FEBRUARY 2022: The Male Issue

Genetics and Hair Loss CPD

Dr Ingrid Wilson explores the role of genetics in hair loss

Injecting the Male Lip

Practitioners discuss approaches to treating male lips and avoiding feminisation

Balancing the Male Profile

Dr Joshua Van der Aa shares a case study masculinising the male face

Consultative Selling

Business consultant Vanessa Bird shares her soft-sales

techniques

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Clinical Contributors

Dr Ingrid Wilson is a GP and director for Crewe Hair & Skin Clinic. She is on the specialist register for Public Health Medicine and is a Fellow of the Faculty of Public Health. Dr Wilson is a member of the International Association of Trichologists.

Dr Joshua Van der Aa is a cosmetic practitioner specialising in rejuvenation of the periorbital area. He is a graduate of Leuven University’s medical school. Before opening Dr Joshua Harley Street Aesthetics in 2020, he worked in clinics in London and Europe.

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon. She is lead oculoplastic surgeon at the Cadogan Clinic. Miss Hawkes is a full member of the British Oculoplastic Surgical Society.

Dr Priya Udani is a senior registrar in ophthalmology with a special interest in oculoplastics within the NHS, and an MBBS and a BSc in Human Biology from King’s College London. She is also currently a trainee lead at King’s College Hospital.

Dr Martyn King is a GMC registered doctor and the director of Cosmedic Skin Clinic, Cosmedic Online and Cosmedic Pharmacy. He is medical director of the ACE Group World. He has completed a Master’s Degree with distinction in non-surgical aesthetic practice.

Dr Victoria Manning is an aesthetic practitioner and GP, with more than 22 years’ clinical experience. She is the co-founder of River Aesthetics in New Forest, Dorset and Wimpole Street. She is a global trainer and KOL for Sinclair Pharma’s Silhouette Soft, Ellansé and MaiLi range.

Dr Charlotte Woodward is an aesthetic practitioner and GP with more than 25 years’ experience. She is the co-founder of River Aesthetics in Bournemouth, New Forest and Wimpole Street, which specialises in thread lifting.

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Well, hasn’t there been some excitement over the past month! With the announcement of our Aesthetics Awards Finalists, it’s been so lovely to see such buzz in the specialty. The votes are in, the scores from our 80 expert judges are being collated, and the Winners will be announced on March 12 – I hope to see you all at the ceremony! Dubbed the Oscar’s of Aesthetics, remember to book your tables as soon as possible to avoid missing out on this much anticipated event! I myself have started shopping for my gown – I am determined not to leave it to the last minute this year (here’s hoping). Now onto the journal… this month we have a focus on treating your male patients. The latest statistics released in December 2021 by the International Society of Aesthetic Plastic Surgery (ISAPS) suggest that men make up 14.3% of the global non-surgical market for cosmetic procedures and 13.7% of the demand for surgical procedures worldwide. Although females are still very much your dominant

Shannon Kilgariff Acting Editor & Content Manager @shannonkilgariff

demographic, these numbers have very slightly increased from the previous year’s data, meaning that you may start to see more men present to you for your cosmetic solutions. To learn top tips for treating the male perioral area with dermal fillers, turn to p.21, and our CPD this month focuses on hair loss – a big concern for many male patients (p.27). Eye treatments are very popular for men, so we have made sure to include an article on tear trough rejuvenation on p.41 – it’s a nice introductory overview of different treatment approaches. We also have some interesting case studies featuring male patients – turn to p.35 and p.47 – and we have even covered threads on p.53!

Of course, to learn more about treating male patients, you can come to ACE 2022 on March 11-12 in London, which will cover a wide range of topics to help the needs of all your patients. You can learn more about our exciting content from Headline Sponsor Teoxane on p.18 and register for free – see you there next month!

If you’d like to tell us what you enjoyed reading this month, or what you want to read next, send us an email editorial@aestheticsjournal.com or tag us on Instagram @aestheticsjournaluk – we may even feature you in our Social Media column on p.8!

Clinical Advisory Board

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

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

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

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

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

Alison Willis Director

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

EDITORIAL

Shannon

shannon@aestheticsjournal.com

Leonie

T: 0203 196 4268 leonie.helm@easyfairs.com

Holly Carver Journalist | T: 0203 196 4427 holly.carver@easyfairs.com

Ellie Holden Content Writer | T: 0203 196 4265 ellie.holden@easyfairs.com

DESIGN

Peter Johnson • Senior Designer

T: 0203 196 4359 | peter@aestheticsjournal.com

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

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

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

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

Emma Coyne • Sales Executive T: 020 3196 4372 | emma.coyne@easyfairs.com

MARKETING

Aleiya Lonsdale • Head of Marketing

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

Aimee Moore • Marketing Manager

T: 020 3196 4370 | aimee.moore@easyfairs.com

Abigail Larkin • Marketing Executive T: 020 3196 4306 | abigail.larkin@easyfairs.com

Email: editorial@aestheticsjournal.com

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

ARTICLE PDFs AND REPRO Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Chloe Carville, contact@aestheticsjournal.com

© Copyright 2022 Aesthetics.

Sharon Bennett, Clinical Lead

#Safety

Talk #Aesthetics

Miss Elizabeth Hawkes

@dr_elizabethhawkes

#AestheticsAwards

Miss Sherina Balaratnam @missbalaratnam

What a way to start 2022, very proud of my super team! So delighted to announce we are Finalists in an incredible four different categories at the Aesthetics Awards!

Industry The aesthetics specialty remembers Mr Niall Kirpatrick

On January 10, the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) announced the tragic loss of consultant craniofacial plastic surgeon Mr Niall Kirkpatrick. Mr Kirkpatrick was cycling when he was fatally hit by a car. Our condolences go to his friends, family and colleagues.

Mr Kirkpatrick worked at the Chelsea and Westminster NHS Foundation Trust in London where he was a core member of the Northwest London specialist multidisciplinary team for the management of skin cancers, and a member of the multidisciplinary team for vascular anomalies. He has also previously written for the Aesthetics journal, alongside consultant plastic surgeon Mr Pericles Foroglou on Treating Permanent Dermal Filler Complications in 2016 and was known as a specialist in managing dermal filler complications. Consultant plastic and reconstructive surgeon Mr Dalvi Humzah, said, “It was a sad day to hear that Mr Kirkpatrick had passed away in tragic circumstances. He was a colleague who came through the ranks with me as senior house officer to consultant during our training. He was a true gentleman and a gentle giant in the speciality; for me he was one of the ‘consultant’s consultant’ to whom complex and difficult cases would be dealt with great expertise and empathy. He will be truly missed within the specialty as well as with friends and family.”

Safety

Instagram video raises concern over tear trough techniques

A recent video on social media showing dermal filler being injected into the tear trough through the mouth has sparked concern among practitioners. The video was published on Instagram Reels and shows a patient having tear trough filler injected into their face through the mouth by a US-based facial plastic surgeon. The video claims that the technique results in ‘zero pain and helps to minimise and eliminate the chance of bruising.’ Aesthetic practitioner Dr MJ Rowland-Warmann commented, “The mouth is a haven for bacteria and adding an injectable implant with mouth germs on its way to a delicate area such as the eye spells bad news! Two concerns are biofilm affecting the filler and infections such as cellulitis around the eye, notwithstanding the fact the infraorbital foramen housing important vessels and nerves has to be directly bypassed using this route. My concern is that there are more effective and less risky access points that don’t present such avoidable hazards. Alongside this, it’s essential the mouth is adequately disinfected or checked for prior pathology. I think this is a classic scenario where the ‘wild’ idea is not pioneering but may end up causing the patient significant harm.”

Headline Sponsor Teoxane announces ACE agenda

Aesthetic manufacturer and Headline Sponsor at the Aesthetics Conference & Exhibition (ACE), Teoxane, has unveiled its educational agenda.

Live demonstrations will take place, treating the temple and lateral brow on the anatomy of both female and male patients, using products from the Teosyal RHA and Redensity ranges. There will also be symposiums discussing anatomy, technique and products.

Speakers include key opinion leaders and aesthetic practitioners Dr Raul Cetto, Dr Lee Walker, Dr Wassim Taktouk, Dr Kam Lally, cosmetic surgeon Mr Benji Dhillon and consultant aesthetic oculoplastic surgeon Mrs Sabrina Shah-Desai. Event manager Courtney Baldwin, commented, “With ACE next month, we are so excited to share some of the fantastic speakers and CPD-accredited content from our Headline Sponsor Teoxane! With two jam-packed days of learning, discovering new products, and networking with fellow healthcare professionals, ACE is the ideal place to reunite with the aesthetics speciality once more!” ACE will be taking place on March 11-12 at the Business Design Centre, London. Register for free on p.18

Galderma to host Restylane webinar

Pharmaceutical company Galderma will host an exclusive webinar in partnership with the Aesthetics journal.

The webinar will discuss Restylane’s 3D facial profiling techniques and products with Restylane Defyne, Volyme and Lyft. Speakers include aesthetic practitioner Dr Munir Somji and Dr Yusra Al-Mukhtar, who will be performing demonstrations using the products and explain how to include in your treatment offering. The webinar will take place on February 17 at 7pm GMT. You can register for the webinar on p.62. Regulation

Katie Price begins training to administer injectables

TV reality star and model Katie Price is currently training to administer injectables, including botulinum toxin. Price revealed her plans on her Instagram account that she was completing an aesthetics course and her aim was to eventually administer injectables to patients.

Sharon Bennett, chair of the British Association of Cosmetic Nurses (BACN), and Clinical Lead of the Aesthetics Clinical Advisory Board said, “Katie Price undertaking a short course in facial injectable implants, demonstrates a lack of understanding, and highlights the difficult situation our industry is in. This is not a quick easy ‘beauty’ treatment to be learnt in a day or so, and those responsible should be held to account.”

Vital Statistics

An estimated 6.5 million men are currently experiencing male pattern baldness in the UK (Lloyds Pharmacy, 2021)

76% of 1,302 respondents say that the media promotes an unattainable body image for women (YouGov America, 2021)

A study of 200 patients showed that botulinum toxin injections reduced anxiety by up to 72% (Skaggs School of Pharmacy and Pharmaceutical Sciences, 2021)

A typical user actively manages or visits an average of 6.7 different social media platforms each month

(Data Reportal, 2021)

In a study of 2,000 adults, 45% choose skincare products that have been proven effective by clinical research (Medovie, 2021)

88% of 1,212 people either ‘agreed’ or ‘strongly agreed’ that social media is partly to blame for the rising popularity of cosmetic surgery (Cosmetic Surgery Solicitors, 2021)

Events Diary

11th-12th March

Aesthetics Conference and Exhibition aestheticsconference.com

12th March

Aesthetics Awards aestheticsawards.com

7th-8th May Beauty Uncovered Live beautyuncovered.com

15th-16th September

The BACN Autumn Aesthetic Conference bacn.org.uk

13th-14th October

CCR ccrlondon.com

Marketing The BACN launch digital marketing education

The British Association of Cosmetic Nurses (BACN) is launching a new monthly series of digital events. The BACN is working in collaboration with digital marketing agency Web Marketing Clinic to bring its members Digital Drop In, a new series which focuses on teaching digital marketing techniques and skills to enhance members’ online presence. These sessions are suitable for all BACN members, from those starting out in the industry to experts in the field. The platform includes one Instagram Live, one Zoom webinar, and a monthly blog post. The sessions will be hosted by Alex Bugg, digital marketing professional at Web Marketing Clinic, and will run as part of a ‘lunchtime learning’ initiative, taking place at 1pm GMT. Bugg said, “I’m looking forward to providing some bespoke education for BACN members. Web Marketing Clinic already have some members as clients, so it’ll be great to draw on our experiences of working with them and give back to the aesthetic nurse community!” The monthly blog post can be accessed in the Resources page in the Member’s area of the BACN website on the last Friday of the month.

Industry New BCAM Board of Trustees member unveiled

Aesthetic practitioner Dr Sophie Shotter has joined The British College of Aesthetic Medicine (BCAM) Board of Trustees.

Dr Shotter has joined the board following her own work uncovering cases of breached regulations and unethical practice, BCAM explains. The Board of Trustees has an active role in the BCAM’s day-to-day workings, sharing knowledge and experience whilst influencing planning and strategy, notes BCAM.

Dr Shotter said, “I’m thrilled to have been appointed to the BCAM Board of Trustees. I hope to help BCAM throughout our fight for improved patient safety and regulation, and to provide strong representation for doctors within our specialty.”

Skin

Revision Skincare releases new cleanser

AestheticSource, the UK distributor for Revision Skincare, has added the Gentle Foaming Cleanser to its portfolio. According to the company, the soap-free cleanser is formulated to hydrate, nourish and soothe skin while providing antioxidant benefits. The cleanser aims to remove makeup, excess oil and environmental impurities from the skin. The product is suitable for all skin types, including mature skin which is dry as well as sensitive or irritated skin. Ingredients include chamomile to calm irritated skin, allantoin to moisturise and improve moisture retention, aloe vera to enhance the skin’s natural moisture barrier, panthenol to nourish skin and sodium cocoyl glycinate to cleanse the skin of impurities.

CEO at AestheticSource, Lorna Bowes, commented “We are delighted to announce the launch of the new Gentle Foaming Cleanser from Revision Skincare. It’s ideal for those who prefer a foam or lather cleanser and is created without sulphates so it doesn’t leave skin feeling dry. Calming and nourishing allantoin, chamomile, aloe vera and panthenol, along with the pH neutral formula, make it ideal for all skin types, including sensitive skin.”

Training

The BAS begins new sclerotherapy initiative

The British Association of Sclerotherapists (BAS) will be launching a new Register of Approved Sclerotherapy Training Providers in 2022.

The initiative will be led by nurse prescriber Emma Davies and operations manager at the BAS Hilary Furber. The register will meet the BAS standards for training new practitioners and provide a framework and standards against which training courses can be benchmarked, explains the BAS.

Furber said, “This initiative is driven partly by an increase in enquires from aesthetic practitioners seeking sclerotherapy training from a reputable provider, and partly by concerns about the safety and efficacy of treatments offered by some inexperienced and inadequately trained practitioners. We plan to publish the application process and start accepting applications from providers by Spring 2022.”

Perfectha filler adds lidocaine

Pharmaceutical company Sinclair Pharma has evolved its hyaluronic acid (HA) filler brand, Perfectha, with the addition of lidocaine. Perfectha Lidocaine is designed for application from the lips and chin to non-surgical rhinoplasty/ nasal corrections and nasolabial folds, explains the company. There are four products in the portfolio, which include Fine Lines, Derm, Deep and Subskin aiming to address different areas of the face, as well as differing in particle size, adds Sinclair.

Chloe Attunes, UK marketing manager at Sinclair Pharma, said, “As a global leader in scientifically advanced aesthetic products, Sinclair plays close attention to patient trends and continually develops new products that respond to market demand. This enables clinicians to provide a comfortable and safe experience, while achieving natural-looking results and boosting confidence for their patients.”

New booking system InDesk launches at ACE

Private healthcare search engine WhatClinic.com is launching a new booking system at the Aesthetics Conference & Exhibition (ACE) on March 11-12, as well as sponsoring the café at the event. The booking system, named InDesk, is designed to answer every phone call, email and social media post received by the clinic, which reduces the number of voicemails to be listened to and followed up later. According to the company, the clinic will forward its telephone number, email address, website forms and social media interactions to the dedicated InDesk patient concierge team. This team will answer all enquiries in real time within the opening hours of InDesk. Appointments will be booked directly into the clinic’s patient management system. Any queries that the team are unable to answer will be forwarded to the clinic via email or phone call which connects the patient and clinic directly, all non-treatment enquiries will be summarised and sent to the clinic and the InDesk team will reach out to all appointments at least four times prior to the appointment date, the company explains.

Each InDesk customer will have access to the total volume of enquiries received and answered, confirmed bookings and conversion rates.

David Roe, CEO of InDesk, said, “We are excited to be showing our new product InDesk at ACE. We think it is going to excite clinic owners and managers and we can’t wait to finally be able to show it to our customers in person. We want to show clinics how we can help save them time and make more bookings, simply and easily. Being the café sponsor at ACE is the first chance we’re going to get to do that in person and we just can’t wait to meet everyone there.”

BACN UPDATES

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

JANUARY EVENTS

The first round of BACN events have kicked off around the country, and it was wonderful to have members come together and to network in-person after a long time apart. BACN regional meetings are vital to prevent isolation and to showcase best practice, alongside engaging with new and innovative products from partners that the association works with in aesthetics. Thank you to all members who took the time out to come along, and a full list of locations for February can be found on the BACN website, along with information on how to book.

