skincare is required.

Miss Jennifer Doyle has a Bachelor in Medicine and a Bachelor of Surgery with distinction, as well as a Master’s in Medical Sciences from the University of Oxford. She is a Fellow of the Royal College of Ophthalmologists and has completed the Level 7 in Injectables, as well as being a lead trainer at Harley Academy. Miss Doyle currently works as an NHS registrar in ophthalmology, as well as leading her clinic, Oxford Aesthetics. Qual: BMBCh, MA(OXON), L7Cert, FRCOphth REFERENCES 1. Anand SP et al. Artificial preservatives and their Harmful Effects: Looking toward Nature for Safer Alternatives. International Journal of Pharmaceutical Sciences and Research. 2013; Vol 4(7): 2496-2501. 2. Garner N. et al. Parabens as preservatives in personal care products. Chemistry in Action! #103 Summer 2014. 3. European Commission. Preservatives in the EU. <https://ec.europa.eu/health/sites/health/files/scientific_committees/docs/ infograph_preservatives_en.pdf> 4. Glavac N K. Lunder M. Preservative efficacy of selected antimicrobials of natural origin in a cosmetic emulsion. International Journal of Cosmetic Science/ Volume 40, Issue 3. 5 May 2018. 5. Safe Cosmetics. Butylated Compounds. <http://www.safecosmetics.org/get-the-facts/chemicals-of-concern/butylated-compounds/> 6. Dirty Dozen’ cosmetic chemicals to avoid. <https://davidsuzuki. org/queen-of-green/dirty-dozen-cosmetic-chemicals-avoid/> 7. Winter, R. Dictionary of Cosmetic Ingredients. Publication date 01 April 2005. Publisher Random House USA INC. ISBN 1400052335. 8. Weber K. New Alternatives to Paraben- Based Preservative Blends. <http://www.schulkemicrosites.de/media-cosmetic-preservation/Literature/New-Alternatives-to-Paraben-Based-Preservative-Blends-C-T-2005.pdf> 9. Harvey P W. Parabens, Oestrogenicity, underarm cosmetics and breast cancer: a perspective on a hypothesis. Journal of Applied Toxicology/ Volume 23, Issue 5. 8 September 2003. 10. Darbre P D. Underarm cosmetics and breast cancer. Journal of Applied Toxicology/ Volume 23, Issue 2. 19 March 2003. 11. European Commission Scientific committee. Parabens used in Cosmetics. <https://ec.europa.eu/health/scientific_committees/ docs/citizens_parabens_en.pdf> 12. U.S. National Library of Medicine, in Haz-Map: Occupational Exposure to Hazardous Agents, 2010, 13. Goodman DL et al. Chronic Urticaria exacerbated by the antioxidant food preservatives butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT) Journal of Allergy and Clinical Immunology Volume 86 Issue 4 Part 1, October 1990, Pages 570-575. 14. Dreger M. Weilgus K. Application of essential oils as natural cosmetic preservatives. Herba Polonica Vol. 59 No. 4 2013. 15. Herman, A., Herman, A.P., Domagalska, B.W. et al. Essential Oils and Herbal Extracts as Antimicrobial Agents in Cosmetic Emulsion. Indian J Microbiol 53, 232–237 (2013). 16. Kunicka-Styczyńska, Alina & Sikora, Magdalena & Danuta, Kalemba. (2009). Antimicrobial activity of lavender, tea tree and lemon oils in cosmetic preservative systems. Journal of applied microbiology. 107. 1903-11. 10.1111/j.1365-2672.2009.04372.x. 17. Kocevar Glavac N. Lunder M. Preservative efficacy of selected antimicrobials of natural origin in a cosmetic emulsion. International Journal of Cosmetic Science/ Volume 40, Issue 3. 5 May 2018 18. Kunicka‐Styczynska, A., Sikora, M. and Kalemba, D. Lavender, tea tree and lemon oils as antimicrobials in washing liquids and soft body balms. Int. J. Cosmetic Sci. 33, 53– 61 (2011). 19. European Commission. Regulation (EC) No 1223/2009 of the European Parliament and of the Council of 30 November 2009 on cosmetic products. Official Journal of the European Union L 342/59. 20. Flanagan, J. Preserving Cosmetics with Natural Preservatives and Preserving Natural Cosmetics. In: Formulating, Packaging, and Marketing of Natural Cosmetic Products. (D. Kromidas, ed.), pp. 169– 178. John Wiley & Sons, Inc, Hoboken, New Jersey (2011). 21. Steinberg, D.C. Preservatives for Cosmetics. Alluredbooks, Carol Stream (2013).

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

CHANGING THE FACE OF AESTHETICS ANATOMY - GEOMETRY - ARTISTRY - BEAUTY

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‘well’ appearance. I also detailed the ageing process using the Allergan anatomy app to demonstrate visually the anatomical and physiological changes to ensure the patient really understood what was happening during this process. This is extremely important,4 and into why I would be advising a holistic Dr Manav Bawa shares his approach to addressing feeds rejuvenation treatment plan over a number an aged face with staged injectable treatments of sessions. I created a bespoke full facial rejuvenation Full facial rejuvenation can be one of the most rewarding treatment plan and explained in detail the individual treatments, as well treatments to provide, both for patients and practitioners. as how we would move through his patient journey together. A good consultation can help educate and set expectations with the I took into account his stronger concerns and budget, so tailored his challenging and lengthy patient journey, and, with the increase in plan to fit around those and the treatment outcomes we both aimed males seeking non-surgical procedures,1 it is important to tailor your to achieve. His plan was created with a treatment session every four consultation and treatment plans to this demographic. weeks, depending on his availability, and using approximately 2-4ml of In this case study I will present a 61-year-old male patient, who had dermal filler per session, with the additional use of botulinum toxin at never had treatments before, looking for help with a general tired and regular intervals. aged appearance, which was affecting his confidence. I will take you I use the MD Codes created by Dr Mauricio De Maio for my through his patient journey from start to finish, using a bespoke full treatment planning and techniques,5 as this allows me to create facial approach with a range of products and techniques. a bespoke plan, with a standardised structure, which has been successfully tried and tested with reproducible results. The MD Patient consultation Codes represent specific anatomical units and subunits. Each code I usually take 45-60 minutes on the initial consultation as it is also describes the ideal product, depth of dermal filler placement, important to take the time to really understand your patient and the delivery method and technique, as well as the recommended find out who they are,2 as well as their motivations and emotional product volume.6 3 attributes. It is also important to really understand what they are Following our initial consultation, I organised a follow-up looking for, as well as what would suit them best; remember there consultation two weeks later to allow him time to reflect on our is frequently an inconsistency between the two, which is why consultation and digest the information I provided, as well as the patient education is extremely important. risks I had explained during the consultation.7 I shared information During our consultation, I explored this patient’s concerns and sheets for him to read at home, with the aim of helping him emotional attributes, where he explained that he felt his appearance understand the treatments and products I would be using. This portrayed a tired and saggy emotion when looking in the mirror. He also gave him time to think of any questions he had. When I saw was also searching for the positive attributes of enhancement and the patient again, he was happy with the plan, and asked about pre contouring, especially of the cheeks. and aftercare for the sessions, which were explained in detail. The patient had recently suffered a couple of life-changing At this follow up I also took photographs for his records. circumstances, which had a negative impact on him and made him Standardised photography documentation helps with assessment feel as though he had aged. He also said that he had not been and treatment planning,8 so I documented numerous angles, looking after himself as much as he once used to. This in turn led to ensuring I captured the patient in a static state with frontal, oblique a lack of confidence, which was all part of a vicious circle, for a once and lateral views, as well as taking frontal dynamic images, with the extremely confident individual. patient making a number of expressions. He stipulated he wanted natural results, where no one would be able to tell he had any treatments or procedures, and ideally a ‘healthy Treatment look’, as well as subtle enhancement and reversal of the negative I used the Juvéderm Vycross range and Botox throughout this full-face emotions as described above. rejuvenation. I started with wrinkle relaxation and general mid-face restructuring, followed by temple rejuvenation and contouring in Assessment more superficial layers using a lighter product, as detailed below, and I identified several factors that needed addressing, including finished with improving the texture of the skin. hollowing of the patient’s temples, static rhytids of his forehead, The iS Clinical and Obagi skincare ranges were discussed with the the glabella region and around the eyes. He had loss of volume in patient, with the aim of improving his overall skin texture and tone. his lateral and medial cheeks, subsequently leading to nasolabial Informed written consent was taken for every treatment and every lines and vertical lines on each cheek. He suffered with tear trough session, as well as further before and after pictures per session. deformities and a labial mental crease was also present. His skin was Strict aseptic technique was adhered to throughout all treatments dehydrated as well as suffering with textural issues. using Clinisept+ Prep & Procedure, marking the treatment site using I assessed his psychological needs, as well as ensuring he did the MD Codes and cleaning the injection site with an Alcowipe not suffer from body dysmorphic disorder, using a variety of just before insertion of the needle. I used 27 gauge needles (with subtle questions and scores. He did not present with anything aspiration for nine seconds) and 25 gauge blunt tip soft tissue of significance. I explained the holistic approach, as well as the cannulas throughout the treatment plan. The amount of product was importance of achieving natural results, with the aim of a ‘healthy’ and equal bilaterally unless stated.

Case Study: Male Facial Rejuvenation

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Session 1

Volift Botox

• Zygomatic arch (Ck1): Juvéderm Voluma placed in three points down to the supraperiosteum of the zygomatic arch, using a needle to leave a bolus of 0.1ml for each injection site. • Lateral lower cheek/parotid area (Ck4): Juvéderm Volift inferior to the zygomatic arch within the subcutaneous tissue using a cannula to fan 0.7ml of product on each side. I would normally use Voluma here, however I felt the skin was frail and Volift would provide a more favourable result. • Botulinum toxin: injected to the frontalis, glabella complex and orbicularis oculi.

Voluma

Session 2 (four weeks later)

Voluma Volift – deep placement Volift – superficial placement Volbella

• Anteromedial cheek (Ck3): Juvéderm Voluma down to the supraperiosteum of the maxilla using a needle to deliver a bolus of 0.3ml. • Anteromedial cheek (Ck3): Juvéderm Volift to treat the deep malar fat pad using a cannula to fan 0.4ml. • Anteromedial cheek (Ck3): Using the same entry point, I used Juvéderm Volift for the superficial medial cheek fat compartment using a cannula to fan 0.3ml. • Infraorbital (T1,2,3): I used the same entry point as above and placed Juvéderm Volbella onto the infraorbital periosteum using a cannula to place micro aliquots of the product, 0.4ml on the left and 0.3ml on the right.

Session 3 (six weeks later)

Voluma Volift Volbella

• Anterior temple (T1): Juvéderm Voluma to the supraperiosteum using a needle to place a bolus of 0.5ml. • Anteromedial cheek (Ck3): Juvéderm Volift for the deep malar fat pad using a cannula to fan 0.3ml. • Nasolabial folds (Nl1,2): Juvéderm Volift targeting the subcutaneous layer using a cannula to fan 0.5ml. • Superficial vertical cheek and chin lines: The patient requested these be subtly reduced next as they had concerned him greatly. Juvéderm Volbella was used in a subcutaneous layer using a cannula to place linear threads deep to the wrinkles. 1ml was used on each side.

Session 4 (four weeks later) • Anterior temples (T1): Revisited using Juvéderm Voluma to the supraperiosteum using a needle to place a bolus of 0.5ml. • SOOF (Ck3): Juvéderm Volift to treat the SOOF using a cannula to fan 0.5ml. • Botulinum toxin: To the frontalis, glabella complex and orbicularis oculi.

Voluma Volift Botox

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Voluma

Session 5 (four weeks later)

Session 6 (eight weeks later)

• Chin (C1): Further correction of labial mental crease using Juvéderm Voluma in a subcutaneous layer using a cannula to fan 0.2ml on each side.