Nottingham – 4th February

Cambridge – 7th February

Birmingham – 11th February

Maidstone – 14th February

Liverpool – 18th February

DIGITAL EVENTS

Thank you to director at Inspire to Outstand Tracey Jones for a fantastic start to 2022, with a digital webinar and Instagram Live on understanding the benefits of healthcare regulation for aesthetic medicine and how to prepare for the journey. The events were led by Jones alongside regional leader for the Northwest Michelle Mclean. Recordings can be found in the BACN member’s area.

SPRING SYMPOSIUM

The BACN is excited to announce the first national get-together which will be held at the Royal College of Physicians in London on April 29, with a range of speakers including headline sponsor Galderma. Along with educational content there will be an opportunity for networking, with a drinks reception and canapés held at the College postevent. All tickets and details are now on sale and more info can be found on the BACN website at www.bacn.org.uk/events

AESTHETICS AWARDS

The BACN would like to congratulate every member who is a Finalist in the Aesthetics Awards this year – a great year for aesthetic nurses who are featured in a range of categories. The BACN will be exhibiting at ACE 2022 and are looking forward to celebrating with members at the ceremony following the conference and exhibition.

This column is written and supported by the BACN

Exhibition

Dr Samizadeh publishes two new books

Aesthetic practitioner Dr Souphiyeh Samizadeh has released two new books. The first book named The New Me: Healthy and Successful details the science of meditation, mind training, and mental rehearsal for success and wellbeing. Inside, the book is separated into four parts covering topics on stress, the science of relaxation, the lost science of better living and meditation, explains Dr Samizadeh. The second book named Non-Surgical Rejuvenation of Asian Faces provides a guide to facial aesthetics, non-surgical treatment and enhancement in patients of Asian ethnicity. The book details the range of available techniques when treating an Asian patient and relevant aspects of facial analysis, treatment planning and provision are covered. Dr Samizadeh commented, “I am very excited to have my books published! I wanted to showcase in my first book how stress is making us all unwell physically and emotionally and how we can take back control. In my second book, I discussed the evidence and details on how to use the latest available non-surgical techniques for facial rejuvenation in this group of patients and it is aimed at aesthetic medical professionals and trainees alike seeking a reference on the topic.”

GetHarley introduces new Mother & Me consultation package

Skincare platform GetHarley has launched joint skin consultations to celebrate Mothering Sunday. Using Mother & Me, practitioners will be able to market this joint consultation gift and the opportunity to sell two skincare regimes at once, as well as benefit from auto-replenishments, which are handled by the GetHarley concierge team, explains the company.

The team will also provide marketing assets for practitioners to post on social media, to start a PR and marketing campaign on the new offering.

Charmaine Chow, CEO and founder of GetHarley, said, “It’s a great time to join GetHarley as we launch this new product development (NPD) whilst existing customers are able to increase their patient-base and generate more passive income. At GetHarley we are constantly innovating to help drive revenue for our practitioners and delight their patients.” Peel

New skin peel treatment hits UK market

Cosmeceutical brand PCA Skin has added the No Peel Peel to its portfolio. The peel aims to remove impurities, detoxify pores, and reduce inflammation post-treatment, whilst restoring collagen production to help signs of premature ageing, explains PCA Skin. The peel is suitable for all Fitzpatrick skin types. Ingredients include lactic acid and alpha hydroxy acid to help exfoliation, hydration, and minimise discolouration, as well as gluconolactone and poly hydroxy acid to offer antioxidant benefits. Lizzie Shaw, brand manager at PCA Skin, commented, “We are so excited about this launch. This peel really does differ with its lack of discomfort on the skin. Natural functional ingredients in the peel help to reduce sensations, irritation, and visible redness post-treatment, and the unique formula promotes skin hydration while helping support barrier function and skin recovery. We’re looking forward to getting it into clinics across the country.” The company explains that the product is for professional use only.

Training

Cosmetic Courses unveils training course updates

Aesthetic training provider Cosmetic Courses has launched a new course called ‘Introduction to Cannula’ and released additional dates for its cadaver training.

The new one-day cannula course is aimed at practitioners looking to start using a cannula within their practice, whether they are new or have used a cannula in previous training, explains Cosmetic Courses. Alongside aesthetic needle and cannula company TSK Laboratory, the course covers the fundamentals of cannula techniques and usage including its background within aesthetic medicine, patient assessment, safety within aesthetics and product knowledge.

Cosmetic Courses explains that a large amount of the day will be spent gaining hands-on experience, with live models provided by the training company. The next training date is March 7 in Nottingham.

Medical director of Cosmetic Courses, Mr Adrian Richards, said, “Over the past years, we have seen the use of cannula techniques become increasingly popular within the industry. Working alongside my team, we have built a course that will safely teach and demonstrate the cannula for aesthetic treatments with the aim to leave delegates confident as they progress their knowledge and skillsets.”

In addition, the Cadaver Facial Anatomy Training Course for Aesthetic Medicine has an added date on February 19 at Nottingham University, with the training provider currently working with the university to confirm more dates.

Celebration Cherry Healey unveiled as Aesthetics Awards host

TV presenter Cherry Healey will host this year’s prestigious Aesthetics Awards ceremony for the second year. Healey began her onscreen career with numerous immersive documentary series on BBC Three. She has also presented 10 Years Younger in 10 Days on Channel 5, where she detailed the latest beauty advice and non-invasive cosmetic techniques. Last year, Healey presented the Aesthetics Awards virtually and has also appeared as Beauty Uncovered’ s front cover star. Event manager Courtney Baldwin said, “We are delighted to announce Healey as our Aesthetics Awards host for the second time. Her enthusiasm and fun personality will be a great addition to the Awards ceremony! We are so excited to celebrate the wonderful achievements of the aesthetics specialty over the past year so make sure to grab your tickets to attend.” An exciting new Awards sponsor has also been announced! Medical aesthetic supplier John Bannon Pharmacy will be sponsoring the Award for Best Clinic Ireland and Northern Ireland. The Aesthetics Awards will be taking place on the evening of March 12 at the Royal Lancaster Hotel, London, following the second day of ACE. Make sure to secure your tickets to attend on p.72

Device

Lumenis launches Splendor X

Aesthetic device company Lumenis has launched the Splendor X device to the UK market. According to the company, the device has been CE cleared for hair removal, vascular treatments, pigmented lesions and the treatment of wrinkles. The device is powered by BLEND X technology, a binary laser emission of Nd:YAG (1064 nm) and Alexandrite (755 nm) wavelengths with synchronised and adjustable proportions. According to the company, the device is suitable for both men and women and can be used on all Fitzpatrick skin types. It can treat any area of the body, including the face, bikini line, legs, arms, stomach and under arms, the company explains. Vice President of Europe, Middle East and Africa at Lumenis, Claire Dubowski, commented, “As with all our products, the launch of Splendor X brings the next generation in hair removal to the UK and truly expands our offering in this category. The unique BLEND X technology is like nothing else currently available in the UK market and allows our partners to create completely customisable treatments for their patients with the reassurance of Lumenis’ commitment to quality and innovation that they have come to expect. Our ground-breaking products have redefined medical treatments and have set numerous technological and clinical gold standards across the globe –Splendor X is no different. It is truly remarkable.” The company is hosting two preview events for practitioners to see the device and speak with the Lumenis team. The first is at the Varsity Club, Oxford on February 24 at 7pm GMT and the second is at the Hotel Gotham, Manchester on February 28 at 7pm GMT.

ACE 2022 – YOUR NEXT MUST-ATTEND AESTHETICS EVENT

The countdown begins, we are now just over a month away from the Aesthetics Conference & Exhibition 2022 – the event which the aesthetics industry has been waiting for! On March 11-12, more than 2,000 medical professionals will arrive at the Business Design Centre in London for two days of learning, networking and celebrating our industry. ACE welcomes our specialty back together after two years, and our brands, exhibitors and KOLs are so excited to share their latest innovations and services with you. With so many product launches having been delayed, ACE will be the perfect place to discover the latest aesthetic technologies for your clinic. Conferences at ACE will be sponsor-led, with TEOXANE, Galderma, Allergan, HA-Derma and more lined up to host the 2022 education with their highly skilled KOLs. All education is free-to-attend and CPD-accredited, making ACE the place for practitioners to come together and source the newest products and information for their clinics.

Connect with our community As well as education and the latest clinical advancements, ACE provides an opportunity for you to connect back with the aesthetics community. After running CCR as a COVID safe event, we are confident that the measures we have in place in partnership with SGS ensure our events are safe for communities to meet and do business. Meet with peers, colleagues and clients as you discuss, share and learn about the advancements in the industry. As we unite the aesthetics specialty, the networking doesn’t stop after the event – the Aesthetics Awards are taking place on the evening of March 12 and is the official ACE after party! All our incredible Finalists, judges, KOLs and top brands will be there, so take the opportunity to extend your ACE experience and celebrate the achievements, innovations and outstanding talent in our industry. Register FREE now for ACE 2022 by scanning below.

Ageing

Nuchido releases CPD accredited webinars

Skin health

New product allows glutathione to be taken orally

Supplement company Nuchido has launched a series of CPD accredited webinars on nicotinamide adenine dinucleotide (NAD+) and the role it plays in the ageing process. The first webinar named ‘The Future of AntiAgeing Is Not Injectable’ is available free now to all medical professionals working in aesthetics. The webinars have been launched as part of a new online educational resource about NAD+ which includes the latest insights from scientific journals, as well as social media assets that can be posted online. Dr Steven Land, aesthetic practitioner at Novellus Aesthetics, has been working with Nuchido throughout 2021 and said, “The insights I’ve gained from Nuchido have really educated me on the emerging field of cellular ageing and the latest best practice in addressing it. This has helped me not only diversify my current services but to also consider how my business needs to develop in the future in order to stay current and capture this new market coming to the UK.” Chief commercial officer at Nuchido, Alix Mackay, commented, “This resource will enable professionals in aesthetics to access the very latest research and expert opinion on the subject, putting them on the front foot to capture a market that is very much coming to the UK.” Eyes

Skincare

NeoStrata introduces new serum

Skincare distributor AestheticSource has released the new NeoStrata Glycolic Renewal Serum as part of the Resurface range. According to the company, the serum aims to prevent uneven skin, enlarged pores, acne scars and hyperpigmentation.

Ingredients include glycolic acid to maximise exfoliation, stimulate cell renewal and improve skin radiance whilst maintaining an optimal pH, lactobionic acid to deeply moisturise and exfoliate whilst strengthening the skin’s protective barrier, green tea antioxidants to provide protection against external stressors as well as 10% alpha hydroxy acid and antioxidants to renew the appearance of skin’s surface texture, NeoStrata explains.

Vikki Baker, marketing manager at AestheticSource, said, “This is the perfect product to recommend to patients during the 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.”

Vitamin and supplement manufacturer HINNAO has created a new liposome technology which allows glutathione to be taken orally rather than through IV drip therapy. Previously, glutathione molecules couldn’t pass through the stomach and gastrointestinal tract, therefore failing to reach the bloodstream when taken orally. However, the new technology is able to absorb through the mucous membrane within 60-90 seconds into the bloodstream, the company explains. The technology uses a high shear process which subjects the particles to 40,000 per square inch, encapsulating the particles uniformly, whilst the phospholipid medium-chain triglycerides base, ensures the product does not fall out, adds HINNAO. Nayan Shah, superintendent pharmacist at Mediva Pharmacy and distributor of HINNAO, said, “Regular use of the HINNAO nano-sized liquid drops helps overcome the short half-life of glutathione, regulating an immune response and protection against oxidative stress. Our practitioners tell us how their patients’ skin looks and feels revitalised, as well as reporting marked improvement on overall health.”

New study unveils less painful treatment for periorbital wrinkles

A recent clinical report has highlighted that thermomechanical fractional injury (TMFI) could be a less painful treatment alternative to non-ablative fractional laser for the treatment of periorbital wrinkles. The report was led by Dr Fares Salameh, senior doctor at the department of dermatology, laser and advanced technology clinic and centre for Aesthetic Dermatology at Tel Aviv Sourasky Medical Centre. The report was published in Lasers in Surgery and Medicine

In the study, 68 patients (64 women and four men) with skin types I-VI from two medical centres (34 from Israel, 34 from the US) were randomised to receive either TMFI or non-ablative fractional laser treatment for periorbital wrinkling. Patients each received three to five treatments, spaced three to five weeks apart. Six months after the last treatment, the change in Fitzpatrick Wrinkling Classification System (FWCS) was calculated by three non-involved physicians and compared to pre-treatment results. Side effects and downtime profiles were assessed in each group.

A moderate improvement in periorbital wrinkling was demonstrated in both groups. Approximately 80% of subjects returned to both work and social activities two days post-procedure. Crusts were reported by 52% of patients in the TMFI group, compared to 16% of patients in the non-ablative fractional laser group more than 48 hours post-procedure. Dr Salameh said, “Periorbital wrinkles are an early manifestation of photoageing, starting as early as the third decade of life and often distressing to patients. Our study introduces a new effective and alternative treatment for this challenging indication.”

Endosphères Therapy supports networking drinks

The networking drinks sponsor at the Aesthetics Conference & Exhibition (ACE) has been announced as Endosphères Therapy, from Italian manufacturer Fenix Group.

After a full day of education, delegates can have refreshments and network with colleagues during the drinks reception. UK country manager Chantal Fenix said, “We are super excited to be sponsors at ACE 2022! Endosphères Therapy is delighted to be showcasing our incredible new technology for body sculpting and antiageing facial systems. Come and see what compressive microvibration technology at our stand on March 11-12 and if you have time, come and chat to us at our drinks reception.” ACE will take place on March 11-12 at the Business Design Centre, London. Register free on p.18

Education

HA-Derma holds masterclass on Profhilo Body

In December, distributor and training provider of the IBSA Derma portfolio in the UK and Ireland, HA-Derma, held an advanced masterclass on Profhilo Body. The two-day agenda, held in Milan, began with a talk on the NAHYCO technology and the new Profhilo studies, which were overviewed by head of IBSA’s Medical Affairs Gilberto Belia. Aesthetic practitioner Dr Antonello Tateo discussed Profhilo’s evolution from face to body, and Dr Gabriel Siquier spoke on his personal clinical experience. The agenda continued, discussing patient approach, evaluation and combined treatments with energy devices, and finished with Profhilo Body live injections. The company explains that practitioners were able to gain insight into the production of Profhilo and Profhilo Body whilst also having a tour of the facility located in Lodi. Iveta Vinkler, director of HA-Derma, commented, “We were delighted to have the opportunity to invite a group of practitioners, including our lead trainers from the UK and Ireland. IBSA Derma is addressing a need on the market, and they can offer a complete treatment to counteract existing skin laxity and prevent its onset.”

Finance

Snowbird Finance launches new offering for patients

Medical finance broker Snowbird Finance has introduced a new offering called Treatment Finance. The company is offering finance plans to clinics, helping their patients to minimise the focus on treatment costs and break the overall payment into smaller, more manageable instalments. Working in partnership with dedicated funders, Snowbird offers an automated application process which takes three minutes to complete, with funds transferred to the clinic the next working day, increasing patient commitment and cashflow.

News in Brief

Sciton expands sales team

Aesthetic laser manufacturer Sciton has expanded its sales team in the UK and Ireland. The new additions include Jordan Sizer as an area sales manager, covering parts of London and the north of the UK, and Mat Lane who will be the new territory manager, focusing on business development and customer support initiatives throughout the UK. David Hingham, UK and Ireland country manager, said, “For 2022, we have brought on top level talent so patients and providers can experience proven aesthetic treatments. Sizer and Lane are the perfect team to support our future growth.”

OBE title awarded to Matthew Patey

The chief executive officer at the British Skin Foundation (BSF), Matthew Patey, has received an OBE in the New Year’s Honours list. Patey has been awarded the title for services to research into skin cancer and other dermatological conditions. Since 1996, Patey has expanded the charity and has raised money for skin disease and skin cancer research. Patey commented, “I’m surprised and flattered to receive this honour. The BSF set out to increase public awareness and raise funds for dermatological research and I am proud to have played my part in helping to fight skin diseases and skin cancer.”

BioID Health updates website

Hormone replacement therapy provider BioID Health has launched a new website. The company offers treatments by using bioidentical hormones that are engineered to imitate your natural hormones. It targets patients suffering with menopause, perimenopause and andropause. The website now includes an online system checker as well as a breakdown of treatment options. Patients are provided with specialised treatments and a plan to replenish the hormones they are deficient in after a comprehensive assessment by a specialist and a blood/saliva test.

Epionce unveils new eye serum Skincare distributor Eden Aesthetics has released the Epionce Luminous Eye Serum. The serum aims to brighten and smooth the eye area for a more refreshed appearance, the company explains. In a clinical study conducted by the company, the product has been shown to reduce the visible appearance of puffiness, dark circles, fine lines and wrinkles and droopiness without irritation. In a clinical trial of 23 female panellists who used the serum twice daily, 87% experienced significant improvement in crow’s feet wrinkles, 95.7% experienced improvement in undereye puffiness and 100% showed improved undereye crepiness.

Injectable Treatments and COVID-19 Booster Jabs

With the recent controversy surrounding the vaccination status of tennis player Novak Djokovic, and Prime Minister Boris Johnson announcing that 90% of the patients in intensive care with COVID-19 haven’t had their booster, the COVID-19 vaccination debate rages on.1

According to the latest data from the NHS, fewer than half of women in their 30s in England are fully vaccinated against COVID-19, and this figure drops to just a third for women in their 20s.2

Since Aesthetics last reported on the link between dermal fillers and the COVID-19 causing adverse effects in April 2021,3 according to representatives of both the Aesthetics Complications Expert (ACE) Group World and the British College of Aesthetic Medicine (BCAM) incidences of patients experiencing complications have continued to be reported, and there is concern that these reports are putting people off their booster jabs.

Currently the NHS and the UK Government do not provide any information about injectable treatments interacting negatively with the COVID-19 vaccinations, however practitioners are noting a link with women in their 20s and 30s, who are a key target demographic for preventative botulinum toxin and dermal filler injectables.

Previous action taken

In April 2020, Aesthetics reported that in the phrase three trial of the Moderna vaccine with 30,000 people, three patients who had previously been treated with soft tissue filler experienced mild facial swelling following the vaccine.3 Filler injections had been given two weeks before the vaccine in one patient and six months earlier in another, the third was not disclosed. In response to this information, the ACE Group World released a six-page paper entitled ‘The Impact of SARS-CoV-2 Vaccination and Infection on Soft Tissue Filler’, written by aesthetic practitioner and founder Dr Martyn King.4 Its key findings included that provisional evidence suggested tear trough, malar, and perioral regions are most susceptible to delayed onset reactions (DORs).4 ACE Group World guidelines were also amended to recommend that patients who have had lip filler or tear trough treatments in the last six to 12 months should be considered at higher risk of developing a reaction than those with other facial fillers. They also recommended that practitioners should not perform soft tissue filler treatments two weeks before or three weeks after COVID-19 vaccination or infection. This guidance was applied to all vaccines, not just the Moderna.4

An increase in complications

Complications with fillers and vaccinations are well documented in the literature and not specific to COVID-19,4 although according to Dr King, “mRNA vaccines are particularly immunogenic and more likely to trigger a reaction but typically, outside of the COVID-19 pandemic, vaccinations have not been offered to our patient

demographics (commonly the very young and old are given vaccines).” Recent studies undertaken in late 2021 have documented this increase in adverse reactions to filler in conjunction with the COVID-19 vaccine, explaining that treatments based on hyaluronic acid represent one of the most largely use practice of aesthetic medicine.5,6 One case study from September 2021, examined adverse effects in a 39-year-old female who developed swelling days after receiving the mRNA Pfizer-BioNTech COVID-19 vaccine, and another 61-year-old female who developed intermittent facial swelling in areas previously treated with hyaluronic acid soft tissue filler days after receiving her first dose of mRNA PfizerBioNTech COVID-19 vaccine. The study concluded that although rare, considering the ongoing pandemic and the worldwide demand for vaccines against COVID-19, that aesthetic providers should be conscious of the risks post by treating patients with hyaluronic acid who have had or are planning on having the vaccine.7 Dr King has noted an increase in patients experiencing swelling and nodules following vaccination or infection with COVID-19, through people presenting to the ACE Group World with complications. “We have certainly seen an increase,” he explains, “Mostly when filler has been injected in the previous four months. ACE Group World are helping to manage two to three cases a week, but this number has certainly increased over the past couple of months.” This could partially be due to a spike in people requesting injectable treatments around the festive period to be ‘Christmas party ready’, coinciding with the booster roll out, but Dr King believes it is more to do with COVID-19 infections rather than vaccinations. “The uptake for the booster programme has not been as good as anticipated,” he explains, adding, “It may well be that the mRNA vaccinations (Pfizer and Moderna) are more likely to cause adverse events with dermal fillers as we did not see such a high increase for the first and second doses when AstraZeneca vaccines were more predominant.”

Aesthetic practitioner and president of BCAM Dr Uliana Gout agrees, stating, “There has been a definite increase in adverse effects of filler and the COVID-19 vaccine reported to BCAM and we are still hearing patients ask about filler safety pre-treatment, so clearly there is an ongoing interest in the data, but no facts as of yet. We should also not fail to appreciate filler reactions can also be precipitated by any surgery, dental work, illness and other vaccines, so it’s important to put everything into perspective for our patients.”

Updating the consultation

Both Dr Gout and Dr King express the importance of educating patients on prioritising their boosters over injectable treatments. “I strongly recommend that practitioners address this in the consent and consultation process,” states Dr Gout, “Practitioners should be educating patients in advance of the potential risks and guide the patient in making an informed decision.”

Dr King agrees stating, “Consultations in aesthetic practice should now include vaccination status including number of vaccinations and approximate dates as well as anticipated date of booster if they have only had the first two. Practitioners should also be advocating the vaccine over injectable treatments during the consultation. There has been some controversy surrounding asking people their vaccination status; however, personally, I

Aesthetics revisits the link between COVID-19 vaccinations and aesthetic complications in light of the booster jab roll out

do not see any ethical issues in asking these questions. This is because I consider this as part of our responsibility as professional medical practitioners to ensure patient safety and that complications and risks can be reduced and better explained to patients.”

Dr King reiterates that previous guidelines recommended by the ACE Group World, and circulated via the British Association of Cosmetic Nurses and BCAM, should still be adopted and adds, “It would also be sensible to advise patients to avoid filler treatments for a period before attending a large gathering, event or holiday, due to the increased risk of catching COVID-19 at large gatherings and therefore increasing the risk of adverse effects, so practitioners should also be asking about any upcoming events they may be planning.”

Going forward

The aesthetics specialty is calling on a push for further guidance on this matter but Dr King states, “I would always advocate that vaccinations should take priority over filler treatments.”

Both Dr King and Dr Gout agree that more data on these potential complications needs to be gathered as it is possible that more vaccinations will be necessary. “ACE Group World is continuing to collect statistics and reviewing our guidelines as more data is available and we can ascertain which approach is best for managing these complications,” explains Dr King, “This information will be circulated as it becomes available.”

Dr Gout stresses the importance of regularly reviewing the information. “We still need to collect more global data,” she says, “My first publication on this with my international colleagues went to press in April 2021 and it’s important to review the data annually to ascertain the finer nuances and latest evidence-based approaches.”8

REFERENCES

1. The Guardian, ‘Up to 90% of COVID-19 Patients in ICU Are Unboosted says Boris Johnson’, 2021, <https://www.theguardian.com/world/2021/dec/29/up-90-COVID-19-patients-icuunboosted-boris-johnson>

2. NHS, Vaccination Statistics, 2022 <https://www.england.nhs.uk/statistics/wp-content/uploads/ sites/2/2021/07/COVID-19-19-weekly-announced-vaccinations-01-July-2021.pdf>

3. Carver, H, ‘Dermal Fillers and COVID-19’, Aesthetics Journal, 2021, <https://aestheticsjournal.com/ feature/news-special-dermal-fillers-and-covid-19>

4. Dr Martyn King, The Impact of SARS-CoV-2 Vaccination and Infection on Soft Tissue Fillers, 2021, <https://uk.acegroup.online/blog/2021/03/06/COVID-19-19-fillers/>

5. Savva, D. et al., ‘Hypersensitivity Reaction to Hyaluronic Acid Dermal Filler After the Pfizer Vaccination Against SARS-CoV-2, Internal Journal of Infectious Diseases, 113:233-235, 2021, < https://pubmed.ncbi.nlm.nih.gov/34597761/>

6. Osmond, A., Kenny, B,. ‘Reaction to Dermal Filler Following COVID-19 Vaccination’, Journal of Cosmetic Dermatology, 20(12):3751-3752, 2021, <https://pubmed.ncbi.nlm.nih.gov/34597761/>

7. Michon, A., ‘Hyaluronic Acid Soft Filler Delayed Inflammatory Reaction Following COVID-19 Vaccination – A case report’, Journal of Cosmetic Dermatology, 20(9):2684-2690, 2021 <https:// pubmed.ncbi.nlm.nih.gov/34174156/>

8. Gotkin, R, Gout, U et al., ‘Global Recommendations on COVID-19 Vaccines and Soft Tissue Filler Reactions: A Survey-Based Investigation in Cooperation with the International Society for Dermatologic and Aesthetic Surgery (ISDS), Journal of Drugs in Dermatology, 2021

Teoxane Reveals Unmissable

The time has finally come – the sessions for our ACE 2022 Headline Sponsor and leading international brand TEOXANE have been revealed! We are delighted to announce that you can now book to secure your place in these coveted talks for FREE. There are limited spots available, so you need to move fast! TEOXANE will host two full days of free talks, reinforcing the company’s dedication to providing exceptional world-class clinical education to medical aesthetic practitioners. If, like thousands of your peers, you take your aesthetic education and learning seriously, then the Aesthetics Conference and Exhibition (ACE) is the perfect medical aesthetics event for you! This year’s agenda is more comprehensive than ever, with the introduction of more clinical sessions and business workshops, expert speakers, and brands never before seen at ACE, as well as a packed exhibition space for eager delegates to explore. So, what does award-winning education look like?

Live demonstrations

What better way to learn about the latest treatment styles than through up close and personal live demos? The experts from TEOXANE will provide delegates with demonstrations treating the temple, lateral brow and mid-face areas on both male and female patients, using products from TEOXANE including the RHA and Redensity ranges. The company’s top key opinion leaders (KOLs) will also evidence how to treat the lower third with combined indications, as well as how practitioners can achieve natural outcomes in the middle third.

Learning from the best

The programme does not disappoint when delivering KOLs to take you through these sessions! Six of the world’s leading medical practitioners will feature across two days of content. Each symposium will include a focus on anatomy, techniques

and products, leaving you fully equipped to implement the skills learnt into your own practice. With more than 60 years of experience between them, along with multiple qualifications and training academies, this is a line-up you won’t want to miss.

In-depth injectable symposiums

The symposiums will cover facial anatomy, looking at full anatomical mapping, how to identify danger zones, and reviewing treatment indications. This will then be followed by discussions on how to choose the best rheological profile for the targeted facial layer, depending on the desired patient outcomes.

What else can you expect?

At the Expert Clinic, Masterclass, In Practice and Symposium agendas, you can see live treatment demonstrations, discover new techniques and protocols, and enhance your learning on the science behind the most effective modalities. These are all from the industry’s most reputable, experienced speakers, and all sessions are CPD certified. With huge takeovers, launches and big reveals from Allergan, Croma-Pharma, Galderma, HA-Derma, Enhance Insurance, and many more, you won’t want to miss it!

Secure your spot at ACE 2022

Attend the sessions that suit your learning needs the most and contribute to your clinical and business development, whether that involves laser treatments, body-contouring methods, skincare approaches or a new business strategy. Further details on the agenda will be revealed soon with some sessions taking bookings. There are limited places available for the clinical sessions from aesthetics giants TEOXANE, Allergan, Galderma and more. Register now before all sessions become fully booked.

Dr Kam Lally Cosmetic doctor

Dr Raul Cetto

Aesthetic physician

Dr Lee Walker Dental surgeon

Mr Benji Dhillon Cosmetic surgeon

Dr Wassim Taktouk Cosmetic doctor

Mrs Sabrina Shah-Desai Aesthetic oculoplastic surgeon

Injecting Male Lips

While dermal fillers can be used to treat a variety of different areas, they’ve become heavily associated with one area of the face in particular: the lips. For better or worse, we’ve seen women splashed across the media with lips in various shapes, sizes and volumes, with many now a lot more open about having a little enhancement in that area. What isn’t so common is men discussing the same thing –however that doesn’t mean it’s a treatment that should be ignored for your male patients.

“Attractiveness is not mutually exclusive to females and impacts on male social standing,” explains aesthetic practitioner Dr Jeremy Isaacs. “Interpretation of attractiveness signals health, fitness, reproduction, and employment success, with the lips occupying a crucial role,” he adds. The reason why less men are having their lips treated, explains oral and maxillofacial surgery registrar Mr James Olding, is that it can often be seen as a feminine treatment area. He explains, “I think a lot of men are open to having their lips done, but it’s not something you see represented that much – plump and voluminous lips are something synonymous with women and I think some men are unaware that you can actually gain subtle and natural treatment results. The main desire for men in terms of attractiveness is a strong lower face – such as a square jawline/chin, and they may not realise how the lips actually have a role to play in creating a strong lower third.” Dr Isaacs agrees, noting that another one of the main reasons men are hesitant to attend aesthetic clinics is because of the fear of feminisation. He says, “In 2018 the American Society of Aesthetic Plastic Surgery estimated that the proportion of procedures performed on males was around 8%, with the greatest fear being over feminisation.1 This statistic demonstrates that men have reservations about all non-surgical cosmetic treatments,” he says, adding, “Unfortunately, the unnatural and overinflated female lips influenced by social media probably is the single most significant contributor to hesitancy and suspicion that prevents more males from undertaking these non-surgical cosmetic procedures.”

Anatomical differences

Mr Olding emphasises that the most important difference for treating men and women comes down to the anatomical differences. He comments, “Looking in profile, in women patients the chin ideally sits posterior to the lower lip, whereas with men they may commonly be in line. The result is a slightly convex profile in women, and a flatter one in men, ideally. Men also tend to have larger mouths, but smaller lips (particularly the upper lip) with wider and thicker philtral columns. In men, the ideal facial shape also has a chin width that corresponds to the width of the mouth, as opposed to a more defined, narrow chin point in women. Vertical considerations, such as dividing the lower face itself into thirds, are also important.”

Dr Isaacs adds that while there are no global standards for male lip morphology, they are generally wider, the upper lip is thinner, and the vermillion show is less than a female. He continues, “The pertinent anatomical concentric layers of the lip remain the same, but if considering the complete aesthetic subunit of the lip, including the cutaneous portion, the male lip ages less because the dermis in male lips is thicker because of the density of the hair follicles. Consequently generally male cutaneous lips show less perioral rhytids.”

Aesthetic nurse Kerry Hanaphy adds that respecting sex differences is important for patient satisfaction, noting, “Both men and women come in trying to attain the ‘ideal’ face for their sex – women want to look ‘sexy’ with rounder and more volumised features, and men have stronger jawlines so want to shape the lips and get symmetry along with the jaw to portray their masculinity. So, it’s important for practitioners to understand the proportions of male and female faces before these can be treated for the best outcome.”

Mr Olding agrees, noting, “If you’re not well versed in anatomy, you won’t be able to tailor your technique to the individual sitting in front of you. Being unaware of this is what results in male feminisation, which in most (but not all) cases is the opposite of what you’re after. I can’t recommend enough that all practitioners really get to grips with anatomy before they start treating.” He explains that a few ways practitioners can do this is by attending training courses, going to conferences like the Aesthetics Conference & Exhibition

(more info on p.18), and undertaking external reading from educational resources. Mr Olding adds that to ensure delegates are getting sufficient knowledge of the above, aesthetic training providers should ensure their programmes are incorporating male models so as to equip practitioners with sufficient knowledge in how to treat both sexes. He comments, “Training courses have historically revolved almost singularly around injecting white females, so it’s important that providers are diversifying their content to reflect the wide variety of patients that will come through our doors. If we don’t, there will be practitioners out there who treat every face the same way, meaning patients will get bad results.”

Mr Olding explains that to help lessen male anxiety around presenting to clinic, he focuses his communication with male patients on subtlety and natural results. He says, “Prior and during the consultation I ensure that it’s clear to the male patient that the outcomes of the treatment will be extremely natural – I find that men are a lot more concerned than women in this regard. I use slightly different wording, such as ‘hydrating the lips’ or ‘creating structure’ to the lips, rather than plumping or adding volume, as this puts them a bit more at ease about not getting an overdone or feminine look.”