Post-procedure care After every session I took time to explain what the patient may encounter over the next seven days, as well as advising no makeup that day to reduce the infection risk. I also advised the patient to refrain from strenuous exercise, saunas and alcohol for 24-48 hours to avoid vasodilation, thus an increased risk of bruising and swelling, as well as avoid facial massage for two weeks following the session.9

Before

• Jawline (Jw1): Increased definition of jawline and the bigonial distance for a more defined look using Juvéderm Voluma down to periosteum with a needle, delivering a bolus of 0.3ml. • Top Model Look (Ck1 TML): The ‘Top Model Look’ is an additional MD Code for the lateral cheek used to describe additional contouring using dermal filler to project the zygomatic arch laterally, creating a wider bizygomatic distance. Additional dermal filler was added to define the zygomatic arch further using Juvéderm Voluma to the zygomatic arch at the sub-SMAS level, using a cannula with a linear technique, depositing 0.5ml. • Upper nasolabial fold (Nl1): Juvéderm Voluma was used at the supraperiosteal depth using a needle to deposit a bolus of 0.2ml. • Submalar/buccal cheek (Ck5): Juvéderm Voluma was placed at a subcutaneous depth to provide more support using a cannula to fan 0.3ml.

After

• Skin booster: Juvéderm Volite was used over the entire face to improve skin texture, hydration and elasticity; 2ml was used in total, which completed the treatment plan.

I provided our emergency telephone number in case the patient had any urgent concerns and booked the next session before he left. The full set of aftercare was emailed after every session. I explained to the patient that as we were using a premium product, he will benefit from these results for 18-24 months (on average), and we scheduled a review in one month for a general follow up and then three months for his next wrinklerelaxing treatment.

Summary A holistic assessment, patient education and clear treatment plan is important to achieve successful outcomes and can lead to lifechanging results, for example, in this case, the confidence the patient had following a successful treatment journey was fantastic, and he felt he had the energy as well as the confidence he had 10 years ago.

Figure 1: Frontal view of patient before and after six treatment sessions with the Juvéderm range and Botox. Before

After

Dr Manav Bawa is an aesthetic practitioner and GP with a surgical background. He is the medical director of Time Clinic in London, an injectables trainer, and has completed a Diploma in Aesthetic Injectable Therapies. Dr Bawa is an associate member of BCAM and is passionate about mentoring, education and patient safety. Qual: MD, PGDip(ESSQ), MRCS(Eng), M Ed(SE) & DIC, MRCGP, PGDip(CAIT)

VIEW THE REFERENCES ONLINE! WWW.AESTHETICSJOURNAL.COM Figure 2: Profile view of patient before and after six treatment sessions with the Juvéderm range and Botox.

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and singing, or via evaporation, generating aerosol particles. These are easily carried on air and thermal currents and can be distributed around a room in a short time, creating an invisible ‘cloud’ of virus-laden droplets (Figure 1).5

Reducing Viruses in Clinic Air Physicist and bioengineer Mike Murphy explains how to reduce the presence of viruses in your clinic’s air through UV light energy The COVID-19 virus is in the air. It has long been known that the common cold and the flu are more readily caught during the winter months. This is because people tend to stay indoors for longer periods compared with the warmer months. It is also because the virus ‘sits’ on aerosols in the air that we breathe if there is an infected person shedding viral particles nearby.1 The possibility of COVID-19 cross-infection through aerosols has been discussed since March 2020.2 Authors have pointed out that this method of transmission appeared to explain some infections in Mongolia and Wuhan, where direct, physical contact had been ruled out. They also indicate that other research has proven that the SARS-CoV-1, MERS and H1N1 viruses are known to spread via aerosols, as supported by other authors.3 Influenza viruses and rhinoviruses are also well-known to spread via aerosols.1 The well-established case of the Diamond Princess, a cruise ship that was docked in Yokohama in March 2020, appears to show how easily an aerosolised virus can spread. 712 people became infected on that ship, even though many were quarantined in their cabins. Cruise ships employ ventilation, but they do not routinely use high efficiency particulate absorbing (HEPA) filters, which are discussed below. With the new UK COVID-19 variant becoming more prominent in the UK, which is more infectious than its predecessor, it’s more important than ever to consider your clinic’s air quality.4

It is known that viruses may be contracted through mucosal areas – nose and mouth – and conjunctiva – the eyes.6,7 Consequently, we should not only wear masks to minimise exhalation of virus particles, but also eyewear to minimise contracting viral particles through our eyes. Even ordinary spectacles will offer some barrier to airborne particles.8,9 A very interesting study looked at the importance of respiratory droplet and aerosol routes of transmission from ‘seasonal’ coronaviruses (this study was carried out before COVID-19 emerged), influenza and rhinoviruses.10 They measured the amount of exhaled respiratory virus particles from 246 infected patients, half of whom were wearing face masks, while the other half were not. They found that patients with influenza were more than twice as likely to exhibit fever symptoms and temperatures greater than 37.8°C, compared with coronavirus and rhinovirus patients. They also observed that coronavirus patients coughed much more than the other patients, thereby increasing the likelihood of generating virus-laden aerosols. However, their most important observation was that coronavirus patients who did not wear face masks generated detectable respiratory droplets and aerosols from their exhalations. Those patients who did wear face masks generated virtually no detectable coronavirus-laden respiratory droplets or aerosols. This clearly indicates the vital importance of wearing face masks to reduce the spread of the COVID-19 virus.10

How viruses enter and stay in the air Bioaerosols – aerosols containing potentially hazardous biological materials – may contain components in the size range 1 to 5 microns. Expelled saliva droplets created through speech, coughing or sneezing may be mostly between 1-5mm (1,000-5,000 microns), but these generally fall to the floor, and other surfaces, within a short distance of the exhaler, typically 1-2 metres.1 These may contain viral particles which can remain active on surfaces for days, particularly hand-sanitising equipment.5 However, smaller droplets carrying virus particles can form either during exhalation, simple speech or shouting

7-8 metres

Figure 1: The amount and distance of saliva droplets ejected during a sneeze is significant. Droplets can travel up to 8m from the source and aerosols are formed at the same time, which can fill a room over a short time.

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Direction of airflow: Microdroplets containing virus

Air filtration (HEPA/ULPA)

Increased ventilation

Ultraviolet light

Direction of airflow: Microdroplets containing virus

Figure 2: UVC devices have been used to destroy airborne contaminants such as viruses and bacteria for years

The same conclusions were made following a meta-analysis of 172 observational studies from 16 countries.11 This report, in The Lancet, found that the wearing of face masks ‘could result in a large reduction in the risk of infection’, with a higher protection level with respirators (N95, FFP2 etc.). They also noted a lower level of infections when eye protection was also used. There are many other publications which highlight the increased infection rates associated with aerosols.12-16 Lu et.al. found that the peak of infectivity of COVID-19 occurred one day before symptoms became obvious and that around 70% of all viral transmissions occurred during the incubation period, which had a median of around 11.5 days.17 This suggests that most people are being infected by carriers who are unaware they have the virus, and before they exhibit any fever symptoms such as high temperatures.

Understanding infectious dose ‘Infectious dose’ is an important parameter. This is the average number of viral particles needed to infect a person. Infectious dose is related to the concentration of viral particles in the air (and on surfaces). Clearly, the viral concentrations are higher in smaller rooms, or when there are more people in a room,

rooms with poorer ventilation, and if more time is spent in a room (assuming an infected person is, or has been, shedding in that room). The infectious dose for COVID-19 is likely to be “In the region of a few hundred or thousand particles,” according to microbiologist Professor Willem van Schaik of the University of Birmingham, England.12 Many people often confuse ‘infectious dose’ with ‘viral load’. Viral load is the concentration of virus in the blood, not the air, and determines the progression of an illness in individuals, but a person with a ‘high’ viral load is more likely to shed more viral particles.12 A report from Ryan et.al. indicates that ‘medium’ to ‘high’ doses of SARS-CoV-2 can result in severe illness, while a relatively low dose may, or may not, induce illness.18 They also found that low doses of the virus typically resulted in a milder level of symptoms, compared with the higher doses. This clearly indicates that minimising potential exposure is paramount in reducing the probability of developing any symptoms. The same results were found in an earlier study of the influenza virus.19 The authors found a clear relationship between the infectious dose of influenza and the final outcomes of patients. People exposed

to ‘high’ doses were much more likely to become ill, compared with those that only received a relatively small dose. Swedish scientist Per-Arne Torstensson has calculated that around 80-90% of all COVID-19 infections probably result from inhaling virus-laden aerosols, thereby increasing the need for a comprehensive approach to reducing such risks.20 This calculation is supported by research from Australia.21 It has long been known that ordinary breathing and speech can result in the exhalation of a large amount of aerosol particles.22 In fact, a 10-minute conversation with an infected, asymptomatic (or presymptomatic) person, speaking normally, can generate an invisible ‘cloud’ of around 6,000 aerosol particles, which are potentially virus-laden. These particles will distribute throughout a room within minutes and may linger for many hours if there is no attempt to clean the air.22 The newly discovered mutated COVID-19 strain, first identified in England in late 2020, is around 70% more transmissible, according to UK government authorities.4 This is likely due to infection occurring from a lower infectious dose than with the previous strain. A recent article looked at the spread of COVID-19 in 10 of the largest cities in the US, using computer modelling. They found that more than 80% of infections likely occurred in restaurants, bars, gyms, cafés, hotels and religious establishments – locations with high densities of people. It is most likely that many of these places do not employ good ventilation/filtration and/or ultraviolet cleaning (UVC) systems.23

Cleaning the air in your clinic To reduce the risk of infection from airborne viral particles we need to ‘clean’ the air. Apart from using a simple air-spray containing an anti-viral solution, this may be done in a number of ways. Increased ventilation As mentioned, colds and the flu spread much more readily in the winter months because we all spend much more time indoors or in enclosed spaces with closed windows i.e. much less ventilation than during the warmer months.24 As a result, we breathe in more contaminated air, resulting in more infections. However, we don’t really want to open windows when it might be near freezing outside, so this may not be the first option in many situations!

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Particles will distribute throughout a room within minutes and may linger for many hours Filtration systems using HEPA/ULPA filters A simple way to reduce air contaminated with unwanted airborne particles is with the use of appropriate filtration systems. High efficiency particulate absorbing (HEPA) and ultra-low particulate air (ULPA) filters can filter airborne particles down to 0.3 microns with a 99.95% efficiency in Europe (99.97% in the US), and 0.1 microns with a 99.999% efficiency, respectively.25 These are standard issue in many hospitals and ‘clean room’ facilities but are not routinely used in many clinical/ aesthetic settings. To illustrate the effectiveness of these filters, the 10-minute conversation generating 6,000 aerosol particles, discussed earlier, would be reduced to less than two particles with a HEPA filter and zero particles with an ULPA filter. Even floor-mounted, portable air filtration systems would add an extra layer of protection. However, the filters need to be removed and disposed of as ‘infectious clinical waste’ since they are potentially very hazardous, as they may contain significant numbers of active viral particles. Such systems appear to be relatively easy to source and the cost varies from a few hundred pounds to many thousands, depending on size and requirements. Ultraviolet light cleaning UVC light is composed of high-energy photons which are not particularly safe for tissues since they can alter cellular DNA/RNA, leading to mutagenicity.26 Consequently, high intensity UVC light should not be openly used routinely in the same space as humans, or any other living creatures. A recent study has demonstrated very clearly that the use of far-UVC (207-222 nm) can effectively increase disinfection rates in ‘typically ventilated’ rooms by a factor of between 50-85%.27 This suggests that rooms should be cleansed by UVC light while empty – perhaps overnight when those rooms are not usually occupied (see Figure 2). Alternatively, ‘self-contained’ units which do not allow the light to spill out into the local environment may also be used. A Danish company has developed such units

called the Sanispace device, which draws room air through a sealed unit and may be active continuously, even while the room is occupied. Other systems include the UV CleanLight, Energi Vac and the Woodpecker units. Such units might be ideal for clinical/ aesthetic settings where relatively high numbers of people may ‘pass through’ each day. At the time of publishing, these units vary between around £500 and £3,000 per unit. Various floor-mounted devices are also available from around the world, but many of these are not suitable when people are present, since they output high doses of potentially harmful UVC into the environment. Examples of such systems include the VioUV device from the US, and the Camlab unit or the Germiled device, both from the UK. Again, such systems range in price from a few hundred to a few thousand pounds. ‘Upper room’ UVC systems have been in wide use for many years. These units are typically placed at a height of two metres or higher and emit UVC in an upward direction to create a high-intensity zone in the upper part of a room, while minimising the dose in the lower part of the room, which may be occupied.28 UV light has proved useful in the reduction of active coronaviruses in the air and on surfaces.28,29,30 One study reports that hospitals in China have been instructed to run UVC lamps for one hour, three times a day, every day.8 The author recommends that increased ventilation, even via open windows, more sunlight and that UVC lamps should be routinely used in hospital settings. Recently, the University Hospitals of Derby and Burton have installed ‘robotic’ UVC devices which autonomously roam through wards, theatres and corridors, during quiet times.31 Dr Ewan Eadie of the University of Dundee, has stated, “UVC is proven to inactivate viruses and bacteria and has been used for the past 90 years for this purpose. When deployed appropriately in the ‘realworld’ it can significantly reduce the risk of transmission from airborne viruses.”32 The evidence is clear that UVC is an excellent method for deactivating coronaviruses. While

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the above procedures may not remove viral particles completely, they can reduce the infectious dose significantly, which can only be a good thing.

Help reduce the spread The simplest, most effective ways to reduce cross-infection of this virus are to wear a mask, at all times, and avoid crowded places (including public transport, sporting events etc.) until vaccines are widely available. Do not stay indoors where the risk of contraction is greater for any longer than absolutely necessary. The science is very clear on this. The Chang report clearly shows that crowded places such as cafés, restaurants, supermarkets and gyms, are all ‘high risk’ locations – this is simply because the air in such places is laden with virus particles on aerosols with poor ventilation.23 Aerosols form while breathing, speaking, singing and shouting. These aerosols can ‘sit’ on air currents for hours in poorly ventilated rooms. The air must be removed and/or cleaned using filtration, air sprays containing airborne anti-viral agents and/or UVC light. Asymptomatic and pre-symptomatic people can shed viable virus unknowingly for days before symptoms become obvious, if at all. Quite frankly, detecting a fever temperature in a carrier is too late – that person may well have been shedding the virus for days. New protocols should be introduced into clinics to reduce virus-laden aerosols and the probability of infecting patients/clients. Mike Murphy is a physicist and bioengineer with 34 years’ experience in medical lasers. He started Dermalase Ltd in 1989 to launch the QS ruby laser into medical markets in the US, EU and Asia. Murphy is currently the General Secretary of the UK Council for Surgical Plumes and General Secretary of the Association of Laser Safety Professionals, is a Certificated Laser Protection Adviser and registered as an LPA with Healthcare Improvement Scotland. He has published more than 25 articles, reports and papers in peer-reviewed medical laser journals and trade publications. Qual: B.Sc., M.Sc., LPA

VIEW THE REFERENCES ONLINE! WWW.AESTHETICSJOURNAL.COM

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

VOTE F OR YO U R W I N N E R S RECOGNISE AND SUPPORT THE PRODUCTS, CLINICS AND PEOPLE YOU LOVE! THE FOLLOWING CATEGORIES WILL BE PARTLY JUDGED AND PARTLY VOTED FOR BY YOU: PRODUCT/PHARMACY DISTRIBUTOR OF THE YEAR SALES REPRESENTATIVE OF THE YEAR THE ACE AWARD FOR MANUFACTURER OF THE YEAR THE SKINCEUTICALS AWARD FOR ENERGY DEVICE OF THE YEAR INJECTABLE PRODUCT OF THE YEAR SURGICAL PRODUCT OF THE YEAR - NEW

TOPICAL SKIN PRODUCT/RANGE OF THE YEAR SUPPLIER TRAINING PROVIDER OF THE YEAR THE CCR AWARD FOR INDEPENDENT TRAINING PROVIDER OF THE YEAR CLINIC SUPPORT PARTNER/PRODUCT OF THE YEAR THE BEYOND BEAUTY AWARD FOR PROFESSIONAL INITIATIVE OF THE YEAR

VOTE FOR YOUR FINALIST BEFORE FEBRUARY 28 TH A ES THETICSAWAR DS .CO M

Advertorial Thermage FLX®

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Grow Your Business With Thermage FLX® A real opportunity to grow your business during this unprecedented time Thermage®, one of the most popular non-surgical skin tightening treatments worldwide1 Using monopolar radiofrequency technology, Thermage FLX is a well tolerated,2 innovative and non-invasive skin tightening procedure which can be used on most areas of the face and body, including the eyelids. With more than 50 clinical studies* attesting to its efficacy, Thermage pioneered the use of radio frequency** in skin tightening and as such set the standard for this effective versatile treatment. Thermage benefits from being part of US-based company Solta Medical®, pioneers and global leaders in the field of non-invasive skin tightening.1 Since 2002, Solta Medical’s continued investment has resulted in impressive technological improvements, delivering enhanced patient and practitioner satisfaction both in terms of outcomes3 and comfort.4

Thermage FLX, a real opportunity to stand out from the competition during this unprecedented time. With more than 2.5 million treatments*** performed worldwide, Thermage has a very good reputation borne out by the 78% of patients who said it was worth it,5 and a very high level of patient satisfaction, with 94% of satisfied patients.6 One of the main advantages is that Thermage FLX requires only one session to achieve results. The session takes between 30 to 90 minutes, depending on the area

treated. The Total Tip 4.0cm2 tip reduces the session time by 25%**** and as such increases the potential profitability of each treatment. In addition, Thermage FLX’s sheer versatility allows clinics to maximise revenue opportunities with each patient by offering solutions for areas of the body, face and eyelids. With a single handpiece, it is now possible to treat different areas in even less time****. Indeed, Thermage FLX is one of the only treatments which can be used on the periorbital and orbital areas – giving great results3 with patients with droopy eyelids. Besides, with its large touchscreen with a userfriendly interface, making the system easier to navigate, Thermage FLX is an easy-to-use device which can also be used by healthcare team members increasing revenue opportunities for your business. Post-treatment monitoring is limited with minimal side effects7 – a critical advantage for both clinician and patient alike. *Studies available in the clinical evaluation report (CER), ** The first version of Thermage was launched in 2002, ***Based on sales data,**** All comparisons are made with Thermage CPT and its components.***** The vibrating function is not available when using the Eye Tip 0.25 cm2.******R&D Report

Single session Thermage FLX delivers visible results after a single treatment. The results gradually increase 4 to 6 months’ post- treatment3 and, depending on the skin condition and ageing journey of the patient, can last years. An annual treatment maintenance is recommended by doctors to maintain the results.

Faster treatment The new ‘Total Tip 4.0’ covers 33% more surface skin area than the previous design, and so the duration of the session is reduced by 25%******, improving patient comfort, satisfaction and allowing more time to treat multiple parts of the body.

REFERENCES 1. Medical Insight report-Energy Based Body Shaping & Skin Tightening– August 2020, 2. M. Fritz and al. Radiofrequency treatment for middle and lower face. Arch Facial Plast Surg. Nov-Dec 2004;6(6):370-3, 3. R. Fitzpatrick et al. Multicenter study of non-invasive radiofrequency for periorbital tissue tightening. Lasers Surg Med. 2003;33(4):232-42., 4. Solta Medical, 2009. Report on Gazelle Clinical Study 09-100-GA-T‘Validation of the Thermage 3.0cm2 STC and DC Frame Tips, Comfort Software and Vibration Hand piece on the Face and Thighs’ (#09-019ER). Bothell., 5. Realself report - January 12, 2021 –Thermage rating 6. J.S Dover, et al. Results of a survey of 5,700 patient monopolar radiofrequency facial skin tightening treatments: Assessment of a low-energy multi-pass technique leading to a clinical, 7. E. Finzi, A. Spangler. Multipass vector (mpave) technique with non ablative radio frequency to treat facial and neck laxity. Dermatol Surg. 2005 Aug;31(8Pt1):916-22.

Enhanced comfort The system also features a new multi-directional vibrating hand-piece***** to help enhance patient comfort4 for body and face, making the treatment much more comfortable than the previous version.

This advertorial was written and supplied by Thermage FLX®

Versatility Thermage FLX can be used with the same handpiece on face and body where loose skin and sagging are of concern. Thermage FLX can be used to treat fine lines and wrinkles, and tighten up the skin around the eyes, face, neck, arms, hands, abdomen, thighs and buttocks.

Aesthetics | February 2021

www.thermage.co.uk Thermage FLX®, Thermage CPT®, Thermage®, and Solta Medical® are trademarks of Bausch & Lomb Incorporated or its affiliates. ©2021 Bausch & Lomb Incorporated or its affiliates. THR.0014.UK.21

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A summary of the latest clinical studies Title: Botulinum Toxin in Movement Disorders: An Update Authors: Anandan C, Jankovic J Published: Toxins, January 2021 Keywords: Botulinum toxin, Parkinsons, Movement disorder Abstract: Since its initial approval in 1989 by the US Food and Drug Administration for the treatment of blepharospasm and other facial spasms, botulinum toxin (BoNT) has evolved into a therapeutic modality for a variety of neurological and non-neurological disorders. With respect to neurologic movement disorders, BoNT has been reported to be effective for the treatment of dystonia, bruxism, tremors, tics, myoclonus, restless legs syndrome, tardive dyskinesia, and a variety of symptoms associated with Parkinson’s disease. More recently, research with BoNT has expanded beyond its use as a powerful muscle relaxant and a peripherally active drug to its potential central nervous system applications in the treatment of neurodegenerative disorders. Although BoNT is the most potent biologic toxin, when it is administered by knowledgeable and experienced clinicians, it is one of the safest therapeutic agents in clinical use. The primary aim of this article is to provide an update on recent advances in BoNT research with a focus on novel applications in the treatment of movement disorders. This comprehensive review of the literature provides a critical review of evidence-based clinical trials and highlights recent innovative pilot studies.

Title: Men’s Attitudes and Behaviors About Skincare and Sunscreen Use Behaviors Authors: Roberts C, et al Published: Journal of Drugs and Dermatology, January 2021 Keywords: Skin, Skincare, Skin cancer, Suncare Abstract: Skin cancer is the most common cancer in the United States, and men experience higher rates of skin cancer than women. Despite publicized preventative measures, men are less likely than women to use sunscreen. The objective of the study is to assess men’s motivations, behaviors, and preferred characteristics towards daily sunscreen use. The study used a cross-sectional online survey of 705 men, administered July-August 2019, using Survey Monkey and distributed through Amazon Mechanical Turk. Men ages 20-70, having completed at least High School/GED, and living in the United States were eligible. Sampling strategy ensured diversity in terms of race, ethnicity, and sexual orientation. Main Outcome(s) and Measures: Men’s sunscreen use, behaviors, and preferred skincare product characteristics. The most frequent skincare products used regularly were liquid soap/body wash (65%), bar soap (47%), and moisturizers (32%). Most men (n=612; 83%) reported not using sunscreen daily, and 38% reported using sunscreen weekly. Income was related to daily and weekly sunscreen use. Age, sexual orientation, race, ethnicity, and region were not related to daily or weekly sunscreen use. This survey shows lapses in evidenced-based sunscreen behaviors to reduce skin cancer among men.

Title: Lay Rater Evaluation of Naturalness and First Impression Following Treatment of Lower Face Wrinkles with Hyaluronic Acid Fillers Authors: Pires V, et al. Published: Journal of Drugs and Dermatology, January 2021 Keywords: Filler, Injection, HA Abstract: Hyaluronic acid (HA) dermal fillers formulated with XpresHAn Technology were subjectively assessed by investigators and subjects. Aim: to test whether treatment with HA dermal fillers (HARR and HARD ) deemed natural by injectors and subjects are considered natural by the public and receive positive first impressions. Videos of open-smile expressions of subjects at baseline to Day 42 were assessed by “lay raters” (n = 3004) who indicated agreement with “Face looks natural” and first impressions using Likert-type scales. Naturalness of facial appearance was noninferior at Day 42 compared with baseline. Assessments of first impression demonstrated statistically significant changes from baseline in overall first impression, social skills, dating success, attractiveness, and athletic success. Rater gender and age did not affect scores. Subgroup analysis found three groups had significant positive changes: those aged ≤ 55 years, subjects with natural outcome, and those that received more than 4mL of filler. Subjects without a natural outcome had a significant negative change. While subjective, this study demonstrates that clinicians should aim for a “natural outcome” that receives optimal first impressions from the public.