Dr Isaacs adds that as with any patient, risk mitigation and a proper assessment prior to the treatment is paramount. He comments, “The use of ultrasound vasculature mapping of the lip before injecting is helpful, so as to identify any potential risk areas (such as where the large blood vessels are) and therefore plan where your injection points are going to be, helping to minimise the risk of complications during treatment. In my clinic, I use the Clarius LD20 device. I also find that examination of the dentition is essential for any lip appointment as they have a significant role in lip support. This is because missing or irregular teeth will affect irregularities in support and contribute to lip asymmetries.”

Techniques and products

Mr Olding notes that he often uses Juvéderm Volift for treating the male lips. “For creating better structure you need a product that is quite robust, and this is often what male patients are after,” he notes. “Occasionally, I will use something finer like Juvéderm Volbella if I’m focusing on providing minimal volume, or even Juvéderm Volite for hydration. The quantities will vary patient to patient, and I wouldn’t say that I use different quantities for men or women – it just depends on the desired result and what type of lips you’re starting with. The main difference treating different sexes for me is the injection areas,” he adds.

Consultation style

Hanaphy explains that she doesn’t adapt her consultation style between genders, but rather bases it singularly on the individual. She comments, “I think everyone of every age and sex has questions before the first time they come and see us about fillers – or any aesthetic treatment for that matter. Whether it is debating what the right amount is, what’s the right direction for their skin, or any concern they may have, we always want them feeling totally comfortable. All our practitioners treat every patient the exact same and will give similar advice, with the main aim to make them have confidence in both themselves and in the practitioner/the treatment.”

Dr Isaacs agrees that the fundamentals of the consultation should remain the same regardless of sex, noting, “As always, the consultation should hinge around fully informed consent, covering a full assessment, consideration of relevant anatomy and ageing processes, discussion of techniques, and an explanation of product selection.”

However, he comments that the male consultation is often nuanced to focus on their expectations and allay fears that the procedure will not feminise their features (unless that is a goal). He says, “During the consultation, I find that men are often embarrassed, self-conscious, and impatient, expecting minimal downtime and immediacy of the outcome, so it’s important to evidence good results and also manage expectations. In my experience, the male naturally wants to look fresher, attractive, and masculine (depending on orientation).”

He explains that in men he is more confident in creating a body all along the lip, albeit a small amount, whereas in women he will concentrate and inject it more medially. He explains, “As per the anatomical differences, this is because it creates a more feminine look from front on, as the lips are more projected. I also use a slightly less harsh technique in the male border, for example the tenting technique, as I find that this creates a more subtle outline.”

He adds that more often than not he tends to treat male lips in combination with other areas. He says, “I don’t think you should just treat the lips in isolation – I tend to treat it in conjunction with the chin and jawline for example. This is because if the lips have

Figure 2: 39-year-old patient before and immediatley after treatment using 0.8ml of Juvéderm Volift. Images courtesy of Mr Olding.

Figure 3: Patient before and immediately after treatment using Teosyal RHA 2. Images courtesy of Dr Isaacs.

Before

Before

After After

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a greater projection, the chin often also needs that projection to retain the masculine profile, and a strong lower-face shape. In this way, it’s important to always consider your patient’s face as a whole, instead of just focusing on one particular area as this could disrupt the whole structure.”

Dr Isaacs explains that he bases his treatment approach from the sex dimorphism (where the sexes exhibit different characteristics) in masculine facial characteristics, but adds that the practitioner must also consider the patient’s personal preferences and sexual orientation. He says, “The most common outcome we’re after for male patients is natural harmonious and balanced lips that obey the anatomical boundaries of the individual, without over-exaggeration or looking abnormal. The male lip is generally thinner, wider with less vermillion show, similar to George Clooney or Brad Pitt, but, Harry Styles, Ryan Reynolds and Mick Jagger have much more vermillion high and feminised ratios. Thus, it’s important to note that feminisation of a male lip may not necessarily always make the male face less attractive – there is no one size fits all approach nor any globally accepted approach.”

Hanaphy agrees that a patient’s personal preferences should always be considered alongside anatomy, noting, “While a lot of the time it is about fitting in with masculine proportions, practitioners should be aware that some patients like a feminine look. It is seriously in the eye of the practitioner, looking at their original lips, ethnicity, facial proportions, and the patient’s preferences.”

Dr Isaacs notes that his product of choice will depend on the desired outcome, but he most commonly uses the lip-specific hyaluronic acid fillers from the Teosyal RHA range, usually RHA 2. He explains, “I don’t tend to use a different product for men or women, and I find that the

rheology of the RHA gel allows for natural animation of the muscles of facial expression without static rigidity. The range permits me to select between subtle natural shaping and contouring to more volumising and sculpting to meet all patients’ ideals, so for men this is useful depending on if they’re after a masculine or feminine look. Techniques can include needles, cannula, or a combination of both, and in my opinion, all have merit dependent on anatomical constraints, personal preference, experience, and patient anatomy.”

Hanaphy uses Restylane Kysse as her product of choice. She explains, “The reason I like it is because I know where it’s going to end up, as the pressure and extrusion force is easy to see and predict. It’s a filler that expands with the shape of the lip, and as the person goes by day-to-day life it adapts itself to their lips and structure. It also doesn’t cause a lot of swelling and rests easy in the patient’s lip, which I find is good for male patients as they are often concerned about the downtime and the treatment being too obvious.”

Marketing your results

Mr Olding advises that when marketing to a male patient base, it’s important to show the effects that the lip treatment can have on the profile as a whole. He notes, “If before and after images are a big part of your marketing, this is particularly something to consider – I don’t think a close up of the lips is something that entices men. This is because it’s the lower face for males that exudes strength and power, so you want to assure them that having their lips done won’t impact this – rather, it will benefit it. Evidencing this helps to remove fears of an unnatural or feminine result, instead showing how aesthetics can be used to masculinise them.”

He also adds that practitioners should be ensuring that the messaging for male treatments reflects their desired outcomes. “Like with the consultation, you should be assuring men that you can provide them with natural, subtle, and conservative results – hyperbolic statements won’t appeal to them. This also makes the consultation easier because they’ll already come in with more confidence in what the treatment can achieve,” he notes.

Dr Isaacs agrees, noting, “The number one fear in both genders is an overfilled and unnatural appearance and this must be dealt with. Treatments have the potential for huge impact on a person’s smile, communication, and confidence, so we need to communicate in a way that allows people to be open to that.”

Hanaphy adds that marketing good male patient results is essential for lessening the stigma around men getting treatments, explaining, “As practitioners, it’s important for us to be able to quash the negative connotation that beauty and aesthetics are just for females – everyone can benefit from treatments and men getting lip filler is no different!”

Don’t be afraid of male lips!

Mr Olding concludes that while male lips might seem like a foreign area to some practitioners, it’s not an area that you should shy away from. He concludes, “The more you practice the better you’ll get; so as long as you have the correct knowledge and experience, you can produce some really great results! Word of mouth is something that draws potential patients to your clinic, so once you start treating more men they’ll spread the word to friends or colleagues and it’ll help you build up a bigger male patient base. It can be a great way to expand your business, especially as men (for now, at least) make up a relatively untouched demographic group in the non-surgical aesthetics industry.”

REFERENCES

1. American Society of Plastic Surgeons, 2018, Annual Report, <https://www.plasticsurgery.org/ documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf>

Figure 4: 33-year-old patient before and straight after treatment using 1ml of Restylane Kysse. Images courtesy of Kerry Hanaphy.

“If you’re not well versed in anatomy, you won’t be able to tailor your technique to the individual sitting in front of you”

Mr James Olding

Linking Genetics and Hair Loss

Genetics play a role in hair disorders from childhood through to old age. Genetic hair disorders can exist individually or as part of syndromes which may have significant health consequences, particularly those which present in childhood.1

Aesthetic practitioners have several tools to improve the overall appearance of hair, but diagnosing the underlying cause of hair loss, in my experience, is key to managing expectations.

Hair loss conditions can be scarring or non-scarring. In scarring alopecia, the hair follicles are destroyed, leading to permanent hair loss. In non-scarring alopecia the hair cycle is altered, but the hair follicle is preserved allowing hair regrowth. Hair loss conditions which are most likely to present to aesthetic clinics about which there have been most developments in genetics in the past decade, are the non-scarring forms of alopecia – male androgenetic alopecia (MAGA), female pattern hair loss (FPHL), alopecia areata (AA); and the scarring forms – frontal fibrosing alopecia (FFA) and central cicatrising centrifugal alopecia (CCCA), plus hair loss after chemotherapy or immunosuppressant such as azathioprine. These all need to be managed differently. This article will cover how genetics is relevant to the types of hair loss affecting adults that may present in aesthetic clinics.

Historical background

Since the first Genome-Wide Association Studies (GWAS) were published in 2002, there has been a significant increase in studies that use GWAS as a tool to identify genetic variants associated with communicable and non-communicable disease. GWAS have also been used to identify variants that include human traits including eye colour, hair colour and anthropometric characteristics.2 Genomic variations have been associated with drug resistance and treatment outcome, helping to predict patients’ response to certain medications. In 2011 the potential to make use of the genetic profile to individualise treatments for balding was recognised.3

A variety of intra-cellular and inter cellular signalling molecules play critical roles in the formation of new hair.

Of the diverse intracellular signalling pathways implicated in hair biology, Wnt/β-catenin signalling plays a key role in stimulating hair follicle stem cells and hair regeneration. The Wnt signalling pathways are a group of signal transduction pathways which begin with proteins that pass signals into a cell through cell surface receptors. The name Wnt is a portmanteau created from the names Wingless and Int-1. Wnt signalling pathways use either nearby cell-cell communication or same-cell communication.4

It is known that WNT signalling is important for driving the induction of hair growth in mice, but it was in 2020 that a study found that key WNT pathway regulatory agonists, antagonists and target genes are expressed in the human telogen (resting phase of the hair growth cycle) to early anagen (growing phase) transformation.

This study from the UK, Spain, Germany and the US used scalp samples from five men undergoing hair transplantation. It managed for the first time to isolate human telogen and early anagen hairs. The relevant hairs were dissected and viewed under the microscope. Using specific antibodies to examine telogen follicles, they discovered that the WNT pathway induces anagen by prompting certain cells in the hair germ (part of the follicle) to multiply.4 By studying a whole range of proteins that switch WNT processes on or off they were able to build up a picture of events occurring at the start of anagen, which will help future scientists to develop targeted treatments for hair disorders.

Thus, efforts have been made to develop therapies for hair loss treatment by targeting this signalling pathway. Several plant-derived chemicals have been reported to promote hair growth by activating Wnt/β-catenin signalling in various in vitro and in vivo studies.5

Non-scarring hair loss

Androgenetic

alopecia

The pathogenesis of male androgenetic alopecia (MAGA, malepattern baldness) is driven by androgens, and genetic predisposition is the major prerequisite.6

A polygenic mode of inheritance for MAGA has now been well established due to their high prevalence and wide range of expressed phenotypes. Some genes may require the joint action of other genes to express a particular phenotype, and this collective gene effect, termed epistasis, may be larger than the additive effect of individual genes.7

Single nucleotide polymorphisms (SNPs) are the most common form of genetic variation in humans, with approximately 17.8 million SNPs identified in the human genome that are catalogued in public databases. SNPs are one of the most studied DNA sequence variations in human complex diseases such as baldness.8

Androgens have a clear established role in MAGA which is exerted by the conversion of free testosterone to dihydrotestosterone (DHT) by the enzyme 5 alpha reductase type II and by the binding of DHT to susceptible hair follicle androgen receptors (ARs) in scalp hair follicle. The role of androgens in female hair follicles is less clear.3

The first published genetic link with MAGA was the discovery of a marked association in exon 1 of the androgen receptor gene (AR) in 2001.9 This SNP is present in almost 100% of young and older balding men but is also found in a significant proportion of older men unaffected by baldness, suggesting that this SNP is essential, but not sufficient for baldness in men.9 This particular SNP also cannot explain father to son transmission because it is located on the X chromosome, which males inherit from the mother.

In 2005, a population-based twin study of men aged 70+ (the fourth wave of The Longitudinal Study of Aging Danish Twins) to assess the magnitude of the genetic component affecting hair loss (and to

Dr Ingrid Wilson explores why genetics should be considered when treating different types of hair loss

examine the association between baldness and perceived age). The intrapair correlation of degree of balding was consistently higher for monozygotic than for dizygotic twin pairs regardless of the baldness categorization used, and structural-equation analysis revealed a heritability of 79% (95% confidence interval, 0.40-0.85) for the mean baldness index. The remaining variation could be attributed to nonshared environmental effects.10

By 2008 the EDA2R gene was found to be associated with male androgenetic alopecia in remote Sardinian populations.11 Also, Genome Wide Association studies (GWAS) in families of German descent, helped to bring further knowledge about the susceptibility genes in involved. The identification of 14 regions with nominal evidence of linkage reflected and supported the opinion that AGA is caused by multiple genes. In contrast to the AR gene located on the X chromosome, the autosomal location of the AGA susceptibility loci of that study could explain the resemblance of fathers and sons with respect to the development of AGA.12 There is a strong paternal influence on balding/non-balding in sons.13

In 2013 a German case-control study to determine whether a polygenic component contributes to the genetic risk for AGA, provided molecular genetic evidence that a polygenic component contributes to the individual risk of developing androgenetic alopecia. The study groups comprised 581 severely affected patients and 617 controls. This study provided evidence for the contribution of a polygenic component to the overall heritable risk of AGA. The authors concluded that it is likely that the contribution of a polygenic component and the large number of genes involved reflect the complexity of the AGA associated biological pathways.14

It has been estimated that AR genetic variation accounts for up to 40% of MAGA heritability, leaving up to 60% of its risk profile currently unaccounted for.8 There is evidence for the specific contribution of a polygenic component to the overall heritable risk for AGA. To some degree, the polygenic architecture of AGA might reflect the complexity of the biological pathways involved.9

In 2015 a European based study looked at men below 50 years of age with significant baldness, and aged 50 or older lacking baldness. A total of 605 samples were collected from healthy male donors from the following European populations: 448 males from Poland, 49 from the Netherlands, 36 from the United Kingdom, 27 from Denmark, 20 from Italy, 13 from Germany and 12 from Spain. The results agreed with the genetic data obtained for AGA so far, indicating the involvement of multiple genetic loci with average or small individual effects. The study data indicates individuals carrying seven or more AGA risk alleles, in the five most associated loci, are significantly more susceptible to MPB in European populations.15

The understanding of the pathophysiology of AGA is incomplete, and each newly associated locus provides novel insights into contributing biological pathways. A study published in 2013 analysed a replication set comprising 2,759 cases and 2,661 controls of European descent to confirm the association with AGA at these loci. Combined analysis of the replication and the meta-analysis data identified four genomewide significant risk loci for AGA on chromosomes 2q35, 3q25.1, 5q33.3, and 12p12.1. The strongest association signal was obtained for rs7349332 on chr2q35, which is located intronically in WNT10A. Expression studies in human hair follicle tissue suggest that WNT10A has a functional role in AGA etiology. Thus, the authors concluded that this study provided genetic evidence supporting an involvement of WNT signalling in AGA development.16

The size of subsequent published GWAS increased so that by

In March 2017 a study of a total of 22,518 individuals from eight independent GWAS samples of European descent.17 The analysis identifies 63 genome-wide significant loci that explain 39% of the phenotypic variance in MPB. More than one-third of these loci (N = 23) had not been reported previously. The data highlighted highly plausible candidate genes and pathways that are likely to contribute to key-pathophysiological characteristics of MPB such as the deregulation of anagen-to-catagen transition (FGF5, EBF1, DKK2, adipogenesis); increased androgen sensitivity (SRD5A2, melatonin signalling); and the transformation of pigmented terminal hair into unpigmented vellus hair (IRF4). Some of these genes and pathways may represent promising targets for the development of novel therapeutic options.

Two further GWAS have been published with increasing numbers of subjects: later in 2017 Piratsu et al’s analysis of 43,664 subjects found 71 loci;18 and in 2018 Yap et al. study of 205,327 subjects found 624 loci associated with male pattern baldness.19

The common theme is androgen signalling pathways, WNT signalling pathways, apoptosis and adipogenesis. Besides underlining the key role of androgens, these comprehensive data also implicate a number of other hormonal pathways in the early stages of AGA pathogenesis, thus emphasising the hormone dependency of the trait.20

Female pattern hair loss

Female pattern hair loss (FPHL) is a heritable condition that affects up to 12% of women by age 30 years and up to 41% of women by age 70 years.21 It mostly affects post-menopausal women and is characterised by hair thinning over the crown, sparing the frontal hair line.21

FPHL and male balding share a final common pathway of follicular regression but current knowledge suggests the aetiology is not necessarily the same in both sexes. Unlike MAGA, no FPHL association studies have been able to replicate robust association with AR and therefore it is not clear whether AR is similarly pathogenic for FPHL. In contrast to the Genome-wide association studies in men which have identified several genetic loci for MAGA and have provided better insight into the underlying biology, the role of heritable factors in FPHL is largely unknown.21

The more recently published studies have been restricted to candidate gene approaches and could not clearly identify any susceptibility locus/gene for FPHL but suggest that the aetiology differs substantially from that of MAGA.22

Androgens are a key driver of male balding and are also involved in the aetiology of pattern hair loss in some women. However, it is likely that other non-androgenic factors, as yet unidentified, play a role in causing FPHL. The idea that the aetiologies of FPHL and MAGA are not necessarily identical is supported by the results of genetic studies.22

A genome-wide association study published in 2009 found that the common rs4646 C allele, which has been associated previously with higher circulating oestrogen levels, might be associated with predisposition to FPHL.22

In the early 2010s there was speculation that the FPHL genetic link could lie in variations of the AR gene, which is a nuclear transcription factor that is located on the X-chromosome and that contains a region of CAG (Cytosine, Adenine, Guanine – three building blocks of DNA) repeats that affects its transcriptional activity.23 Around that time a screening test, the Hair Genetic Test was produced which measured the length of the CAG repeats in the AR gene, and shorter lengths are linked to a significant risk of developing FPHL.24

The clinical relevance of such tests is uncertain because a positive gene test is not an indication to initiate therapy. Conversely, a negative test should not alter the treatment offered to a patient. The predisposition to M-AGA is largely due to heritable factors. Although only some of the loci identified as associated with M-AGA have been examined for FPHL, not even the most significant AR/EDA2R locus for M-AGA (p=1×10−320) showed a clear susceptibility for FPHL: other than the association of seven AR/ EDA2R markers in the small group of 57 British patients with early onset, no clear overlap of susceptibility loci between M-AGA and FPHL could be demonstrated by any of the published studies. These results therefore point to distinct risk loci in the two disorders and to different underlying pathomechanisms.25

Similarly, the attempt to investigate the candidate genes of the sex steroid hormone pathway failed to demonstrate significant association with FPHL. This provides further support to the hypothesis that unexpected disease-causing mechanisms lead to the development of FPHL. Two very recent studies have substantially increased the number of gene loci (>60) that associate with M-AGA. These findings have yet to be investigated or replicated in FPHL. Similar studies employing a GWAS approach are sorely needed in FPHL if we are to clarify the uncertainties over its aetiology and pathophysiology, and potentially to develop new approaches to its treatment.25

• Hair cycle & regeneration

• Stimulates hair follicle formation

• Damage repair

• Hair cycle & regeneration

• Increase anagen gene expression

• Damage repair

• Hair cycle & regeneration

• Promote hair follicle growth

Wnt 1a Wnt 4 Wnt 3a Wnt 5a Wnt 10a/b Wnt 7b

Figure 1: The role of WNT pathways in the hair cycle

Alopecia areata (AA)

• Increase anagen gene expression

• Upregulated the stage of early hair follicle morphology

• Target of sonic hedgehog

• Damage repair

status explains the increased level of serum IL-18 in patients with AA. The authors concluded that IL-18 SNP should be examined in large cohort, which contains different ethnic groups. Furthermore, IL-18, its receptors, and inhibitors will be more important to understand the pathogenesis of AA.30

Pharmacogenomic research enables the pharmaceutical industry to understand variability of patient responses to drugs during clinical drug development and during post-marketing surveillance. Understanding the genetic basis for patient response/non-response can enable the development of individualised therapies for those patients with an inherited basis for altered response to drug therapy.

There are multiple examples of drugs that now contain a recommendation for genetic testing before dosing in their drug labels, directing clinicians to obtain genetic information for each individual patient to help direct drug therapy.31

As for other autoimmune conditions, the major histocompatibility complex (HLA) region is associated with AA susceptibility. A case control study published from Italy in 2011 showed a correlation between the HLA-DQB1 locus and the occurrence of AA in Italy supporting DQB1*03(DQ7) as a predisposing allele for the disease and consequently the relevance of the HLA genetic test in the clinical management of AA.32

A 2019 meta-analysis of five case control studies in suggested that rs2476601 SNP was significantly associated with AA susceptibility. On the basis of the results of the current research, the rs2476601 polymorphism of PTPN22 gene is significantly correlated with AA susceptibility. The C-allele and CC-genotype carriers at this locus have a lower risk of AA.33 In 2021 a study’s results suggested that survivin (one of the apoptosis inhibitor proteins responsible for apoptosis suppression and cell cycle regulation) and p53 genes expression was altered in patients with AA.34

Scarring hair loss

• Increase gene expression

• Increase woundinduced follicle neogenesis

AA is a relatively common non-scarring form of hair loss. The prevalence of the disease is between 1% and 2% worldwide, and it takes place at any age from birth to late life.26 Currently available treatment options for AA are of limited efficacy and can be associated with adverse effects. The advancement in understanding of the genetic and molecular mechanisms of AA has led to the development of novel treatment options, with the Janus Kinase (JAK) inhibitor class of drugs being at the forefront of ongoing clinical trials.27 Genetic factors have significant roles in the etiopathogenesis of AA and certain gene alleles have been associated with the disease.28 Petukhova et al. found eight different genomic regions associated with susceptibility to AA in genome-wide association study. They suggested that most of these regions have an important role in T-cell-mediated pathways.29 IL-18, which stimulates IFN-[gamma], is a major cytokine in the Th1 response and affects the development of autoimmune, inflammatory, and infectious diseases. A study published in 2018 demonstrated that allelic variants which relate to the increased production of IL-18, may be a significant genetic factor for AA. The

Primary cicatricial alopecia (PCA)

This group of hair loss diseases share similar core pathways with unique gene signatures characterising individual subtypes. The three most common are lichen planopilaris (LPP), frontal fibrosing alopecia (FFA) and central cicatrising centrifugal alopecia (CCCA). Genetic studies have been used to identify key (shared) genes in these complex diseases among many (hundreds) of genes predisposing to a disease. If these genes have a strong enough effect on disease, they may lead to new targets for therapy.35

CCCA is estimated to affect between 6-8% of individuals of African descent. RNAseq analysis was performed on scalp biopsies of five CCCA patients compared to healthy control subjects. Three major pathways associated with CCCA were identified:36

1. Downregulation of steroid/cholesterol/fatty acid pathways

2. Upregulation of fibrosis and hypertrophic scarring pathways

3. Upregulation of a mast cell signature

Since the three core pathways are shared among all cicatricial alopecias, rational development of therapies focusing on restoring cholesterol and fatty acid metabolism and downregulation of fibrosis and mast cells may hold promise for improved clinical outcomes. FFA appears to be an increasingly prevalent autoimmune disease associated with hormonal dysregulation whereby individuals with an underlying genetic predisposition develop a scarring alopecia and skin changes possibly due to an environmental insult. There

is ongoing debate as to whether sunscreen is a factor. It was first recognised in 1994, and the prevalence has been increasing. GWAS in Spain and the UK published in 2019 provided insight into disease pathogenesis and characterise FFA as a genetically predisposed immuno-inflammatory disorder driven by HLA-B*07:02.37

CCCA is the most common form of scarring alopecia among women of African ancestry.38 The disease is occasionally observed to affect women in families in a manner that suggests an autosomal dominant trait and usually manifests clinically after intense hair grooming. It was first recognised in 1968, and for many years was attributed in large part to hair care practices. In 2019 a genetic basis of CCCA was confirmed by studies in South Africa. Mutations in PADI3, which encodes a protein that is essential to proper hairshaft formation, were associated with CCCA. This was a massive step in changing the narrative around hair grooming practices in this cohort, confirming a genetic predisposition.38

Persistent chemotherapy induced alopecia

Alopecia induced by classic chemotherapy affects up to 65% of patients and is usually reversible. However, there are increasing reports of persistent chemotherapy-induced alopecia (pCIA), especially for patients treated with taxane-containing chemotherapy regimens.39 The total or incomplete hair regrowth six months after completion of therapy in patients who received cytotoxic chemotherapy is defined as persistent chemotherapy-induced alopecia (pCIA). This phenomenon has recently been described in patients with breast cancer and in its most severe from can occur in up to 10%.40 In 2020, the first study which looked into identifying the genetic variants linked to this condition looked at 215 women with breast cancer treated with docetaxel-based chemotherapy with a follow up of 1.5-10 years after the end of the treatment. They were recruited were recruited retrospectively through three hospital oncology units across Spain between 2005 and 2018. The study found an association between a regulatory variant in the ABCB1 gene and the occurrence of pCIA in women who had been treated with docetaxel based therapies.41 This finding suggests an important insight into the biological mechanisms underlying pCIA and opens the opportunity to explore personalised treatment of these patients.

Conclusion

Outside the scope of this article is the fact that genetics can also help to explain or predict the reaction to certain medications causing alopecia. Lifestyle habits can silence or enhance some genes; smoking, exercise, contaminants, or stress for example can do this.

Genetic testing is becoming commercially available that can look at metabolism or even the correct dose of medication for a patient. There are a number of commercially tests that can analyse a number of genes and genetic variations related to alopecia. One such test is called TrichoTest. The test does not diagnose the cause of alopecia may be helpful in personalising treatment.41

Technological advances in DNA sequencing are setting the scene for more personalised medicine. They are helping to provide information about the biological pathways involved in the different types of hair loss which helps to inform treatment options and inform lifestyle choices.

Aesthetic Clinical Advisory Board Member and aesthetic nurse prescriber Jackie Partridge says...

I would like to take this opportunity to thank the author for such a detailed paper. There is certainly much to consider for patients suffering the effects of hair loss and the psychological impact it can have on them. As the author states further advances in genetic testing are proving invaluable for assisting in the understanding of the individual needs of each patient and the possible best treatment plan for their specific case. This is a good example of ‘one size doesn’t fit all’ and yet again reminds us of the need for bespoke care for the individual. I would urge caution for those considering the commercial aspect of this for their own cohort of patients, unless they have specialist knowledge in this field.

Dr Ingrid Wilson became a GP in 1999, is on the specialist register for Public Health Medicine and is a Fellow of the Faculty of Public Health. She is a member of the British Hair and Nail Society, International Association of Trichologists and Affiliate Trichologist Member of the British Association of Hair Restoration Surgery. Dr Wilson is the director for Crewe Hair & Skin Clinic. Qual: MB ChB, BSc(Hons) MPH, FFPH, IAT

TO VIEW THE REFERENCES GO ONLINE AT WWW.AESTHETICSJOURNAL.COM

Test

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

Question Answer 1. Which is the scarring form of hair loss?

Male androgenetic alopecia

Female pattern hair loss

Alopecia areata

Frontal fibrosing alopecia

Since the first Genome-Wide Association studies were published in 2002 the Wnt-catenin pathway has been shown to be important in which part of the human hair growth cycle?

Telogen (resting phase of the hair growth cycle) to early anagen

Anagen to catagen c. Catagen to anagen

Catagen to telogen 3. The phenomenon of genes requiring the joint action of other genes to express a particular phenotype is…

a. Epistaxis b. Epistasis c. Trichorrhexis d. Teloptosis 4. As of 2018 how many genetic loci so far have been associated with male pattern balding? (Male androgenetic alopecia - MAGA)

a. 1 b. 63 c. 71 d. 624 5. Which of the following pathways is not thought to be involved in the pathway of CCCA/FFA/LPP?

a. Downregulation of steroid/cholesterol/fatty acid pathways b. Upregulation of fibrosis and hypertrophic scarring pathways c. Upregulation of a mast cell signature d. Downregulation of a mast cell signature

Answers: 1.d, 2.a, 3.b, 4.d, 5.d

Case Study: Balancing the Male Profile

The goal for most men who turn to cosmetic treatments is to look

In my experience, typically those aged 40 and over prefer rejuvenating tweaks for reducing signs of weathering or tiredness, such as tear trough fillers for restoring hollow under-eyes, and anti-wrinkle injections for a softer-ridged brow. Personal tastes factor highly in terms of how many expression lines are desirable. For men in their 20s and 30s, alteration is more often the quest: understated yet effective solutions, usually with fillers, for helping to achieve stronger, more

However, in recent months, I have noticed a discreet and steady shift among male patients – regardless of age or occupation – towards full-facial ‘refreshment’, as opposed to simply wanting to have ‘this or

in detail the features he found particularly bothersome, namely his lower face, taking a full-face approach and thus ensuring a balanced and proportional outcome was always in sight. I find it satisfying to analyse and interpret the different facial anatomical components together with my patients in this way and it became clear that what he was hoping to achieve was a straighter nose, more defined cheeks and, crucially, a stronger jawline supported by better chin projection. The consultation process was aided by referencing his own photographs, the clinical pictures I took from front, oblique and side angles, and the use of a handheld mirror for helping him visualise my advice. I identified and noted the dorsal hump and drooping tip of the nose, the slight frontal asymmetry with curving towards the left, and a retrognathic chin with overall small mandible, meaning the absence of a defined jawline and chin. My decided strategy was a deliberate but necessary slow progression towards the ‘goal’ through several sessions, because I find that high volume injections administered in one go don’t integrate well; there’s more control if you go slowly and steadily. I’m a firm believer in the maxim that the best results are achieved with a marathon, not a sprint. We also discussed the effects of filler in different parts of the face, the potential risks and inevitable downtime, as well as the products I would use. I explained that the downtime can be negligible but swelling between weeks one and four is possible, and if there’s any bruising, it will last about a week. The patient was encouraged to ask questions and he was invited to contact me via email or WhatsApp if he wanted to know more or to follow-up on any details. For preparation, I advised him that it’s important to avoid drinking alcohol to excess because I find this can increase the risk of bruising. I gave him the necessary aftercare advice he would need to follow, including avoiding exercise and alcohol for two days following treatments; details that I repeated before and after each phase in the plan. As I had already discussed this treatment in detail with the patient prior to this consultation they had already had sufficient time to consider the outcomes and risks. I therefore performed the treatment on the same day, but I would normally recommend a cooling-off period of a couple of weeks.

Treatment

A 33-year-old Caucasian man presented to my clinic concerned with the absence of a defined jawline, which was clearly impacting his self-esteem. He’s highly visible on social media with a significant following – in fact, most people in his close social circle are models and media personalities and as a result, his photograph is taken regularly. This was making him very conscious of how lacking in structure his facial features appeared in pictures. He had never had cosmetic treatments before and after taking a full medical history there were no lifestyle factors of relevance. I deemed his concerns to be valid and was satisfied that his expectations were realistic. I carefully assessed his face from different angles and we discussed

For the first round of treatments, I decided on performing a liquid rhinoplasty and starting the injections to address the mandibular angle, jawline and chin, as these were his primary concerns. When treating, it’s vital to take into consideration the different angles, shapes and projections that must be respected so as not to feminise the male face. The angle of the mandible, for example, tends to be closer to 90-100 degrees in men, whereas in women it’s more typically between 120-130 degrees.2 Similarly, careful consideration is needed when rotating the tip of the nose in men. The angle of the tip of the nose should be at around 90 degrees to the upper lip; rotating any

Dr Joshua Van der Aa details a profile balancing treatment plan administered over six months to

Results

The patient experienced no side effects other than the expected swelling outlined above, and he was delighted with the added definition in his face. It was rewarding to see his confidence grow, something that was noticeable in his demeanour each time he arrived in clinic during the course of treatments.

As can be seen, he doesn’t look warped or unrecognisable, nor feminised or overinflated, just a more polished version of himself – a natural aesthetic that respects his individual anatomy. It was interesting to note that as the jawline looked more sculpted and defined, he chose to grow less facial hair because he was no longer subconsciously disguising a soft jawline.

more than this risks a more feminine ‘sloped’ appearance, something most are typically eager to avoid.2

Once I had signed informed consent and with some additional clinical photographs taken, my patient was invited to recline on the treatment bed. Invariably, patients are positioned at a 45-degree angle, which is comfortable for them and gives me ample access to the face. I work under high lumen LED twin bar lights so I can also ensure that I’m never working in my own shadow, and because it facilitates assessment of light reflections on the face, which arguably allows for greater precision.

I began by disinfecting the area using a 10x10cm square gauze and Clinisept+ Skin, and then marked the nose in white pencil as well as the face along the mandibular border and the width of the chin in line with the corners of the mouth.