Title: Effect of Pelvic Floor Electrical Stimulation on Diaphragm Excursion and Rib Cage Movement During Tidal and Forceful Breathing and Coughing in Women with Stress Urinary Incontinence: A Randomized Controlled Trial Authors: Hwang U, et al. Published: Medicine (Baltimore), January 2021 Keywords: Muscle stimulation, Incontinence Abstract: The pelvic floor muscle (PFM) is associated with respiratory function. We investigated the effects of PFM training by pelvic floor electrical stimulation (PFES) on PFM strength, diaphragm excursion, and upper rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence (SUI). In total, 33 participants with SUI were divided into PFES and control groups. The two groups were measured pre- and post-8 weeks of training. Diaphragm excursion and upper rib cage movement were measured using sonography, electromagnetic sensors, and perineometry. There were significant difference of main effect between pre- and post-training and between groups in PFM strength (between groups: P = .001, between time: P < .001) and diaphragm excursion during forceful breathing (between groups: P = .015, between time: P = .026) and coughing (between groups: P = .035, between time: P = .006). Elevation of the upper rib cage during tidal (P < .001) and forceful breathing (P = .001) was significantly decreased after 8 weeks of training in the PFES group. PFM strength (P < .001) was significantly increased after 8 weeks of training in the PFES group. Pelvic floor muscles training by electrical stimulation can improve diaphragm excursion and breathing patterns in women with SUI.

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Marketing to Skin-of-Colour Patients The founders of the Black Aesthetics Advisory Board (BAAB) share advice on enhancing your engagement

Dija Ayodele (DA)

Dr Ifeoma Ejikeme (IE)

Dr Tijion Esho (TE)

Dr Amiee Vyas (AV)

Tailor your messaging Consider your approach AV: Skin of colour in aesthetics often gets flagged as a separate and ‘difficult’ entity. Instead of approaching it in this way, I recommend using an inclusive approach from the start. In my opinion and from my knowledge of patient experiences, avoid going all in with lots of black skin or skin-of-colour social media posts/marketing collateral that comes out of nowhere for a short time and then goes back to normal. It should be part of a long-term sustainable strategy to benefit your patients and clinics alike. DA: As Dr Vyas says, you shouldn’t have a separate marketing strategy for skin of colour. You should have a marketing strategy that’s comprehensive and has aspects that speak to all your patient groups so that everyone can be carried forward. Looking at it separately is quite worrisome as it puts skin of colour in an ‘other’ group, which then makes people feel like it’s another thing to do. Nobody wants extra work! My advice would be to always try and look at both sides of the coin and see how that impacts different groups and develop an inclusive strategy from the start – skin of colour should not be a bolt on. TE: When we look at any product we should look at the customer base as a whole and the research data readily available. With black women in particular being shown to be one of the highest spending groups collectively in skincare, it doesn’t just make ethical sense to consider their needs, it makes financial sense too – which is a core goal of any business. One example is several papers will show a big concern for black patients and skins of colour is pigmentation, therefore inclusion of this aspect would be a basic prerequisite.

IE: When creating a campaign, use images that portray a range of ethnicities and vocabulary to address a wider audience. Consider if the product or device is suitable for all skin types; if so, stipulate exactly which skin types. If not, understand why not and be clear about it. AV: Highlight your experience treating this patient group. Just as you would normally, share reviews and patient experiences from your patients of colour, as well as your before and after photographs (with consent of course). In your marketing strategy look at your treatment toolkit and how you explain each offering. Where you would explain the considerations for different skin types/concerns, include a few lines on skin of colour. Use imagery encompassing all skin colours and make it authentic. Pepper in your skin-ofcolour marketing with your regular offerings; this will attract patients as well as people of colour to join your team. Ensure you use the words skin of colour, brown skin, black skin, and darker skin types in your marketing. Use these hashtags too. DA: For an example on how to tailor your message, think how ageing affects all demographics. Generally speaking, white skin will reveal fine lines and wrinkles earlier, while pigmentary concerns will be the first concern for those with black skin. So, if you want to sell chemical peels, speak about the benefits of chemical peels in general and then in that same text zone in on the particular benefits to each patient group, all within the same space.

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

Enhance your experience and understanding TE: If you don’t have much knowledge of the interests and concerns of patients with skin of colour, or how to treat it appropriately, I always say that to get the conversation/ process right you have to involve the people the conversation is about in the decision-making process. You can carry out surveys within your own cohort of patients and liaise with black colleagues within the industry and bodies which support work in this area, such as the BAAB. By doing so you will educate yourself and it’s that education that will give you the tools to progress. AV: If you lack experience in treating skin of colour but have the knowledge of how to do so safely and successfully, ensure your marketing messages explain this to help consumers gain trust in your abilities. Don’t overpromise and always ensure you are promoting services within your remit with referral processes in place for when you need support. IE: Make certain you’re staying abreast of current affairs and be genuine. Being genuine doesn’t guarantee success but being disingenuous guarantees failure. If you are confident doing treatments on black skin, ensure your website and marketing channels echo that message.

Remember what to avoid TE: Avoid gimmicks, tokenism and reinforcing stereotypes. It may sound obvious but large commercial companies have made negative press headlines by doing so. IE: Don’t assume your patients know you’re confident treating black skin. You will need to show them in your website, language, marketing channels and before and after images. DA: Avoid negative language that creates mental barriers in your approach to treating different demographics, such as, ‘It’s challenging to treat black skin’ or, ‘Afro hair is thick and hard work to care for’. Be mindful to avoid treating skin of colour as ‘other’ and pigeon-holing it into a separate category. That doesn’t make people feel included and tends to drive more of a wedge. We are all the same, but with different needs.

The BAAB is an organisation dedicated to improving the experiences of patients and practitioners with skin of colour in the aesthetics specialty. The BAAB is also a finalist for Professional Initiative of the Year at the Aesthetics Awards. To find out more about the team’s work, find them on Instagram @blackaestheticsadvisoryboard

B RI N G I N G T H E WO RL D O F A EST H ET I C M E D I C I N E TO YO U

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

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Getting started with your waitlist marketing campaign The key components of a waitlist campaign are regular announcements on all marketing channels (website, newsletters, social media, blog, clinic signage) before and during the campaign, each matched with a clear call to action – underpinned by a structured approach to triage and manage enquiries. The idea is to create momentum and a sense of scarcity among your customers to motivate people to take ACTION quickly – be that to secure a booking, make a purchase or be the first to get access to a limited supply. A critical success factor is ensuring the clinic is equipped to deal with a potential flood of bookings or requests quickly and easily – if people spend forever on hold, or don’t get a prompt response via email or social media direct messages, they will quickly lose interest and go to a competitor.

Utilising Waitlist Marketing PR consultant Julia Kendrick outlines how waitlist marketing can improve business resilience during lockdown dry spells Creating and managing customer demand is a critical element of good marketing and, if carefully activated, it can help increase revenue and create opportunities for months in advance. With COVID-19 lockdowns affecting customer footfall and in-person appointments across many aesthetic clinics, effective waitlist strategies are a valuable tool which can help make up for the months of inactivity and ensure bookings are lined up for when you throw open your doors again. In this article, I will outline how to use a waitlist marketing strategy to drive demand, keep customers engaged and even how to turn demand into a PR opportunity.

What is a waitlist marketing strategy? We all understand the principle of supply and demand, and when a commodity or service is restricted but demand is maintained we see an increased perception of value, exclusivity and sometimes a spike in cost, i.e. people are willing to pay more for a limited resource. A waitlist strategy simply creates a sense of exclusivity and urgency about a product or service – without relying on other methods, such as discounts. A recent example of a well-known waitlist campaign from the consumer beauty space would be The Ordinary, the high street skincare brand that regularly boasts waitlists of more than 25,000 for its new product launches, which have been covered in national news outlets such as the Daily Mail.1 Of course, the complexity and suitability of certain aesthetic treatments means that clinic waitlist campaigns should be responsible and focus on the availability of consultations and appointments, or broadly accessible items like skincare products – rather than injectable or invasive procedures. As always, careful attention should be paid to the CAP guidance for any clinic marketing activities.2

Limited supply can be a good thing for business If there is a very limited window of availability for appointments, or your best-selling products are down to the last few, you might be worried about customers being disappointed and even venting their frustration. The key is to get ahead of the perceived problem with clear lines of communication and pivot to a solution – preferably one that keeps the customer coming back to you, rather than trying to find the item elsewhere – keep reading for some ways to achieve this! Your first priority for a waitlist campaign are your VIP customers – the most loyal, repeat customers, the highest spenders, those star patients on the database. If you’re not sure who these prospects are, spend some time looking through your records to segment these VIPs. Send out a personalised email to this group informing them that as a clinic VIP, they get first priority on the new batch of booking slots (or low stock products). Ensure there is a quick and easy process for your VIPs to book in and be clear that this priority booking window will only be available for 48 hours, before you open the opportunity to more people. The idea is to create urgency and, hopefully, prompt action among your most likely customers. Second priority is your next tier down customers – the less regular visitors. Be systematic in your database; find who was missed, cancelled or rescheduled during the lockdown periods or should now be due for a treatment or product top-up and issue

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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them with a personalised email to invite them to re-book their treatment (or purchase their product online) ahead of the general access, for an exclusive 72-hour period. Finally, once these categories have been prioritised, you can publicise the general booking slots or product promotions to new patients and your general audiences – this is a great way to further increase your marketing database. As always, do ensure you comply with the rules on GDPR – for a refresher, the General Medical Council has some good summary articles.3 Make sure you follow up with any non-responders from the first two groups on a once-weekly basis as well.

Work the waitlist! Don’t forget, it’s important to take an active approach to promoting and managing your waitlist. You can issue regular social media posts and reminders on your website about the status of the waitlist – whether slots are booking up fast, how many are left, or whether you’ve had some extra slots open up. You need to keep the buzz and energy going as much as possible to continue driving people to take action.

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If the waitlist gets to be a certain size, this can be newsworthy in itself – for example, if a few hundred people are waiting, or if your clinic appointments are fully booked for the next three months. Of course, always ensure you put a positive spin on this news and offer direction for how people can get in there quickly in future!

Introducing to your clinic Waitlist marketing can be a valuable tool for reigniting customer interest and sales momentum – particularly after the slow periods caused by lockdowns. By creating a strategic approach across key clinic marketing channels, including websites, social media and email databases, practitioners can boost demand and create urgency for certain products and services to help drive sales and bookings. However, business owners should be mindful not to overuse this high urgency marketing strategy in order to avoid creating ‘fatigue’ among the target audiences, who will quickly discern if a company is always pushing a scarcity message which is evidently not the case in reality. This ‘act now, act fast’ tactic is best employed within

a blended marketing programme or regular communication, promotions, education and service provision in order to maintain authenticity and build trusting relationships with customers. Julia Kendrick is an awardwinning PR, communications and business strategy consultant with more than 16 years’ experience. She is the CEO of Kendrick PR, which specialises in trade and consumer PR for the beauty, wellbeing and aesthetic medicine industries. Kendrick also created the E.L.I.T.E. Reputation Programme – the industry’s first online PR and marketing training developed specifically for medical aesthetic practitioners. REFERENCES 1. Daily Mail Online, Celebrity-loved beauty brand whose products inspire a 25,000+ waitlist launch $21 face mask that will give you ‘glowing’ skin (2019) <https://www.dailymail.co.uk/femail/ article-7120235/Beauty-brand-products-inspire-25-000-waitlistlaunch-21-face-masque.html> 2. Advertising Standards Association, Guidance on the marketing of surgical and non-surgical cosmetic procedures (2016) <https://www.asa.org.uk/resource/cosmetic-interventions.html> 3. General Medical Council, Managing and protecting personal information <https://www.gmc-uk.org/ethical-guidance/ethicalguidance-for-doctors/confidentiality/managing-and-protectingpersonal-information>

LED Facts, Fiction & Fake News: Light Therapy Evidence in a Post-Truth World

PRESENTED BY PATRICK JOHNSON, BIOPHOTAS CEO 18 FEBRUARY 2021, 2 PM GMT

http://bit.ly/celluma-aesthetics-journal-webinar There are so many questions and myths surrounding the science and benefits of LED light therapy that it’s difficult to know where to start. Do not miss this Webinar if you have ever wondered about any of the following questions: • What’s the difference between near-infrared, red and blue light? • What are wavelengths and why are they important? • Which is best, Monochromatic or Polychromatic? • What about LED for hyperpigmentation? • Best positioning for superior results? • What’s all the fuss about blue light? • Does power matter?

Light Therapy

LIGHT THERAPY WEBINAR

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

EXPECT EVERYTHING Introducing the HydraFacial™ Elite. More Performance. More Features. More Profits.

EVEN MORE OPTIONS The built−in Perk Switch and integrated protocols lets you add eye & lip treatments driving even more revenue!

plays well with others The HydraFacial Elite has proven results and pairs well with other aesthetic technologies, helping you to maximise your business potential.

PERSONALIsED PROTOCOLS HydraFacial and our partners have formulated customised boosters to target specific skin needs.

ENHANCEMENTS & BEYOND Add−on therapies include LED light & lymphatic enhancing treatment results & expanding body treatment options.

HYDRALITE HANDPIECE + tips You have total serum control & can easily switch between patented HydroPeel Tips. Convenient single−use w/various exfoliation levels.

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To see how one powerful device provides everything you need to power your business, contact us today:

W: hydrafacial.co.uk E: infoUK@hydrafacial.com T: 01788 572 007

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• 10 questions to ask before choosing an aesthetic injector/cosmetic surgeon • The insider’s guide to facial rejuvenation

Improving Instagram Engagement to Increase Visibility Digital marketing consultant Heather Terveen explores how to increase organic engagement on Instagram to attract the right patients Since Instagram’s launch as a photosharing app in October 2010 it has evolved, similarly to its other social media predecessors, beyond personal social sharing to include business marketing opportunities.1 The focus on images, captions and videos make it a great platform for aesthetic providers to showcase their procedures, treatments and products while building rapport and credibility.2 Understanding Instagram’s machine-learning algorithm while thoughtfully mapping out your ideal patient’s journey from follower to customer is key in strategically using the platform for growth.

Instagram’s algorithm Like most social media platforms, content on Instagram’s feed is populated for users based on its machine-learning algorithm. While many factors affect how a user will see content in their personal feed, Instagram’s overall rule is showing users more of what they want to see so that it keeps users on the platform longer.3,4 How does Instagram determine what a user wants to see? While Instagram doesn’t publicly share all factors weighing into its algorithm, earlier in 2020 they shared some algorithm rules via their public Instagram account called @creators. We’ll use these public recommendations, along with insights and data shared from Instagram’s approved software partners as our guidepost.

The short-hand synopsis? The algorithm tracks and measures what content a user engages with in order to serve more of what it deems as pleasing to that individual user. Therefore, the more a user engages with a specific account and type of content, the more the algorithm will attempt to deliver similar content.3,4

The follower-to-patient journey Before we unpack some follower engagement best practices and strategies, it’s important to map out the customer journey for your followers. The more intentional and premeditated you are with how followers can connect with you off the platform the better. Growing your potential customer database should be a primary focus. Instagram doesn’t allow for direct linking in posts, but does allow for one website link in your profile. It’s important to be intentional with this link and direct followers to a specific page, article or form offering something of value to followers beyond just visiting your main website homepage. You can use platforms such as Linktree or ContactInBio, which enable you to use several links on your Instagram profile. You should include a hero piece of content to encourage followers to go to your website and opt-in to your email list. Some examples of content that might entice email opt-ins include: • The ultimate antiageing guide

You can also utilise a compelling promotional opportunity or entry into a monthly contest in exchange for followers to opt-in to your email list. Then consistently use call-to-actions in your posts, Instagram stories and videos, inviting them to learn more by clicking the link in your bio. Finally, establish a new subscriber email series of three to five automated emails introducing your new subscriber to your aesthetic practice’s clinicians/staff, while showcasing your unique value proposition, specialties and softly introducing procedures, treatments and products.

Strategies for increasing Instagram engagement Once you have a follower-to-patient journey established, it’s time to maximise the visibility of your posts by focusing on increasing follower engagement. Instagram broadly defines engagement as likes, comments, reshares and views. So creating content that invites followers to interact with your posts will mean greater exposure for subsequent posts. Let’s take a look at some strategies and tactics that will help increase meaningful engagement with your ideal patient followers. Firstly, what defines ‘meaningful engagement?’ Does a ‘like’ have the same value as a thoughtful comment? While Instagram hasn’t publicly said whether or not there’s a hierarchy to its engagement metrics, marketers hypothesise that comments, shares, direct interactions and time spent on posts have greater impact than likes.3,4 Plus, Instagram has been playing around with removing ‘likes’ from the platform entirely in certain markets.5 Curiosity-invoking hook Famed British advertising executive David Ogilvy once said, “On average, five times as many people read the headline as read the body copy. It follows that unless your headline sells your product, you have wasted 90% of your money.”6 The same principle applies to your Instagram post captions. When a user scrolls through the feed they only see a limited number of characters before having to click ‘more’ to read the entire caption. Starting your posts with a curiosity-invoking statement or question to entice users to want to keep reading encourages them to interact by clicking to read more.

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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For more product and training information visit www.sinclairpharma.com Sinclair Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. 0207 467 6920 Date of preparation: February 2020

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Instagram copywriting It’s important to note that studies show people don’t actually read digital content; they are more likely to scan it.7 In school, they teach us to write paragraphs with at least four to five sentences – on Instagram, however, it’s best to have paragraph breaks after every one-to-two sentences to make it easier for readers to scan. In my experience, leading with content that educates and inspires your ideal patients to achieve their goals is more effective than being directly promotional. Tailor your captions to focus on specific benefits, results and outcomes your patients can expect from your procedures and products, rather than technical features. Avoid using too much industry jargon and speak using the language, questions and commentary you hear your patients using during consultations. For example, instead of ‘Create more lip volume and projection’ you could try ‘Get beautifully-enhanced lips’, or for younger patients, try ‘Dreaming of a full, sexy, pout? Here are a few things we consider when our little-lip patients have big-lip goals’. Calls-to-action Calls-to-action are direct statements in your captions asking your followers to comment, swipe, like, click the link in bio, direct message or share. Almost every post, Instagram Story or video should have one, and only one, call asking your followers to take some sort of action on the post. The likelihood of your followers responding goes up when you tell them exactly what to do next. These smaller simple asks make it easier for your followers to engage. Plus, it will produce more exposure for subsequent promotional posts that directly ask followers to ‘book a consultation’ or ‘call to schedule an appointment’. Carousel posts Breaking up educational and promotional content visually through using Instagram’s carousel feature (the ability to load up to 10 images for users to scroll through on a single post) increases engagement because users are encouraged to swipe. Plus, Instagram will automatically show the second photo once a follower has already seen the first photo, encouraging your followers to see more of your content organically. Strategically breaking up your content across multiple images like this helps readers consume your content as well. Experiment with the exact quantity of

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images to observe what is most effective. Quick tip: try incorporating before and after images across a carousel post while telling followers to ‘swipe left’ to see a patient transformation. Instagram videos Replicating some of the rapport and trust from your in-person conversations with Instagram marketing is possible with video content. Connecting with followers by weaving one to three videos per week into your overall Instagram content plan helps reduce the friction potential patients may have by seeing and hearing from your practitioners on camera. A quick breakdown of the five types of video content on Instagram: • IG post videos: traditional Instagram feed post videos that can be from three to 60 seconds in length • IGTV: Instagram’s long-form video format where videos can be from one to 60 minutes in length • IG Live: Instagram’s version of live streaming • IG Story videos: videos in 15-second clips shared directly inside of Instagram Stories • IG Reels: this is the newest video feature on the platform (launched August 2020) where users can record 15 and 30 second video clips set to music Some ideas for Instagram video content include: • Behind-the-scenes of treatments, procedures and consultations • Tips and educational videos on procedures, treatments or products while sharing your practice’s unique perspective or protocol • A behind-the-scenes video showing what a patient can expect during their first visit to your practice Quick tip: share all video content to your Instagram Stories. Create ‘highlight’ categories (curated collections of Instagram Stories that live directly beneath your user profile) around your products, procedures, about us, behind-the-scenes and testimonials so that visitors can binge-watch your videos directly from your profile. Simple steps for creating engaging video content 1. Poll patients to put together a master list of their biggest objections, questions, concerns and goals 2. Take one question or topic and write a

brief script for the video. Sample format: a. Start with a curiosity-invoking hook of what you are about to share e.g. three of the biggest myths about acne b. Present three to 10 points/tips or one thoughtful anecdote answering the question or presenting your solution c. Finish with a call-to-action of where they can learn more or connect with you off Instagram 3. Decide if you will pre-record or live stream the video beforehand 4. Once posted, email your subscribers to encourage current patients to engage on the video and connect with you on Instagram as well

A holistic approach to your Instagram marketing Your communication on Instagram should be a direct extension of the personal experience your patients have inside of your clinic. The conversations and commentary happening with patients on a daily basis should inspire your Instagram content planning. Encouraging patients while they are in your practice and through email to connect with you on Instagram is paramount. They are likely to be the most engaged of your followers, in turn, helping your content get more exposure. Creating a follower-to-customer journey while focusing on increasing organic engagement on Instagram is a recipe for attracting more ideal patients to your aesthetic practice. While the machine-learning algorithm changes and adapts dynamically hour-by-hour, one rule that has remained constant is Instagram’s focus on their user experience.3,4 Aesthetic practices that focus on serving their followers with engaging content that speaks to their ideal patient’s goals and pain points will succeed on the platform. Heather Terveen is an online marketing educator and consultant for the aesthetic specialty with more than 10 years’ experience in digital marketing. She is host of The Skin CEO podcast and founder of The Skin Socialite Membership. Terveen holds a Bachelor’s and a Master’s degree in Communication Studies from the University of the Pacific.

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Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Many clinics use before and after images to market themselves, and although they may show great results they are not always visually appealing. Using stock images of models looking fresh or rejuvenated might be more pleasing, but again could throw away your individuality and could also be deemed as misleading if the model isn’t an actual patient of your services. Illustrations can have the ability to capture nuance through gesture and transform the graphic representation of the face or body into a softer and more playful object of desire, with less chances of being misleading or offensive, as well as being more pleasing to the eye. This is not to say that there is no place for photography in your marketing. In fact, I believe the best campaigns for aesthetics include a happy medium of both high-quality photos and videos, as well as relevant illustrations that align to the specific brand. Illustrations can also be found via stock Fine artist Lauren Rogers-Martin shares how image websites online, however to really set illustrations can help captivate your audience yourself apart from the crowd you should consider bespoke illustrations. Unless you If you are trying to grow your aesthetic business, then it’s important are extremely creative, talented and have the time to create your own to stand out from the crowd. You likely use various types of imagery illustrations, working with an illustrator can be a good option to create in your marketing to achieve this such as photos and videos. But are bespoke imagery for your marketing. Here I outline the things you you using illustrations? Incorporating illustrations in your marketing need to know before embarking on this journey. could improve your current or future patients’ response of a new treatment or provide learning material for patient education. Finding the perfect illustrator Finding illustrators online via a simple web search is easy and Why illustration? Instagram is especially great for this. However, finding the right Throughout history, illustrations have been used as narrative images to illustrator suited for your brand may be more difficult. I suggest looking tell stories. When the cave man wanted to share what he had for dinner at the illustrator’s portfolio and Instagram posts to discover their he grabbed his stick and illustrated it. This simple method of storytelling individual style. Reach out to them to provide you with examples of has been used throughout the ages and has been integrated into our similar work and explain what you require to determine if they feel everyday lives in ways that you may not have noticed; yet has had a the project is right for them. Once you find the right illustrator, they subliminal effect on our consumer experience. will be able to thoughtfully and strategically create designs that will Remember the animated Red Bull adverts from the early 2000s that have a unique association with your brand and goals. This will help featured loosely drawn characters with big noses who grew wings your business stand out from the crowd whilst also creating brand and flew away after drinking the product? Of course you do. The style awareness, familiarity and earning trust through distinct custom artwork. and humour were unmistakable and became essential to the Red Bull message in many ways. Those goofy ads were a precursor to a rapidly growing practice in today’s world of branding. Other big companies Clinics using illustrations well such as PayPal, Dropbox, Apple, not forgetting many fashion brands, Harley Cosmetic London is one example of how a high-end also use illustrations effectively. cosmetic company has effectively incorporated illustrations Illustration is all about problem solving and telling a story, and isn’t with their brand through their digital platforms. The clinic that exactly what your aesthetic company is aiming to do? Solving has various illustrations for each treatment they offer, your patients’ problems and then sharing their story and experience which is a different and engaging way to showcase their to potential new customers? I have seen a massive spike of new services while staying true to their brand. They feature customers in the aesthetic field that are commissioning illustrations to these illustrations on their website, and also on Instagram do exactly that; tell patients their brand story. So, what are the benefits where they have 4,500+ followers. On their Instagram page of using illustrations for your marketing? Let me break it down for you. they alternate photographs and illustrations to keep the When it comes to stock art or photography that everyone has access content looking fresh and different. SEV Laser Aesthetics to, there’s no guarantee of how many other brands are using the are based in the US and have more than 17 clinic locations, same imagery as you. Your brand’s story is unique and deserves to celebrity customers like the Kardashians and more than be communicated in an authentic way rather than a ‘one-size-fits-all’ 254,000 followers. They are another clinic successfully using approach. Creating bespoke illustrations and utilising them in your illustrations in many aspects of their brand from their website marketing will set you apart from your competitors and visually shows to price list, gift cards and Instagram posts. your patients that you are different.