I carefully straightened the nose bridge by injecting Teosyal Ultra Deep over and around the rounded dorsum. Then I lifted the nose using the same product because of its G prime and projection capacity. I carefully placed injections in the tip and columella to rotate it upwards and improve the angle of the tip.

For the cheek, jawline and chin areas, I also started by using Teosyal

Ultra Deep, administered using a 27 gauge needle for supraperiosteal injections, down to the bone. I prefer this method of injection for the chin as too much product injected superficially in this area can leave it looking somewhat overly rounded and obvious, making it look feminised or unnatural. Even at this early stage in the process, results could be seen straight away, something which is often quite astonishing for the patient and in this case clearly excited him in terms of what could be achieved over time.

For the second and third appointments (spaced six weeks apart due to the COVID-19 lockdown), I switched from Teosyal to Radiesse because it’s less hydrophilic, and in my experience, there’s more sharpness and less ‘roundness’ and swelling. I administered this with a 27 gauge needle supraperiosteally for extra deep volume and sharper projection. My focus during these sittings was chin balancing, projection and widening. Afterwards I began introducing anterior jawline cannula superficially on either side. During the third sitting I also addressed the pre-jowl dip, injected supraperiosteal again and the rest was done superficially once more using a cannula. I smoothened the dorsal hump in the nose by injecting the radix and middle of the bridge and performed a tip lift to improve the nasolabial angle by injecting small aliquots of filler on top of the ala major cartilage. I also treated the lips during the second session, and a later fourth session, with 1ml of Belotero Intense, using a 27 gauge needle, targeting the lip tubercles for volume so as to optimise the eversion and side profile of the lips.

Respect the anatomy

With the male face, I’d argue that it’s even more important to deliver subtle and almost undetectable results because of the stigma attached to treatments. To successfully treat the male face, it’s all about respecting the sexual dimorphisms; for the female face, it’s about rounded curves but, in men, it’s all about high tight lines. The more we discuss facial anatomy with men in our clinics and explain the differences in the anatomy compared with women’s features, the more we will help increase their confidence in non-surgical tweaks. Doing so will also help break the stigmas about these treatments and demonstrate very clearly how we respect their masculinity. Communicating this at every available opportunity is extremely important.

Dr Joshua Van der Aa is an injection-focused cosmetic practitioner specialising in rejuvenation of the periorbital area. He is a graduate of Leuven University’s medical school. Before opening Dr Joshua Harley Street Aesthetics in 2020, he worked in several reputable and award-winning clinics in London and Europe.

Qual: Master’s Degree in Medicine, Belgium

REFERENCES

1. Lucy Alexander, Robb Report, 2020. <https://robbreport.com/lifestyle/health-wellness/men-turning-tocosmetic-procedures-to-impress-in-bedroom-and-boardroom-2936788/>

2. John Hawks, Mandibles and Sex, 2011, <https://johnhawks.net/explainer/laboratory/mandible-sex.

Figure 1: 33-year-old patient before and after three sessions treating the chin, jawline, lips and cheeks

It’s vital to take into consideration the different angles, shapes and projections that must be respected so as not to feminise the male face

Topics covered in the TEOXANE sessions include:

• Softening and enhancing using a natural and dynamic filler - Temple, lateral brow and midface

• Treating the lower third with combined indications

• Achieving natural outcomes in the middle third

• Focus on anatomy, technique and product for each session (ATP)

• In-depth anatomical mapping and review of areas of danger

• Discussion in choosing the best rheological profile for the targeted facial layer

For any further event information, and to register for free, please scan the QR code.

Lee Walker – Dental Surgeon

Raul Cetto – Aesthetic Physician

Kam Lally – Cosmetic Doctor

Benji Dhillon – Cosmetic Surgeon

Sabrina Shah-Desai – Aesthetic Oculo-Plastic Surgeon

Wassim Taktouk – Cosmetic Doctor

Understanding Male Tear Troughs

Consultant oculoplastic surgeon Miss Elizabeth Hawkes and speciality registrar in ophthalmology Dr Priya Udani provide an introduction to treating male tear troughs

The post-pandemic aesthetic boom has led to an increase in attendances of patients looking for facial enhancements 1

Cosmetic procedures are increasing in popularity, with men accounting for 13% of surgical and 8% of all non-surgical procedures.2 The American Society of Plastic Surgeons (ASPS) 2020 statistics showed that blepharoplasty was the second most popular surgical procedure in men and non-surgical procedures included botulinum toxin.2 In a culture of mask wearing, eyes have become a bigger focus and an imperative form of facial expression. Hence there is no surprise that eye rejuvenation using both surgical and non-surgical techniques is gaining in popularity. An increasingly common ocular complaint presenting to clinics include that of sunken, dark, tired eyes which are secondary to tear trough deformities. There are many treatment options including toxin, filler, chemical peels, energy-based devices and surgical options. In this article we will discuss the male anatomy of tear troughs, which will aid in appropriate evaluation and selection of suitable treatment.

Anatomy of the tear trough

Surface anatomy

The term ‘tear trough’ corresponds to the periorbital hollow inferior to the medial lower lid that extends obliquely away from the

medial canthus to the level of the mid-pupillary line (Figure 1).3 The sulcus that this forms is at the site where the thin eyelid skin meets thicker medial cheek and nasal skin that is the tear trough deformity.4

The eyelid skin is thinner and there is little subcutaneous fat, and in some patients this area can be pigmented in comparison to nasal and cheek skin.4

Pigmentation can exaggerate the appearance of the depth of the tear trough, hence it is an important factor to consider during a consultation. The reason being that once the tear trough deformity is filled, if the skin remains pigmented hence the ‘dark circles’ remain, which would hinder patient satisfaction of the aesthetic result.

Anatomical development of tear trough deformity

Rhytids can exaggerate the appearance of the sulcus. Orbital fat prolapses and herniation secondary to weakening of the orbital septum can accentuate the appearance of the tear trough, resulting in a cigar shaped central fat compartment, deepening the tear trough.3,4 Advancing age leads to bone reabsorption with volume loss of the inferior orbital rim. The mid-face contributes to the appearance of the tear trough, the volumetric loss of central and medial cheek fat as well as increased prominence of the malar eminence deepens the trough deformity. There is also development of generalised laxity of supporting ligaments in the midface, which results in the gravitational decent of the suborbicularis fat pad (SOOF) causing a descent of the mid-face and subsequently the periorbital region, again exaggerating the tear trough.3,4

Female vs male tear trough

In order to treat the male face, it is important to consider the outcome that you are trying to achieve. Studies have shown

that facial maturity is an attractive feature in males, hence men can be perceived as becoming more desirable as they age.5,6 Even though the basic anatomical structures are the same in both sexes there is significant variability, which results in a masculine and feminine face. Masculine facial features include a prominent supraorbital ridge, resulting in deep set eyes, a prominent glabellar and frontonasal suture, flatter eyebrows which sits at the level of the supraorbital rim, chiselled cheek bones and jaw.7 Feminine features are softer with a flat supraorbital ridge, smooth convexity of the forehead, arched eyebrows extending over the supraorbital rim and an upward tilt of the lateral canthus.7 The periocular changes noted with advancing age stem from the loss of bone from the orbital rim; in females there is receding noted at the inferior orbital rim, laterally, conversely the entire orbital rim recedes in males.8 As the masculine face has bulkier facial muscle, ageing results in loss of subcutaneous fat and tissue, hence deeper set lines are visible at an earlier stage in life.7 Ethnicity also plays a role in the appearance of tear troughs; hyperpigmentation is a common complaint in ageing Asian and darker Fitzpatrick skin tones, which accentuates the appearance of the tear trough deformity.7 Considering the change in facial anatomy with time and noting what surface anatomical changes you can observe, treatment options for tear trough deformities can be considered.9

Dermal filler

To obtain good results from filler, patient selection is imperative. Those who benefit the most from tear trough fillers are patients with good skin tone, minimal laxity and moderate tear troughs with no orbital fat prolapse (Class I patients).9 Patients with laxity of the skin and orbital fat herniation benefit from surgical intervention (Class III patients).9 In the cohort straddling these two groups, results obtained with dermal filler alone may be less than desirable (Class II patients). In some cases, dermal fillers can be used as part of a rejuvenation plan in a surgical patient.10 When treating the tear trough area, it is important to assess the volume loss in the mid-face first. By using a highly cohesive filler via subperiosteal bolus injection in the cheek, the lift would reduce the volume of filler required in the tear trough.11 In male patients it is not advisable to inject large volumes of filler in the cheek, unless desired, as the plumpness of the mid-face would feminise features.12

Figure 1: Surface anatomy of the periorbital area

Lying silkworm Eyebag Tear trough

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Class I:  Volume loss limited medially to the tear trough. May have mild flattening extending to the central cheek area. No bulging orbital fat.

Class II:  Volume loss in the lateral orbital area and the medial orbit, may have moderate volume deficiency and flattening of the middle and upper cheek. Mild to moderate orbital fat bulging.

Class III:  Full depression circumferentially along the orbital rim, from medial to lateral. Severe orbital fat bulging.

Table 1: Tear trough deformity classification4,12

Product selection is important in the tear trough area as the skin is thin and lymphatic drainage is poor, hence highly cross-linked fillers are more hydrophilic and cause swelling in the tear trough area resulting in an unsightly oval bulge.10 There is also a risk of the Tyndall effect with these fillers so it is advisable to run a cannula deep to the muscle to prevent lumpy boluses which may result in a ‘sausage’ appearance in the tear trough.11 Due to the hydrophilic effect of the filler, it is sensible to undertreat and then build as some swelling is expected.9-11

Botulinum toxin

An adjunct to tear trough fillers for Class I and II patients is the use of toxin. As the periocular skin changes in males and lines become more prominent a combination treatment of toxin and fillers results in a better cumulative effect.13 If a slight heaviness of the upper lid is noted, the toxin would raise the eyebrows and open the eyes.13 Due to the increased bulk of facial muscle in men it may appear advisable to inject more units. However, it is important to understand particularly for lateral canthal lines, that these lines are deemed attractive and therefore more advisable to soften rather than eliminate lines.7 The recommended dose of botulinum toxin (Botox) around the eyes is 2.5-5 units per injection at three superficial injection points. For wrinkles under the eye, it is possible to inject a lower dose of 1.25-2.5 units, inferior to the mid-pupillary line.13

Surgical lower eyelid blepharoplasty

For patients with prominent orbital fat prolapse, dermatochalasis and eyelid laxity, surgical treatment may be the most appropriate approach in our experience. Due to the age-related changes of the masculine face regarding receding of the entire orbital rim and loss of subcutaneous fat and tissue,7 surgical treatment is a more common procedure compared to females.2 A lower lid blepharoplasty will address the above. The technique used transconjunctival or transcutaneous approach is dependent on the presentation and anatomical changes of the patient and beyond the scope of this article.14

Simply, a transconjunctival fat repositioning or resection is reserved for younger patients with orbital fat prolapse and good lid tone. Patients with orbital fat prolapse, eyelid laxity and excess skin usually require a transcutaneous approach which would tighten the skin and muscle as well as reposition the fat to smooth the tear trough deformity. 14,15

Chemical peels

Chemical peels can be used as an adjunctive treatment to treat fine lines and dark circles. Dark circles can be exaggerated by the presence of a tear trough deformity; however it can be independent of this. Peels can be used to cause controlled skin damage resulting in rejuvenation and reduced pigmentation of the skin post-healing. Chemical peels in the periocular region must be approached with caution as the thickness of the skin can be as little as 0.2mm.14,15 Male patients require a greater number of treatments to gain desired result as their skin has a more sebaceous quality.16

Energy-based devices

Lasers are used for ablations and resurfacing of the epidermal and dermal layers of the skin via selective thermolysis. The light energy which is emitted by the laser is absorbed by melanin and water, which then go on to emit thermal energy resulting in deep tissue tightening by denaturing collagen and subsequently stimulating production of new collagen.17,18 In a study of 259 patients with facial rhytids where individual responses were evaluated independently by two blinded assessors at one, two, four, eight, 12 and 24 weeks post-operatively, on average CO2 lasers have showed a 90% reduction in rhytids and are suitable for treatment of fine lines around the mouth and eyes.17

The Er:YAG laser causes re-epithelialisation of the epidermal layers and the effect is more rapid and the recovery is faster to CO2 lasers. This laser has more precision than CO2 lasers, therefore is suitable for periocular treatment and also causes less thermal damage, although it reduces the amount of skin tightening that can be achieved.18

Radiofrequency devices work differently

to ablative lasers as their thermal energy penetrates deep into the dermis and subcutaneous fat causing neocollagenesis, which results in skin tightening.19

The combination approach

There are multiple treatment modalities available for tear trough deformity. It is imperative to assess the anatomical changes to determine a suitable treatment modality. Male facial anatomy is vastly different from a female, hence this needs to be taken into consideration. There is not a one size fits all when treating this area and a combination approach is usually required, such as chemical peels for hyperpigmentation and tear trough filler to address a Class I deformity. For a Class II deformity you may also require botulinum toxin, energy-based treatments to aid neocollagenesis and dermal fillers. Finally, with Class III, a surgical lower eyelid blepharoplasty combined with a chemical peel to aid treatment of hyperpigmentation might be required.

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon. She is lead oculoplastic surgeon at the Cadogan Clinic in Chelsea and specialises in blepharoplasty surgery and advanced facial aesthetics. Miss Hawkes is a full member of the British Oculoplastic Surgical Society and the European Society of Ophthalmic Plastic and Reconstructive Surgeons. She is also an examiner & fellow of the Royal College of Ophthalmologists.

Qual: FRCOphth, MBBS, BSc

Dr Priya Udani is a senior registrar in ophthalmology with a special interest in oculoplastics within the NHS. She has an MBBS and a BSc in Human Biology from King’s College London.

Qual: MBBS, BSc

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Case Study: Using Fractional Lasers

Gender considerations when treating with laser

Male patients are particularly good canditates for laser treatment because. Male skin is thicker and heavier than females and facial muscles are stronger.3 Men are also less likely to follow a skin regime and use a sun protectant daily, leading to photoageing and the development of lines and wrinkles. In addition, when considering corrective treatments, although soft tissue fillers are an option, by adding too much volume or not considering male anatomy, there is a risk of feminisation and the amount of correction that can be achieved can be limited.3 Botulinum toxins are useful for the improvement of dynamic lines, but do not address static lines that are present at rest. In my experience, male patients also tend to favour procedures that produce minimal pain, little or no downtime and do not require strict aftercare protocols. As such, non-ablative laser tends to be the preferred option.