Using Illustrations in Marketing

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Examples of bespoke illustrations you could include in your clinic marketing

Write a detailed brief Any kind of commissioned work usually involves a brief, so your illustrator has clear instructions of what to create. Remember, they can’t just go and create illustrations that will automatically be perfect for your individual brand! They need your input to understand your desires and how their work can align to your brand. It’s a collaborative experience where you both hold a wealth of opportunity for the ultimate outcome of the illustrations, so get creative. Make sure your brief is detailed and includes what you would like to achieve and, most importantly, what your brand message is. Most illustrators will supply you with their own brief template. To help you write your brief, you may want to do some brainstorming. I usually advise my clients to think of where they believe their brand sits in the market. What are your values? What is your agenda? What are your USPs? Who is your target patient? Now share your perspective with people, get feedback and if you create a story you believe in, your audience and potential patient will definitely respond. Pull this story together in well thought-out arrangement of images, materials, text and colours. This is called a mood board and is often used in the creative world to evoke a particular style or concept. Keep your mood board simple but effective and attach this to your brief. Include some rules and guidelines within the brief. For example, streamline your colour palette and fonts, or even mention that pictures should incorporate different ethnic diversities, genders, ages and sizes. I believe this approach is the best way to first present your ideas to your chosen illustrator as, if they don’t have all of this information in the brief, they will need to constantly ask you further questions which can slow the process.

this is not automatic and is where many go wrong. For freelance artists, the copyright remains with the artist, and for illustration companies, the copyright would remain with the company.1,2 That is unless the artist or illustrator signs over the copyright for the artwork to the person or company who commissioned it. It is paramount that you have this conversation with your illustrator at the start of commissioning if you wish to own the copyrights to your images. It is important to own the copyrights to any illustration that you want the full rights to so that no other company inside or outside of your industry can use it. It’s normally a very simple contract and your illustrator should be able to guide you of the process. For further information on copyrights and trademarks, you can seek guidance from firms such as Trade Mark Wizards.

How to use your illustrations Once you have your illustrations ready, share them! You can strategically place them on your social media feeds, add them to your website, incorporate them within your hard copy marketing materials like price list, leaflets or business cards and more. You can even use them for an advert in a print publication. I have seen my illustrations used for so many things, from Instagram highlights covers, gift and loyalty cards, and YouTube banners, to large window coverings in clinics and animated videos and gifs. The limits are quite literally endless. I do recommend that you regularly review your illustrations to ensure they stay on trend and are fresh. You also don’t want to be overly repetitious, so you should look to get new images and designs as needed.

Start standing out through illustration Prices This is a difficult subject; prices vary from project to project. However, the old saying ‘you get what you paid for’ can also be applied when commissioning any artist. You should always have a conversation with your illustrator and agree upon costs at the beginning. Some illustrators work on an hourly rate or per project and prices will be determined on the brief/project size. It’s important to understand that illustration is complex and requires a great deal of problem solving. Illustrators pour hours of research, concept ideation, sketching, and more, into their work to ensure you get the best possible visual solution to fit your business needs. Therefore, to help to reduce your costs, I recommend you do most of the research yourself and present this clearly to your illustrator, saving them time and you money, because it is likely that you will be charged for additional edits.

Legal and copyright considerations Hiring an illustrator for commissioned work means you’ll be purchasing artwork that you can own exclusive copyright to. However, note that

Illustration can be a powerful tool to distinguish your brand from competitors and, at the same time, create a strong connection with your audience. Hopefully, this article has helped to shed some light on how you can take advantage of this asset to help elevate your aesthetics company and successfully create a brand with originality and personality. Disclosure: Lauren Rogers-Martin creates illustrations for Harley Cosmetic London and SEV Laser Aesthetics. Lauren Rogers-Martin is a fine artist and illustrator. She has a degree in Fine Art Painting from University of the Arts London and currently works with several medical aesthetic clinics in creating bespoke illustrations for their marketing. REFERENCES 1. The Illustrators Guide, 2018. <https://theillustratorsguide.com/copyright-for-illustrators/> 2. The UK Copyright Service, UK copyright law: An introduction, 2020. <https://copyrightservice.co.uk/ copyright/uk_law_summary>

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Enhancing Email Marketing Digital consultant Miriam Shaviv explains how clinics can use email marketing to their advantage If you were asked to name the greatest asset of your business, you might point to your clinic building, a popular treatment or your talented team. The truth is more prosaic. The most valuable asset you own is in a file on your computer, listing your existing patients and contacts and their email addresses. If that list is large enough, every appointment you need to fill up your clinic for the foreseeable future is hiding within it. Your existing patients already know, like and trust you and have proven that they are willing to spend money with you. Getting them to come into your clinic just once or twice more a year is going to be much easier than attracting and converting brand new patients and email is the easiest way to reach them. Whilst your patients may use many different social media platforms, almost all of them will be on email. And while sales messages can feel intrusive on social media, people expect them over email. There’s a reason why marketers say ‘the money’s in the list!’ Email is also a very low-cost tool. Most clinics spend a fortune on advertising on social media and Google AdWords in order to reach new patients. But there are no advertising

costs involved here, because you’re targeting a database you already own. The only investment is for the email service provider. Mailchimp, widely used by clinics, starts at just £10/month.1 Every booking you take over email is highly profitable because the marketing investment is so low. Here I outline some guiding principles to effectively use email to market to your existing contacts and give your clinic a competitive advantage.

Email patients at least once a week As email marketers, we are on the email lists of hundreds of clinics around the world. It’s our business to see first-hand how they communicate. Most of them send no campaigns at all other than the occasional update. The minority of clinics who do use email marketing still under-utilise it by emailing only once or twice a month at most, which isn’t enough. Based on campaigns I have run, the majority of people won’t open every message you send. So if you are only emailing once or twice a month and they miss these, a couple of months can go by without them hearing from you at all. You can’t gain momentum or

build relationships when communication is this infrequent. I recommend to email your list once a week at minimum to stay top-of-mind. If you’re worried about annoying patients by emailing too much, ask yourself whether your emails are providing them with enough value. When your emails are interesting, entertaining and resonate with your patients, you can even email more than once a week! A frequent comment we hear from clients is ‘we don’t want to pester our patients because they will end up unsubscribing’. Here is what actually happens: when we commence a weekly campaign there are initially a small number of unsubscribes, but these are more than compensated for by a rise in engagement, click throughs, replies and bookings. What would you rather do, lose a few subscribers who don’t want to hear from you, or generate more business? Emails are like compound interest. The more often patients hear from you, the more familiar they become with you, the more they trust you – and ultimately, the more likely they are to book a treatment with you.

Segmenting To maximise engagement, ensure you segment your list. This refers to the process of dividing a target market into smaller, more defined categories. There’s no point in sending a campaign on how to treat gynaecomastia to a mostly female audience, or a campaign about wrinkles to subscribers in their early 20s. But don’t just segment according to age or gender. Think about past behaviour. Based on what patients have booked for in the past, what else might they be interested in? Email marketing software also allows you to segment depending on how engaged your audience is around particular topics. For example, you can identify everyone who opened and clicked through on a previous CoolSculpting campaign. These people may be more likely to respond to a future promotion.

Write with emotion The vast majority of clinics who run campaigns use email like retailers do, sending out glossy newsletters or trumpeting a major discount on a particular treatment. Whilst these may have their place and drive some sales, because the emphasis is always on price, this can feel very transactional and pushy. The best emails touch your patients and resonate deeply with them. So, you can’t simply throw offer after offer at your readers.

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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For many people, deciding to get an aesthetic treatment is an emotional decision which they can toy with for months or even years. It can involve challenges to their self-image and self-esteem, not to mention their budget! The emails you send them should reflect their reality. Talk about your patients’ real concerns and frustrations when they’re living with undesired fat or sagging skin. Discuss the ways in which excessive hair or an unwanted tattoo can affect their daily life. What are they typically thinking and feeling when they’re struggling with hair loss or sagging jowls? Then paint a convincing picture of how their lives will improve with your help. The more you focus on what they’re going through, the better they will feel you understand them and the more motivated they will be to book a consultation with you. If there is a disruption to your clinic being open, such as the current lockdown, increase the number of nurture emails you send. You cannot take it for granted that your patients will all return once you reopen. Showing that you care about them and that you’re thinking about them even when they can’t buy from you will pay dividends later.

Get personal Most clinics’ marketing is very impersonal. Emails come from the clinic and are written in the third person. But you need to remember that people buy from people. Your patients will also feel closer to your practice when they hear directly from you, the clinic owner, or from the practitioner who carries out the treatment, and get to know you a little. This doesn’t mean a full confessional with every email, but you should be writing to them in the first person, sharing your real thoughts, stories and experiences and using your own language, not stiff, formal marketing jargon. Practitioners and clinic owners that we have worked with have weaved into their email stories about their holidays, sporting activities, experience working in A&E during the coronavirus lockdown, memories from their medical training and their love of art. In the US, they even occasionally talk about their Bible studies. Somehow, it all ties into medical aesthetics! Patients adore these little vignettes, which make their aesthetic providers feel relatable and approachable. We see a notably high level of replies to these emails. The occasional personal touch also makes your emails more interesting. Your patients will

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never open your emails if they’re boring, no matter how much worthy information they contain.

Nurture – don’t just sell There’s a lot of pressure to get bookings. But your patients need to feel that you have their interests at heart. That won’t happen if all they receive from you is sales material. So, intersperse sales emails with occasional nurture emails. Share useful advice so they’ll want to read your emails, whether or not they’re ready to book with you right now. Provide answers to the most frequent questions you get in clinic or share helpful skincare tips. This would be the same kind of material you might share on your blog. You can also complement these with links to your blog, as well as to videos and even Instagram posts. It’s counter-intuitive, but when you stop trying to sell so hard with every single email, you build stronger relationships with your patients and can end up selling more.

Intergrate all marketing Emails are a very powerful marketing tool, but they’re not a stand-alone. None of your marketing should be. Think about how you tie your emails into the rest of your marketing activities, such as your social media and your website. Ideally, promote the same products or treatments over email and social media on the same week. Can you also reuse some of the material in your emails on your website, or turn the emails into a video? Or can you use email to drive patients to your other platforms and vice versa? A coordinated plan in which you repurpose the material you create as much as possible will save your team time and effort. It will also make your marketing more effective because your patients will hear consistent messages from you on every channel and become more immersed in your world. According to Omnisend, businesses that adopt omnichannel strategies (uniting all communicative channels) see a 287% higher purchase rate than those using a single-channel campaign.2

inactive over 12 months. This can be for a variety of reasons such as updating their email address, their situation changing, or that they are no longer interested in what you’re offering. Ensure your open rates are consistently above 20%. Mailchimp has a useful table showing average open rates for different industries.3 If it’s below 20%, you need to investigate whether (a) your content is relevant or (b) whether your list is engaged. On a monthly basis, review the responses to your emails to see whether you can identify any patterns. Are there topics that consistently get strong engagement? You need to send more of these emails. If a large proportion of your contacts never open your emails, Google, Outlook and other key email service providers will treat your content as junk. If you have inactive contacts (i.e. haven’t opened an email in over three months), move them to a list where they are emailed less frequently, or unsubscribe them altogether. Alternatively, send them a re-engagement campaign to check whether they are still interested in hearing from you.

Start your email campaign When planning your marketing, always focus on your greatest asset: your existing patients. If you have a good-sized email database, preferably at least 1,000 subscribers, that’s where you should always start. The contacts you’ve already accumulated are always going to be the easiest, fastest and cheapest to get into your clinic. Miriam Shaviv is director of content at Brainstorm Digital and specialises in helping aesthetic clinics get patients through digital marketing campaigns. She is also the host of the ‘How I Scaled My Aesthetic Practice’ podcast, where owners of aesthetic clinics and medispas from all over the world share their success stories. REFERENCES 1. Mailchimp, Pricing, <https://mailchimp.com/pricing/> 2. Whitney Blankenship, Omnisend, 2020, <https://www.omnisend. com/blog/omnichannel-statistics/> 3. Mailchimp, Email marketing benchmarks and statistics, 2020, <https://mailchimp.com/resources/email-marketingbenchmarks/>

Keep a close eye on list engagement Whilst your email list is your most valuable asset, quality matters as much as quantity. Even on a highly engaged list, some of your contacts will typically become

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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Incorporating Blogging Into Your Marketing Strategy Digital consultant Rick O’Neill explains why blogging can be an important marketing tool for aesthetic clinics For many businesses, blogging seems to have been somewhat overlooked by the behemoth that is social media. As an aesthetic business owner, you (presumably) want to grow your business and hit milestones, as well as wanting to invest in your digital marketing in a smart way that delivers a return. People don’t realise it, but blogging can help get you there. Amongst all the hype of social media (and I say this as someone who spends a lot of time consulting on social media for global companies), it’s important to remember just how powerful blogging is and some of the reasons why it is so important. A study by HubSpot determined that websites which have a blog receive, on average, 67% more enquiries than websites without one.1 In this article I’ll explain exactly why and what blogging can deliver to you and your aesthetics business.

What is a blog? A blog is a regularly updated website or webpage, run by an individual or small group. Typically, a blog would be between 700 and 1,000 words and focus on one very specific topic or one particular keyword that potential patients or customers might be searching for (for example ‘dermal fillers’, ‘Mayfair’, or ‘Laser treatments, Manchester’).

Why should we blog? You have a higher chance of ranking on Google: According to a study from TechClient, a website has a 434% higher chance of ranking on page one of Google if it has an active blog.2 This is because in the same way that keywords on a website’s homepage are interwoven to help with SEO, keywords throughout blog posts add an extra boost to ranking too. Think about that, you have a four to five times higher chance of your website – your business – appearing on page one of Google if you’re running an active blog. Become the trusted expert: If those eyewidening stats weren’t enough to persuade you to start taking blogging seriously, consider the fact that blog authors are more likely to be viewed as subject matter experts, with a HubSpot survey seeing blogs as the fifth most trusted source of information.3 A survey by ExpressWriters.com also showed that 68.5% of customers believe a website with a blog is more credible.4 Beat social media: Now, this may be a controversial statement, especially coming from a social media consultant, but I believe blogging beats social media in a number of ways. Not only can blogging ‘feed’ your social media, with your blogs being repurposed as podcasts, pull quotes, Tweets, Instagram

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stories, your next YouTube video or the theme for your next Instagram Live video, but it also has a much longer lifespan than any item of social media content. Once you’ve posted a blog, it’s there for life. I posted blogs in 2004 that still get traffic. You do not tend to get that with an Instagram post. Organic (unpaid) posts to Twitter, Instagram and Facebook posts have a relatively limited ‘life’ in terms of the period of time during which they are delivering engagement or traffic to your website (yes, they are still there, but the action all happens in the first 24 to 48 hours). Blogs, in my experience, can live (and deliver traffic) for decades. Of course, it’s important to ensure you have all the right tracking in place so you can monitor which elements of your content marketing are bringing traffic. Google Analytics is your go-to tool for this. Installation of Google Analytics is relatively simple, and it can start to give you in-depth data on your website instantly. Be found by voice search results: Blogging can help your website feature in localised voice search results, such as Alexa, Google Home, or Siri. The long-tail terms and questions used in a well-optimised blog article play to the way in which people tend to use voice search. For example, if someone asks, “Alexa, where can I find an aesthetic practitioner in London?” and you have a blog post that mentions this phrase, then Alexa will be able to tell the person. A study by Review42.com showed that 50% of all searches are now voice activated, and 58% of people surveyed had used voice search to find information about a local business.4 Appear in the Google Map results: Blogging, if it’s optimised well for the town or city that you’re in, will also feed your local rankings and provide signals to Google that your business profile should appear in the map results at the top of page one on Google. Moz.com published an extremely comprehensive report on the ranking factors used by Google to positions your business in local results, including the volume of quality, and locally relevant, content on your entire website.5

Creating your blog Choosing your platform When it comes to choosing a platform for your blog (which should be integrated into your clinic’s website), WordPress (which now powers more than 39% of the entire internet according to W3Techs.com)6 is consistently shown to be the best option in terms of

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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flexibility, speed and search optimisation. In one study of over six million websites by AHrefs.com, it was discovered that just 1.4% of Wix websites achieves organic (natural/ free) traffic from Google.7 This is compared to 46.1% of WordPress sites. Of course, there are numerous platforms out there including SquareSpace, Wix, IONOS and many others. Keep things simple and have your blog live at /blog following the clinic URL (this is where Google expects to find your blog articles). Some platforms work well because there are a number of tools that you can add which help you with your SEO. One of the most impactful in my experience is YOAST. This is a plugin that you add inside the WordPress content system that provides a simple checklist and traffic light system to help you ensure that every element of your page or blog is search-engine friendly.

Meta Title: All web pages and blogs can have a Meta Title tag, which is the blue title usually shown for your page or blog on the Google search results list. A meta title is an important part of website optimisation and is distinct from the headline on the page itself. It acts as a name tag for the web page. The title is displayed on your browser tab and tells you what page you’re on. Meta titles are also read by search engine robots and seen by users searching the web.

Creating content

The URL: This is the web address for the page or blog article. Usually something like www.yourwebsite.com/blog/title-of-blog

Content is everywhere and almost everything you do in your clinic can be turned into content. Every treatment you offer will typically have 10 to 20 questions that patients always ask, giving you 20 blogs per treatment that you could be publishing and optimising. For even more inspiration, visit AnswerThePublic.com, put in your top treatment(s), and it will show you ALL the questions people ask Google about that treatment. While you may not be short of ideas or content, you need to work out the best way to present this to your audience. You can do this by having a clear structure. At the most basic level, a good blog will consist of an attention-grabbing title (relevant to current trends), an introduction to hook the reader in, a solid ‘main body’ which works through a logical sequence of points, and a conclusion (perhaps with a call to action). But there are other formats for blog posts too, such as the ‘list post’ (e.g. 10 things you didn’t know about facial fillers), or the ‘how to’ post (e.g. how to remove makeup properly before your aesthetic treatment). Optimising your blog: Let’s say you intend to write a blog about facial fillers. One of the key search terms (which you can learn from AnswerThePublic or Google Keyword Planner) might be ‘facial fillers consultation’. When publishing the blog, there are several elements that need to be optimised around that search term to ensure that Google positions it in the results when people search for that particular phrase.

Headline Tags: Depending on how the styling is setup for your WordPress site, Headline 1 should be the largest/most prominent heading style, and Headline 2 a smaller, sub-heading style. These tags are read by Google to gain an instant understanding of what the page or blog is about.

Mobile experience: For maximum rank with Google, and the best chance to convert a reader into a patient, your website and your blog content MUST be optimised for a great mobile experience. If it isn’t, the reader is going to get fed up with pinching and zooming to increase the text size, or functions not working. They’re just going to leave. As for Google, if it identifies your site as not being ‘Mobile Friendly’ (according to their Mobile Friendly Test),8 then it is unlikely to position your blog in search results at all. Content Layout: Use imagery to highlight your points, pull out key sections of text to make them stand out, break up the paragraphs with subheadings and bulleted lists and other formatting, and make it easy for the reader to navigate and ‘rest’ their eyes now and then. Speed: Your website and blog must load quickly. This is one of the key factors that Google monitors before deciding to place you in front of their users, and it’s a key reason why users might ‘bounce’ from your site if they have a frustrating experience with a slow-loading website. Check how your website scores using Google’s Page Speed Insights testing tool.9 Improvements you can make to your website to increase its speed are listed for you when you run a test. Most of the changes are likely to require support from an experienced web developer.

Image optimisation: Your blog images are also ‘SEO fodder’. You can optimise your blog images so that people searching on Google Images can find your blog through the tags that you add to the images. Each image needs to have an ‘Alt tag’ so that rather than Google seeing it as image one, image two, etc, it will know that it’s a photo of a facial filler consultation. Keyword optimisation: Whilst maintaining informative and readable content, it’s important to be including your key phrase (e.g. ‘facial fillers consultations’) in the Meta Title, H1 and H2 Tags, in the URL, and within the body of the blog at least once per paragraph. In addition to this, your entire website should be optimised in a similar way towards your geographical area that you serve (e.g. Brighton), so that when someone searches ‘facial fillers consultation in Brighton’, your website optimisation plus your blog optimisation gives you a pretty good chance of appearing in the top search results. For more information on optimising your website for Google, look at websites such as MOZ.com and Google Search Central (https://developers.google.com/search).

Getting started Whilst your competitors obsess over their Instagram feeds and worry about their Facebook algorithm, now is the time for you to double-down on your blog strategy to engage patients in a smarter, more personal and effective manner. I look forward to reading your next blog! Rick O’Neill is a digital consultant to the medical aesthetics, cosmetic surgery and pharma sectors. With more than 20 years’ experience in digital marketing, O’Neill is the founder and owner of digital agency Look Touch & Feel based at Silverstone Race Circuit. He is also a founding partner of The Aesthetic Entrepreneurs, investor and advisor to several other digital businesses and is currently digital consultant UK and Europe to Allergan Aesthetics.

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Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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In The Life of Dr Paula Mann

The aesthetic practitioner and Merz Innovation Partner talks hosting webinars and life in lockdown new challenge. It’s fantastic to be part of new practitioners’ journeys and help them develop their skills in aesthetics!

Fresh air to start the day… Like most people with kids, I find it’s good to get up and out before everyone else! I enjoy a cup of tea first thing, before taking our boxer dog Pepper for a walk in the countryside near our home. It can be difficult if it’s cold and dark, but I always feel like I’ve achieved something before the hustle and bustle of the day. We’re currently in lockdown but I usually practise at Clinetix in Glasgow, one of Dr Emma and Dr Simon Ravichandran’s three award-winning clinics across Scotland, where I focus on injectable treatments and teaching for their training school; Aesthetic Training Academy. As much as I miss seeing the team each day, it’s nice not having to drive into the city! Breakfast is usually something healthy – porridge with some fresh fruit. It’s a little bit of a joke in the clinic that I always have food on me – I hate being hungry! There’ll always be a banana on my desk or a granola bar in my drawer. My mornings are currently made up of virtual consultations and reviews. It took a while to get used to this and was a bit of a challenge technically, but now I’m really enjoying it. They’ve added a real efficiency to the patient journey, making life easier and safer for all – a real positive to come out of the pandemic and something we’ll carry forward in clinic.