Case study

Consultation

Aesthetic medicine is a rapidly evolving discipline with new products and technology appearing all the time and the availability and desire for treatments ever increasing. Lasers have been used for cosmetic purposes for more than 30 years and there have been significant advances, meaning procedures are safer, more effective and there are more indications for their use. Lasers are used for various medical and cosmetic indications including permanent hair reduction, pigmentation, tattoo removal, skin tightening and collagen remodelling, removal of skin lesions, vascular lesions, scarring, thread veins and vaginal rejuvenation.1

The word laser is an acronym for light amplification by the stimulated emission of radiation, where light is part of the electromagnetic spectrum and includes visible light, ultraviolet and infrared wavelengths.1 There are many different types of lasers, dependent on the material used to create the beam, which may be a solid, liquid or a gas, and they all have common characteristics. Laser light is described as monochromatic in that it all belongs to a single wavelength on the electromagnetic spectrum, it is collimated so all waves are parallel, and it is coherent where all peaks and troughs of the waveform are completely synchronised. Laser devices have many variables that can be controlled such as energy and fluence (the amount of energy per unit area), shape, size, stack (several shots fired in the same area), dwell time (the amount of time the laser is firing on one spot), shot density, and scan mode (generally linear, random, or scattered pattern of delivery of individual shots).1

Fractional laser creates tiny dots, leaving healthy surrounding tissue so that pain, recovery, and downtime is minimised. The beam density can be varied according to the area being treated and the outcome desired. Less than 10% of a targeted area is treated creating thousands of microscopic thermal zones in the skin which stimulates repair and regeneration of the whole area but leaving the stratum corneum relatively intact leading to little or no downtime following the treatment.2

A 60-year-old male with Fitzpatrick skin type II and extensive dermatoheliosis presented to my clinic. He was concerned about his general appearance, but mostly the static lines and wrinkles over his cheeks, perioral and periocular areas. He had previously had botulinum toxin treatments, but despite this, many of the lines around his eyes had remained. He had no relevant medical history which would make him unsuitable for aesthetic procedures such as lasers.4 During the consultation, different treatment options were discussed. He lacked volume in the malar area and with some ptosis of the tissue, this created more pronounced nasolabial folds, which could be corrected with soft tissue fillers, but it was not felt that this would really address his concerns because the lines were too superficial. The use of hydrating and bioremodelling hyaluronic acid treatments was also considered, but the lines appeared a little too deep to address these. This is because hydrating fillers improve fine lines and crepiness, but when there is extensive dermal damage and disruption, these products can only offer minimal improvement. He was also interested in a treatment that would be more longer lasting. Finally, we discussed the pros and cons of microneedling or non-ablative fractional laser and after understanding the procedure, the downtime, side effects, risks, complications and seeing some before and after photographs, we agreed that laser would be his best option. The patient was provided with written information and aftercare and a patch test was performed. This did not produce any adverse effects and he was scheduled for treatment a week later. It is recommended to perform a patch test at least 48 hours prior to treatment for Fitzpatrick skin types I to III and for seven days in those with skin types IV to VI.5

Treatment

After completing a consent form, the patient’s skin was cleansed and disinfected with a non-alcohol based antiseptic and a topical anaesthetic applied for 30 minutes. Treatment was carried out using the Juvium non-ablative Erbium 1550 nm laser. A non-ablative laser produces limited thermal damage without causing vaporisation of the tissue and has less downtime, complications, discomfort, and side effects than ablative lasers, although results obtained will not be the

Dr Martyn King presents a case study demonstrating the effects of fractional lasering on the male face

same as an ablative laser and more treatments may be required.6 A wavelength of 1550 nm is not part of the visible spectrum but in the infrared B band and is able to penetrate the epidermis to target water molecules in the dermis. It works on the principle of fractional photothermolysis, laser energy is absorbed by water molecules, producing heat and controlled trauma within the target area. This stimulates the body’s healing response, leading to collagen production and skin remodelling.6

Before we purchased this laser in our clinic, we used a fractional CO2 laser, however there is significantly more downtime, swelling, redness, visible dots on the face after treatment and a higher risk of burns and complications compared to our current device, hence the reason for switching. Results from treatment with both devices have been comparable.7 The procedure was performed using the AccuTip 10x10mm handpiece and the shape and size of the beam was adjusted according to the area of the face being treated to ensure full coverage with no overlap. The AccuTip is one of three headpieces that can be used, allowing a treatment area from 10mm to 20mm maximum size. As the patient was having a full-face treatment, a smaller size was used, which is generally better tolerated although treatment time is longer. The shot density was 350 per cm2 and reduced to 250 per cm2 for above the lip and the energy level set at 35mJ and reduced to 25mJ for the nose, chin and above the lip. Cooling was applied during the procedure using the CryoShot, which can deliver a blast of cooled air up to -10oC for patient comfort. A medical plume extractor with 0.01 micron filtration was used as surgical masks alone are not sufficient to block nano-particles in laser plume, which may contain bacteria, viruses and blood.8

Post-treatment

The patient tolerated the treatment well, with only minimal discomfort. Immediately afterwards, there was moderate erythema and visible reaction of some of the superficial blood vessels. A cooling hyaluronic acid mask was applied for 10 minutes and then a vitamin B5 serum and high-protectant (SPF 50) before the patient left the clinic. Most of the redness of the skin had settled by this time and the patient reported no inflammation, flaking of the skin or other adverse effect over the following days. Aftercare advice included avoiding exfoliating products for a week, avoiding sun exposure and tanning for four weeks, and the use of a high protectant sunscreen. We recommended that the treated area should be cleansed with tepid water (hot water should be avoided for a few days after treatment) and gentle soap and patted dry before applying a simple moisturiser. I suggested that if he experienced any pain, swelling or inflammation, simple painkillers and cold packs could be used as required.9 The patient returned for a further two treatments at four weekly intervals using the same settings as the initial treatment. Before and after photographs were taken and the patient reviewed. Six weeks

Before After

later, he was delighted with the results, felt that it had addressed his areas of concern and was keen to proceed with further laser treatment to maintain his results and for targeting the hooding of his upper eyelids. He has since recommended several other people to have this treatment.

Potential complications

The greatest complication from Erbium laser is the risk of ocular injury. 1550 nm can penetrate the retina and can cause complete and irreversible blindness and so it is essential that certified eye protection is used during the procedure and whenever the laser is in operational mode. Goggles with an optical density of at least five are required by the practitioner, and metal eye shields or disposable laser eye shields need to be worn by the patient. The room needs to be locked, or an interlock installed, and optimised for laser treatments by removing all reflective surfaces. Warning signs and lights should be present outside the room to alert people when the laser is switched on. Erbium 1550 nm laser has a nominal ocular hazard distance (the distance where eye injuries can still be obtained) of over three miles.10 Other side effects and complications may include discomfort, which can be managed using appropriate analgesia, and redness, inflammation, and irritation which can be treated with cold packs, antihistamines and topical steroids if needed. Burns, blisters and crusting can occur if too much energy is applied to the skin, so topical medications and wound management may be needed. However, minor episodes will usually heal spontaneously without any intervention. Hyperpigmentation may occur, but this is often temporary, and tyrosinase inhibitors should be considered pre-treatment in those individuals who are at a higher risk, and lightening creams may be needed if it has already developed. Judicious use of a SPF 50 sunscreen will lessen this risk substantially. Hypopigmentation is also a documented side effect that can occur very rarely.10

Conclusion

Non-ablative Erbium 1550nm laser is a safe and effective treatment for lines, wrinkles and skin tightening. It is a particularly popular treatment for men due to it being virtually pain free, with little downtime, minimal aftercare and long standing results, not requiring regular maintenance treatments. It can be used complementary to other aesthetic procedures or as a stand-alone therapy. Several treatments are usually required but there is very little or no downtime or discomfort from the procedure.

Dr Martyn King is a GMC registered doctor and the director of Cosmedic Skin Clinic, Cosmedic Online and Cosmedic Pharmacy. He is medical director of the ACE Group World, vice-chair of the Joint Council of Cosmetic Practitioners, a member of the British College of Aesthetic Medicine and board member for the British Association of Sclerotherapists.

Qual: MBChB, MSc, PGDip, PGCert

Figure 1: 60-year-old patient before and after fractional laser treatment

FEEL GOOD

LOOK GOOD

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

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

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard for the UK. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

*Botulinumtoxin type A, purified from cultures of Clostridium Botulinum (Hall strain)1

References: 1. BOCOUTURE® (incobotulinumtoxinA) Summary of Product Characteristics. Merz Pharmaceuticals GmbH. 2. Vistabel® (onabotulinumtoxinA) Summary of Product Characteristics. Allergan Ltd. 3. Dysport® (abobotulinumtoxinA) Summary of Product Characteristics. Ipsen Ltd. M-BOC-UK-0443 Date of Preparation: December 2021

is the only toxin that can be transported and stored prior to reconstitution without the need for cold chain1–3

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PRP offers patients a natural treatment result without the use of foreign substance.

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Optimal platelet concentration of 2.5 x increased over baseline, which improves skin texture, wrinkles as well as firmness. 2

Secretion of autologous hyaluronic acid which is stimulated effectively by a platelet concentration in this range. 3

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1 Wang X et al. Fluid platelet-rich fibrin stimulates greater dermal skin fibroblast cell migration, proliferation, and collagen synthesis when compared to platelet-rich plasma. J Cosmet. Dermatol. 2019;1–7.

2 Aust M. Platelet Rich Plasma (PRP): eine sichere und effiziente Therapieoption zur Hautverjüngung. HAUT 2019;30(5):210-213

3 Anitua E et al. Fibroblastic response to treatment with different preparations rich in growth factors. Cell Prolif. 2009 Apr;42(2):162-70. doi: 10.1111/j.1365-2184.2009.00583.x. Epub 2009 Feb 24. 4 Nacopoulos, C. & Vesala, A. M. Lower facial regeneration with a combination of platelet-rich fibrin liquid matrices based on the low speed centrifugation concept-Cleopatra technique. J Cosmet Dermatol 19, 185-189, doi:10.1111/jocd.13196 (2020).

Exploring The Male Face With Threads

Dr Victoria Manning and Dr Charlotte Woodward discuss how to treat men with threads

We are seeing more men than ever seeking to enhance their appearance and reduce the signs of ageing by harnessing the effectiveness of non-surgical clinical treatments.1 At our clinic, around 10% of our patients are male, and this number is growing year on year. Typically, we find that male patients are seeking treatments which ensure they are ‘naturally’ enhanced and importantly, do not feminise their appearance in any way. Subtlety is key, and like our female patients, they are very reticent to have any treatment that leaves them looking like they have had ‘work done’. Generally speaking, we now enjoy a greater cultural acceptance of aesthetic treatments, which has undoubtedly contributed to higher numbers of men seeking treatment.2 Procedures like dermal fillers and toxins have paved the way for thread lifts, which are thought of as the next ‘step up’ for lifting, contouring, and defining an ageing male face.

It’s well known that a chiselled jawline and strong chin are characteristic and classically preferable male features. It is important to recognise that while a man’s indications and motivations to seek treatments will be similar, male and female patients require very different treatment protocols to restore the correct desirable features.3

Threads are particularly suitable for enhancing facial definition by addressing sagging skin, and they are effective for treating male jowling, marionette lines and nasolabial folds, as well as addressing facial asymmetry.4 We always educate our patients that facial rejuvenation is a combination approach to volume, skin laxity, and skin texture and we frequently use a two-phased approach of filler and threads to give men the maximum results possible for a lift through the mid-face.

In our experience, thread treatments are particularly popular with our male patients who are typically aged between 40-55 years old. Most attend the clinic actively requesting thread lift treatment, having undertaken their own, in-depth research online.

Anatomical and physiological considerations when treating male patients with threads

There are a number of factors that must be considered before embarking on thread treatment for men. Male skin is thicker than female skin, resulting in a deeper dermis, and a greater volume of subcutaneous, fibrous tissue.5 Therefore, as when treating both genders, it is paramount to be aware of the five layers: skin, superficial fat, the superficial muscular

aponeurotic system (SMAS), deep fat and bone. With threads, we are addressing the superficial fat layer. Knowledge of these layers is important to understand the ageing process and the development of a successful treatment strategy.5

The thickness of the male skin and the fact that biologically male faces are larger than female faces means that the tissue to be repositioned and lifted by the threads is heavier. As a result, the depth of thread placement is typically deeper than that of female patients.5 In general, thread placement in females is about 5mm to reach the subcutaneous layer, and in males this is about 8mm.5 Besides facial hair, there are structural differences between the skin of men and women. Androgen stimulation causes an increase in skin thickness, which accounts for why a man’s skin is about 25% thicker than a woman’s.5 In addition to being thicker, a man’s skin texture is tougher 5 While female beauty mostly lies in the cheekbones, male attractiveness is thought to be in the chin and a stronger masculine appearance can be achieved by creating a square chin.6 Mandible projection is more acceptable in men; the chin is flatter and wider and has the same width of the mouth. In female patients, the width of the chin is the same as that of the nose and it also corresponds to where most of the volume of the lips is.6

Generally speaking, we now enjoy a greater cultural acceptance of aesthetic treatments, which has undoubtedly contributed to higher numbers of men seeking treatment

Laxity scale Key indications of ageing

Entry level

Mild

• No sagging

• Mild dynamic lines

• Mild sagging and loss of skin quality

• Looking for beautification or rejuvenation

• Transverse forehead rhytids, lateral canthal lines and glabellar frown lines, nasojugal groove, nasolabial fold, marionette lines

Recommended treatment protocol

• Correcting minimal imbalances

• Hyaluronic acid filler for specific complaints such as nasojugal groove, thin lips, nose deformities, bone imbalance and masculinisation of the face

• The approach of muscular hyperactivity with botulinum toxin (BoNT) should only focus on the upper third

• Treatment of dynamic lines with BoNT should focus on the upper and lower third, with injections in the depressor angulis oris muscle and platysma muscle

• Combination of dermal filler and thread lift treatment in the first session, followed by a second session of dermal filler for refinement. Suggested products: Ellansé, Silhouette Soft

Moderate

• Moderate sagging and increased loss of skin quality

• The transverse forehead rhytids and glabellar frown lines are deep and at rest, sunken temples, nasojugal groove, nasolabial fold and marionette lines are more prominent. Less bone prominence (zygomatic arch and mandible angle)

• Lengthening of the lid cheek junction

• Energy based devices and botulinum toxin for the upper, lower third and neck

• Dermal filler: first treatment – volume replacement and biostimulation

• Threads: second treatment – reposition

• Dermal filler or HA: third treatment – refinement

Severe

• Severe sagging and significant loss of skin quality

• All the signs of age (sunken temples, zygomatic arch and mandible angle less prominent, deeper nasolabial folds and marionette lines)

Treatment strategy for the male lower face

To develop a successful treatment plan, a consultation and detailed medical assessment should be carried out. Practitioners should ensure there are no contraindications to treatment, such as a history of autoimmune disease, blood thinner medication, unrealistic expectations for example.7 After exploring the patient’s aesthetic ideas, concerns and expectations, a comprehensive facial analysis must take place. Anterior, lateral and dynamic assessment of the lower face should be performed, including assessment of vectors, fat pad distribution and degree of skin laxity.

It is important to keep in mind how the male face will specifically age when deciding on treatment. Understanding the ageing process of the male lower face tends to follow a sequence of events:8

1. Atrophy of deep and superficial fat

2. Dehiscence of the mandibular septum, resulting in the ptosis of both fat compartments

3. Gradual loss of definition of the jawline as bone is resorbed and remodelled, starting around 35 years, leading to loss of height and length and a more obtuse mandibular angle, chin retraction and more appearance of pre-jowl sulcus

As clinicians, it is important that we consider the forces that individual threads will be placed under and ensure that the weight is correctly distributed. We find that male patients typically benefit from

• Plastic surgery is required

• If the patient is unable or unwilling to undergo a surgical procedure, combined treatments protocol will be indicated

• Energy based devices + botulinum toxin + dermal filler + threads + HA, advisable for optimal results

more threads per treatment than females to ensure the correct force distribution, and more thread cones to enable a greater area of skin and fat pad to be lifted. For my male patients, we prefer to use threads with 12 cones, as opposed to our female patients, where we typically use eight cone threads. The larger male face allows the longer thread to be used without extruding cones on tightening of the thread.

Clinicians must always be mindful that when injected correctly, thread treatment does not feminise the face, unless this is the desired effect. In our male patients, we typically insert threads lower, near the jawline and more vertically in the mid-face than we do for our female patients to ensure maximum lift through the mid-face via perpendicular vectors to improve jawline definition.

Combining treatments

We often recommend male patients combine thread lifts with other non-surgical treatments to maximise and enhance the result.

Restoration of mandibular and chin projection is essential when treating age-related changes of the male lower face. In our experience, this is best achieved by layering dermal fillers deep in the supraperiosteal plane and at the level of the superficial fat, in addition to placing threads in the subcutaneous layer.9

We pay particular attention to chin projection, and lateral mandibular projection from the anterior view. The male chin, as discussed, is wider, with the width usually corresponding to the width of the mouth.10

For example, to address marionette lines and nasolabial folds, and have associated volume loss in the buccal hollows, we administer filler (typically Ellansé which is also a biostimulator)

Complete care concepts for every skin type.

for more information visit www.dermaroller.com

Dr Charlotte Woodward is an aesthetic practitioner and GP with more than 25 years’ experience. She is the co-founder of River Aesthetics in Bournemouth, New Forest and Wimpole Street, which specialises in thread lifting and feminine rejuvenation. She pioneered the UK’s first non-surgical breast lift in the UK using threads and is a national trainer for PDO threads.

Qual: MBCHB, MRCGP, MBCAM

Dr Victoria Manning is an aesthetic practitioner and GP, with more than 22 years’ clinical experience. She is the co-founder of River Aesthetics in New Forest, Dorset and Wimpole Street. She is a global trainer, speaker and KOL for Sinclair Pharma’s Silhouette Soft, Ellansé and MaiLi range and an aesthetics industry media contributor, writer and speaker.

Qual: BM, DFFP, MBCAM

REFERENCES

to the area two weeks before thread treatment. In our experience, this ensures the depth of the thread insertion can be maintained for the subsequent repositioning of the tissue. For treatments to restructure the chin and jawline (a particular area of interest to our male patients) threads are placed in phase one of the treatment to reposition tissues which have migrated south as part of the ageing process. This is then followed by the use of collagen stimulating fillers to create the chiselled definition along the jawline and add lost volume.