Demand doesn’t stop… For treatments or for training, which usually fill my afternoon! In regard to treatment, despite the pandemic, people still want to look their best and feel confident. When the clinic reopened after the first lockdown, everyone followed the new regulations appropriately and were so appreciative of the new systems we had in place. It was lovely to get feedback that was not only complementary to the treatments given, but also that we made patients feel safe. I noticed a big demand for aesthetic training last year, particularly from dentists. This is likely due to the difficulty they’ve had in being unable to carry out much of their usual work; they’ve now got time to explore new paths. As a previous dental surgeon, I personally believe dentists are really well-placed to practise aesthetics. They’ve got the clinical environment and a patient base already set up, as well as transferable clinical skills. It’s 68

Adapting to teaching online…

also really nice to move into a field where patients actually want to see you! Similarly, there’s been a lot more demand from nurses but for very different reasons. In my experience, it seems many are, quite frankly, just tired. The stress of their roles and difficult working environment is taking its toll and many seem to be looking for an exciting

I love reading… Anything by neurologist Professor Oliver Sacks – his work is fascinating. Or some good crime fiction for something a bit lighter. I use my Kindle as it makes it harder to indulge in my habit of flicking to the end of a book to decide if I like the ending!

I’m currently listening to… This American Life podcast while walking the dog. They’ve got a great mix of short stories about real people – they can be really thought-provoking, which I love.

When lockdown’s over… I’m looking forward to going to my favourite champagne bar in Glasgow, which is great for people-watching and a glass of fizz with friends!

Taking a break is important… The team and I always have time blocked off for lunch – it’s a small thing, but something that can often be ignored if you don’t set time for it, making you feel drained of all energy by the end of the day. I think everyone’s realised just how vital self care is in recent years!

Aesthetics | February 2021

Was nerve-wracking! I’ve been a Merz Innovation Partner since 2019, training and supporting practitioners in how to get the best results with the company’s injectable products. Despite plenty of experience teaching in-person, I was really apprehensive of moving to webinars. You can’t read the room, so it’s more difficult to tell how many people are engaged or even if they’re still watching, as well as the challenges of ensuring you’ve got a good WiFi connection! Merz has been brilliant, though; the team quicky worked with Partners to ensure the training was suitable for webinars, creating fantastic educational slides and videos of practical skills. We rolled out sessions throughout the year and have loads more ready for the next few months. There’ll be webinars on all of Merz’s injectable products. Last year, I found that people especially loved the Belotero® Lips sessions. With two products – Shape and Contour – there’s lots to learn and everyone’s really engaged. I’m looking forward to hosting more! As well as introductory webinars, we run Masterclasses for those who are a step ahead and ready to advance their learning. A big focus of these sessions is on treating multiple facial areas and creating holistic results for patients, which is so important. For me, teaching has really helped give me a much-needed boost throughout lockdown so I’m looking forward to doing more for Aesthetic Training Academy, as well as Merz, this year! 1. Belotero Shape IFU. 2. Belotero Contour IFU.

You can join a Merz webinar every Monday until the end of February. For more info visit www.merzwebinars.com This article is sponsored by

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“I view myself as being an eternal student in this field” Dr Paul Nassif discusses his career in cosmetic surgery and explains why Botched is more than just an entertainment show Born in Los Angeles, California, Dr Paul Nassif began his career in medicine as a trainee otologist. Fast forward to 2021, and he’s now a global TV star and an international multi-business owner. But how did he get there? Dr Nassif notes, “Originally I wanted to get into otology, but during my training I was exposed to facial aesthetic surgery. I found it so interesting that it became my new passion. After I graduated as a medical student in 1992, I proceeded to do a facial plastic and reconstructive surgery fellowship at Saint Louis University School of Medicine. This led me to opening my own plastic surgery clinic in Beverly Hills in 1999.” After 15 years of working in plastic surgery and seeing a huge rise in treatment popularity, as well as mishandled procedures, Dr Nassif partnered with his friend and fellow surgeon Dr Terry Dubrow in 2014 to create the TV show Botched. The programme focuses on correcting complications caused by surgical and non-surgical cosmetic procedures. On his decision to start the show, Dr Nassif says he wanted to help patients who otherwise wouldn’t have been able to afford to get their procedures corrected, as well as to educate viewers on the potential dangers of cosmetic surgery. He comments, “There are many layers to the show. Firstly, it’s entertaining for viewers because we have a wide variety of people come on, all with their own stories to tell. Secondly, it’s rewarding for us, because we can help people who are negatively affected by their appearance. But the other side to it is that it’s communicating with the viewers what they should and should not do when it comes to invasive and non-invasive aesthetic treatments.” He continues, “A lot of people that we see don’t do their research and tend to base their treatment decisions on cost rather than the quality of the practitioner or the safety of the procedure. Most people don’t even

know what they should be looking for when selecting a practitioner! People really need to be educated in the realities of what can happen if they don’t look into things properly, and it’s down to practitioners to get that message across.” In 2019, 21 years after opening his Beverly Hills office, Dr Nassif opened NassifMD MedSpa in Manchester, England. On why he decided to open a clinic in the UK, he comments, “The second largest audience for Botched is in the UK, and we actually have a lot of people fly over to be on the show. They regularly talk to us about the lack of regulation the UK industry has and how anyone can become an injector, which leads to a lot of complications from filler and botulinum toxin. It’s truly shocking to me! Of course, even the best injectors can cause a complication, but the important thing is being able to recognise and manage them.” He continues, “I wanted to do something about it, and provide patients with a safe and trusted place to get their treatments. When we were looking for UK locations, we found there’s actually a higher percentage of people in the North West getting non-surgical procedures than in London, so we thought Manchester was the best place for us!” On whether he would open any more clinics in the UK, Dr Nassif comments, “London would definitely be the next step, but we need to get the world in order first and get everyone protected from COVID-19! The Manchester clinic is still very new, so I want to focus on that first before I branch out.” As well as running two aesthetic clinics and being on TV, Dr Nassif has released his own skincare line, NassifMD Dermaceuticals, and has launched a skin booster with treatment brand HydraFacial. He says his decision to start working in skincare was because he sees it as an integral part of enhancing any surgical and non-surgical procedure. He comments, “I can perform surgery on the

face, but that in itself doesn’t take care of the fine lines, blemishes or sun damage many patients have. Because of this, I think it’s important to always make sure the patient’s skin is prepped prior to cosmetic procedures to ensure that the results are optimised. Before facial surgery for example, I often recommend patients start an exfoliation and hydration routine to help repair the skin and restore elasticity. While I can operate on the inside skin tissue, we need skincare products to take care of what’s on the outside.” On what advice he would give to practitioners to help them become successful in the industry, Dr Nassif comments, “No matter how long you’ve been in the business, you should never stop learning. Even at this point in my life, I am still making changes to how I do my procedures. I view myself as being an eternal student in this field because I am always finding out ways to become better at my job. So, just keep working as hard as you can to improve everything you do – success doesn’t come easy.”

My favourite surgery to perform… Rhinoplasty, always! To me it’s the most fun and it’s what I do the most of. Unfortunately, I do see and correct a lot of noses that have been overdone. How I spend my spare time… I’m a keen golfer, so I always try to fit that in at the weekends. I also have a new-born son, so being with him and having family time is very important. My mentor in the industry… Dr Regan Thomas was my fellowship director, and he is still my biggest mentor and good friend. I credit him for my growth in facial plastic surgery.

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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The prestige of ‘Harley Street trained’ Despite its strong reputation, the address is no guarantee of qualification or competence. As the prestige of the address grew, so did the price to purchase or rent premises, meaning it’s unfeasible for many practitioners to practice there. Second only to owning a clinic on Harley Street seems to have developed the qualification ‘Trained on Harley Street’ – if you can’t have the prestige of being based there, you can at least claim some kind of association. Although it’s a fair enough claim to make provided you were trained there, when it comes to this unregulated field, in my opinion, this statement is not without problems. There are some fantastic training establishments on Harley Street, but this glamour attracts the wrong sort as well. Anyone can rent a training room and train on Harley Street With many practitioners using the phrase ‘Harley and their candidates can then tell everyone they are ‘Harley Street trained’. Street trained’ as an indicator of their education Whilst this term is essentially meaningless, the public still regard the street as the pinnacle of standards, Dr Steven Land debates its use medical excellence and so it will continue to carry Training is always a subject of debate in the unregulated aesthetics status. Many of us in the industry know, however, that ‘Harley Street field. Something that has become apparent is the popular use of trained’ is no guarantee of quality and the more it is bandied about, ‘Harley Street trained’ in practitioners’ marketing to indicate their level especially by poorly trained, non-medical injectors, the more danger of competency for clinical practice. there is that the general public will start to lose trust. Which begs the However, what does this phrase actually tell patients about our level of question, what do we do? training, and is it enough to say that you are ‘Harley Street trained’ or The easy thing would be to nothing – allow the name to become ‘qualified’ to assure your patients’ safe and successful results? more and more tarnished and let it slowly lose its shine. This approach, I believe, risks patient safety and allows any medic or nonWhy the cachet in a Harley Street qualification? medic to be ‘Trained on Harley Street’ and it becomes a pointless claim with no guarantee of the practitioner’s competence. In order to fully understand why being ‘trained on Harley Street’ is a If we think it is worth protecting, then the good training facilities need such an often-used claim of credibility, we need to look back a little to maintain their high standards and campaign for others on the at the history of Harley Street itself and why it became synonymous street to aim for and meet those same standards. Practitioners using with the ‘expert practitioner’. Cavendish Square – from where Harley the ‘Harley Street trained’ claim need to make clear what this means Street begins – was developed around 1717 and construction of Harley to their patients – clarify who they trained with and in what – on their Street began in 1729, on land owned by Edward Harley, the Earl of websites and in their marketing materials. Oxford and Mortimer.1 The street had matured and looked much as I, for one, think something like a good reputation is worth fighting it does today by around 1770. The first doctor known to move into for. The Harley Street residents and landlords need to band Harley Street was Dr Robert Perrean in 1775. He found the address so together to prevent poor practice and poor teaching and help desirable that he was found guilty of forging documents to acquire his maintain its ‘street credibility’. residence and publicly hanged for his troubles – an ominous start…2 Dr Steven Land qualified in 2001 and has trained in Various well-to-do doctors continued to move to the area, beginning medicine, surgery, plastic surgery, and emergency medicine its reputation as the place to visit for expert medical opinion during the on his journey to becoming an A&E doctor at the regional Major Trauma Centre and an aesthetic practitioner. He late 18th century. Following their prosperous patients into suburban has a special interest in dermal filler complications and areas, doctors continued to open their consulting clinics around lower is the clinical director of award-winning clinic Novellus Aesthetics in Harley Street and Cavendish Square. By the mid-19th century, Queen’s Newcastle. Dr Land is due to launch his own training academy later this College girl’s school opened its doors on Harley Street and renowned year. He is not Harley Street trained. Qual: MBBS, MRCEM British nurse Florence Nightingale had taken up residence to open an institution for sick gentlewomen. With the arrival of the Royal Society REFERENCES of Medicine and Royal College of Physicians around the area, Harley 1. Harley Street, About us. <https://www.harleystreet.com/about-us/> 2. Wolstenholme, G & Hurt, R, A Harley Street Address, Journal of the Royal Society of Medicine, vol.92 Street’s role as a medical hub was solidified. Aug 1999. <https://journals.sagepub.com/doi/pdf/10.1177/014107689909200817> Around a century later, approximately 800 doctors were believed to consult from Harley Street, with 600 more in the surrounding streets and squares.2 The stampede to bask in the glamour of such an address had begun and to use Harley Street for your clinic was considered the sign of competence and quality, and still is to this day.

The Last Word

Reproduced from Aesthetics | Volume 8/Issue 3 - February 2021

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References 1. Tran C. et al., In vivo bio-integration of three hyaluronic acid fillers in human skin: a histological study – Dermatology, 2014, 228:47-54. 2. Micheels P et al; Two Crosslinking Technologies for Superficial Reticular Dermis Injection: A Comparative Ultrasound and Histologic study; J Clin Aestheti Dermatol 2017; 10(1) 29-36. 3. Sundaram & Fagien 2015 Cohesive Polydensified Matirs Hyaluronic Acid for Fine Lines. Plast Recon Surg. 136:149S, 2015.

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Published on Feb 2, 2021

FEBRUARY 2021: THE MARKETING ISSUE

Discover everything you need to know to grow your practice this year

FEBRUARY 2021: THE MARKETING ISSUE

Published on Feb 2, 2021

Discover everything you need to know to grow your practice this year

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