Side effects and guidance

Clinicians must always be mindful that when injected correctly, thread treatment does not feminise the face, unless this is the desired effect

Common short-term side effects including bruising, swelling, dimpling, temporary skin contour irregularities, and puckering.7 While post-treatment care is the same for both sexes, male patients tend to find it more of a challenge not to touch their faces or perform large movements, including exaggerated yawning, and exercise posttreatment than female patients. Patients should be reminded frequently during and after treatment what protocols they should undertake post-treatment, particularly stressing the importance of hand hygiene to ensure the entry and exit points of the needle do not become infected. It is important to ensure that patients have realistic expectations of treatment results and longevity. They are advised thread treatment will last 15-18 months, which of course depends on the products chosen; however, like a car’s yearly service, if patients are keen to maintain results for as long as possible, repeat treatments are necessary.11

A growing interest in threads

Interest and demand for male thread treatments continue to grow, as male patients embrace the growing evidence for the effectiveness of the treatment to treat their ageing concerns. Clinicians should be mindful of the physiological differences male patients present with, paying particular care to depth of thread placement, force distribution on each thread and the desired result of defined, masculine features that male patients require.

1. Cosmetic Physicians College Australia, ‘The Changing Face Of Male Cosmetic Surgery In Australia’, 2016, <https://cpca.net.au/ wp-content/uploads/2017/03/24-03-2017_Mens_trends_in_ cosmetic_ surgery.pdf>

2. Monheit GD, Prather CL, ‘Hyaluronic Acid Fillers for The Male Patient, Dermatol Ther, 20(6): 394-406, 2007

3. Wieczorek IT, et al. Injectable Cosmetic Procedures for the Male Patient, J Drugs Dermatol.;14(9):1043-1051, 2015

4. Guida S, Persechino F, Rubino G, Pellacani G, Farnetani F, Urtis GG, ‘Improving Mandibular Contour: A Pilot Study for Indication of PPLA Traction Thread Use’, J Cosmet Laser Ther. 2018 Nov-Dec;20(7-8):465-469. Doi: 10.1080/14764172.2018.1427875. Epub 2018 Feb 20. PMID: 29461124.

5. Firooz A, Rajabi-Estarabadi A, Zartab H, Pazhohi N, Fanian F, Janani L, ‘The Influence of Gender and Age on the Thickness and Echo-Density of Skin, Skin Res Technol, Feb;23(1):13-20. Doi: 10.1111/srt.12294. Epub 2016 Jun 8. PMID: 27273751, 2017

6. de Maio, M, ‘Ethnic and Gender Considerations in the Use of Facial Injectables: Male Patients’, Plastic and Reconstructive Surgery, November Supplement, Volume 136, Number 5S, 2015

7. Li YL, Li ZH, Chen XY, Xing WS, Hu JT. Facial Thread Lifting Complications in China: Analysis and Treatment. Plast Reconstr Surg Glob Open. 2021 Sep 17;9(9):e3820

8. Reece EM, Pessa JE, Rohrich RJ., The Mandibular Septum: anatomical observations of the jowls in aging-implications for facial rejuvenation’ Plast Reconstr Surg, ;121:1414–1420, 2008

9. Mommaerts MY, ‘The Ideal Male Jaw Angle – An Internet survey, Journal of Cranio-Maxillo-Facial Surgery, 44 381e391, 2016

10. Venkman MJ, et al., ‘Role of Nonsurgical Chin Augmentation in Full Face Rejuvenation: A Review and Our Experience’, Dermatol Surg, 00:1–9, 2018

11. Paola Roasalba, Franco Vercesi et al. ‘Histological findings after insertion of PLLA sutures with bi-directional cones in human: Two years follow up’, Journal of Plastic and Pathology Dermatology, 2018 Vol 14

Figure 2: 50-year-old patient before and six months after treatment with two pairs of eight cones using Silhouette Soft threads. Image supplied by Sinclair Pharma

Introducing the Latest Innovation from SkinCeuticals: NEW Phyto A+ Brightening Treatment

The newest member of the Phyto family, Phyto A+ Brightening Treatment, is a lightweight moisturiser that soothes inflammation and corrects hyperpigmentation for a brighter complexion. Patients in search of brighter skin can face challenging obstacles when using ingredients such as acids, hydroquinone and retinols, as for some they can create secondary skin concerns such as visible redness, post-inflammatory discolouration and blemishes. Not all skin types can tolerate these ingredients and therefore patient noncompliance is not uncommon and can result in dissatisfaction with results. By tackling and modulating three key common skin complaints; dullness, rough texture and visible redness, patients can achieve bright, smooth and clear skin. SkinCeuticals Phyto A+ Brightening Treatment is a silicon-free and noncomedogenic formulation containing:

• 2% ALPHA ARBUTIN – helping to even skin tone and reduce pigment production

• 3% AZELAIC ACID – improves cell turnover and balances oil production, resulting in smoother skin

• 5.75% PHYTO BOTANICAL BLEND – modulates inflammation to calm and soothe the skin

Phyto A+ Brightening Treatment helps in the following three key areas:

• Lack of cell turnover which causes dullness, visible pores and imperfections

• Inflammation that gives a visible redness in the skin

• Excess melanin production which contributes to an uneven skin tone

Dermatologist Professor Firas Al-Niaimi commented, “Until now, for most patients our approach as dermatologists has been to improve the look of the skin using ingredients and treatments available to us that exfoliate the skin on the face and we use products with high levels of actives to do so, some of which can cause mild irritation. It is true to say that not all patients are able to or wish to tolerate dryness or redness that retinoids, for example, can cause. It is good to have an

alternative that addresses the three main contributing factors to dull skin without clogging pores or introducing unnecessary ingredients to the skin.”

Product results

After a 12-week clinical trial, Phyto+ Brightening Treatment is proven to:

• Brighten – reducing post blemish marks by 20%*

• Smooth – improving rough skin texture by 19% *

• Clarify – reducing pore clogging surface oil by 28%*

By modulating the three skin pathways to brighter skin; dullness, inflammation and pigmentation, patients can receive clinically proven results without irritating the skin.

SkinCeuticals brand background

Born from decades of research, SkinCeuticals’ high potency formulas are proven to absorb optimally into the skin. Our mission is to improve skin health. Dedicated to this purpose, we make one simple promise – to provide advanced skincare backed by science. Made in the USA, we provide complete skincare solutions recommended by dermatologists, plastic surgeons, medispas and other skincare professionals worldwide to both correct the appearance of the signs of ageing and help prevent future damage.

This advertorial was written and supplied by SkinCeuticals

Speak to your SkinCeuticals representative for more information on NEW Phyto A+ Brightening Treatment and the full Phyto range.

If you do not have a dedicated contact please email contact@skinceuticals.co.uk.

*Protocol: A 12-week, single centre, clinical study on 64 male and female subjects, aged 18-55, Fitzpatrick I-VI, with normal to oily skin types and mild to moderate skin discoloration and rough texture. Phyto A+ Brightening Treatment was applied to the face twice a day in conjunction with a sunscreen. Evaluations were conducted a baseline and at weeks, 2, 2, 8 and 12.

A science-based approach to improving radiance, texture, and clarity to help correct out-of-balance skin

A summary of the latest clinical studies

Title: TULUA Male High-Definition Abdominoplasty

Authors: Babaitis R, et al.

Published: Plastic and Reconstructive Surgery, January 2022

Keywords: Abdominoplasty, Lipoabdominoplasty, Surgery

Abstract: Abdominoplasty is a surgical technique for body contouring that has been shown to improve the patient’s quality of life. It has become more common among male patients, so differences between procedures for men and women have to be stated. The authors present their experience with high-definition lipoabdominoplasty with transverse plication in men. Records of male patients undergoing transverse plication full abdominoplasty in addition to high-definition liposculpture were analysed. 24 consecutive cases were found between January 2017 and June 2019. Patient ages ranged from 24 to 60 years. Body mass index ranged from 25 to 33 kg/m2. Photographic records were taken before and during follow-up at two days and one, three, six, and 12 months after surgery. Male TULUA (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar) with high-definition lipoabdominoplasty was achieved in 24 cases. Six minor complications were reported. Rectus abdominis diastases are less common in men compared to women, as pregnancy is the most determining factor in its development. Fat distribution is a difference when performing lipoabdominoplasty for the male or the female patient. The authors recommend a transverse plication of the abdominal wall, instead of a vertical one, as flap viability is preserved and enhanced muscular definition can be accomplished. Combining transverse plication with high-definition lipoabdominoplasty is a safe and reproducible technique for the male patient.

Title: Treatment with Oral Vitamin D Alone, Topical Minoxidil, or Combination of Both in Patients with Female Pattern Hair Loss

Authors: Hassan G, et al.

Published: Journal of Cosmetic Dermatology, January 2022

Keywords: Female Pattern Hair Loss, Treatment, Vitamin D

Abstract: One of the most common dermatological complaints among female is female pattern hair loss (FPHL). Serum vitamin D is a factor taken into consideration in approaching patients complaining of hair loss. The study aimed to evaluate the serum level of 25-hydroxy vitamin D in patients with FPHL and the efficacy of vitamin D therapy alone or combined with minoxidil in the treatment of this disease. 45 patients with FPHL and 15 controls to measure serum level of vitamin D were enrolled. Patients were subdivided into three groups: group I received topical minoxidil and oral vitamin D, group II received topical minoxidil, and group III received oral vitamin D for six months. Clinical and dermoscopic evaluation was done for the three groups before and after treatment. Vitamin D level was decreased in patients compared to controls. After treatment, as regard to the Ludwig scale, there was significant improvement in group I than II while no improvement was found in group III. Dermoscopy revealed that thin hair and single-hair unit were significantly improved in groups I and II, while it was not significantly improved in group III. Oral vitamin D combination to topical minoxidil is recommended to treat patients with FPHL; they had better results than vitamin D or topical minoxidil alone.

Title: Improvement of Facial Skin Laxity by a Combined Technique With Hyaluronic Acid and Calcium Hydroxylapatite Fillers

Authors: Bravo B, et al.

Published: Journal of Drugs in Dermatology, January 2022

Keywords: Ageing, Dermal Filler, Hyaluronic Acid

Abstract: The current objective of cosmetic facial filling is to re-establish the overall aspect that was lost during the ageing process. Hyaluronic acid (HA) and calcium hydroxyapatite (CaHA) fillers are indicated for facial rejuvenation, and promote dissimilar effects regarding volume restoration and dermal biostimulation. This study aimed to assess clinical and ultrasonographic improvements in facial skin laxity using a technique that combines the injection of HA and CaHA. A 120-day follow-up, quasi-experimental study was conducted based on the enrolment of 15 women with mild face flaccidity scores who underwent subcutaneous injection of up to 3mL of HA (zygomatic-malar region, pyriform aperture, temporal region, and jaw) followed by 3mL of 1:1 diluted CaHA using a fan technique (temporal, zygomatic-malar, and jaw regions). Adverse effects were registered, and monthly assessed outcomes included clinical improvement, satisfaction, and high-frequency ultrasonography parameters. At 120 days of follow-up assessment by blinded physicians yielded six (40%) very improved patients and nine (60%) exceptionally improved. All participants were satisfied with the results and reported improvement. Dermal thickness increased 11.1% and augmented dermal homogeneity was evidenced by ultrasonography. Local adverse effects were mild and transient. The combined technique with HA and CaHA fillers was well-tolerated and yielded high satisfaction and safe improve in facial skin laxity and dermal thickness.

Title: Therapeutic Effects of New Pulsed-Type Microneedling Radiofrequency for Refractory Facial Pigmentary Disorders

Authors: Park B, et al.

Published: Dermatologic Surgery, January 2022

Keywords: Microneedling, Pigmentation, Radiofrequency Abstract: The aim of this study was to evaluate the efficacy and safety of a pulsed-type RF microneedling device for treatment of facial pigmentary disorders. 45 patients diagnosed with facial melasma or Riehl melanosis received five treatments with RF at two-week intervals, and evaluation was performed at each visit, including four and eight weeks after the last treatment. Treatment outcomes were evaluated by investigator global assessment, patient global assessment score, and skin biophysical parameters of erythema index, melanin index (MI), and transepidermal water loss. Gene array and immunohistochemical staining including melan-A, Fontana silver, CD44, basic fibroblast growth factor (bFGF), and periodic acid-Schiff were performed. Most patients showed clinical improvement. Erythema index, MI, and transepidermal water loss decreased after the first treatment. Histopathologic examination showed decrease of melanin pigment, melanophages, and blood vessel proliferation but thickened basement membrane after treatment. Expression of CD44 and b-FGF was decreased after treatment. No serious adverse events were reported.

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Balancing Your Marketing for Clinic Growth

What is owned media?

Owned media is the content you have on platforms you own, where you have complete control over the message, design, and branding. They belong to you; you aren’t paying for space or promotion. A typical clinic’s owned media platforms:

• Website – needless to say, you own your website. Your key pages such as the impact of your homepage, treatment/condition landing pages and any content you share on them

• Email database – your email database, opted in subscribers from your patient database

• Physical media in-clinic – for example printed media such as posters and flyers, displays on TV screens

Growing an audience who see this owned media has the highest potential to drive enquiries to your clinic. Your website should contain key information on landing pages about the treatments and products available and make it simple to contact the clinic in multiple ways (for example, contact form, phone, chatbot).

The emails your clinic sends work to keep current patients retained and continually engaging and booking appointments. Getting sign-ups from interested parties who aren’t yet opted into marketing is possible by offering incentives such as subscriber-only offers, downloadable skincare guides and early access to new treatments.

Some argue that social media fits into owned media, as you do control the messages and the design that goes out. However, you do not entirely control the distribution and visibility of the content. You will find that visibility changes over time at the mercy of algorithms. The focus should be on the profile information, once somebody finds your content on your platform, with details on reaching your true owned media.

What is earned media?

Clinics cannot avoid the modern business need of putting out content to attract and retain patients. It is my opinion and commonly agreed that content which educates, entertains and inspires works at every stage of the buying and selling process. For most, a clinic’s main focus is usually putting out content on social media. However, the six-hour Facebook outage of October 4, which cost the platform $79m in revenue alone,1 showed us the fragility of heavy reliance on social networks for clinic marketing. Businesses have become more reliant on Instagram, Facebook and WhatsApp to generate leads and run their operations, but this outage presents clear reasoning for growing and improving audiences and databases you own and spreading out your digital marketing efforts to mitigate against social media companies’ outages and constant algorithmic changes.

We have the opportunity to deliver content to patients in three broad avenues: owned media, earned media and paid media. All three play an important role in marketing your clinic to the public and to current patients. Where ‘organic vs paid’ marketing gives you a crude understanding of where different platforms fit into the bigger picture, looking at owned, earned and paid gives a broader perspective and allows you to identify overlaps that can save you time and effort in content production.

Earned media is any third-party mentions of your brand, such as: PR activity, shares of your owned media, guest posts, reviews. Earned media builds brand awareness and is like a modern-day word of mouth which establishes credibility, and is becoming increasingly important in a growing industry such as medical aesthetics. These mentions can be written, video or audio.

Although earned media does have its important place in business promotion, the difficulty here is that you cannot control third-party mentions of your clinic or practice. This does leave you exposed to inaccurate or negative mentions. Review platforms are a priority for clinics, as consumers are more researched than ever; gathering reviews for free via the Google My Business (GMB) platform which allows potential patients to compare practitioners. Whether you use a free platform such as GMB or a paid review platform, they should be regularly monitored for negative posts.

If you’re submitting content to a third party, you can of course control the message, but the owner of the platform may opt to remove this content at any time, for example a post on a local website promoting your business can be edited by the owner, and may be taken down. The return on investment of earned media is more difficult to track than that of owned media. Resulting enquiries which come directly from this are not built into your systems, so may be harder to attribute directly to earned media efforts. This is because unless you ask explicitly at enquiry about how a new patient found you, they may not credit the PR activity or first discovery of you not on your own platforms – a click to your site from a piece in a newspaper site can be tracked, but not via print.

Whether you’re engaging in PR activity or not, you can track your mentions across the internet for free by setting up Google Alerts. Use your name and your brand terms to monitor this. This allows you to stay on top of what’s being said about you online, and allows you to address it if necessary.

What is paid media?

Paid media is exposure you pay for. It covers pay-per-click (PPC) where an advertiser pays a publisher when the ad is clicked on, for example social media advertising, YouTube ads, print advertising, advertorial and other digital sponsored content. Although they can be impactful, ad blockers and an individual’s own scepticism on sponsored content are roadblocks to paid media as they can choose not to see it.

Paid media is effective to pay to promote key lead-generating pages – such as treatment or condition pages – on your owned media platforms. It is more effective than owned media for generating leads, as prospective patients are further along the buying journey when searching directly for a treatment on a search engine. The buyer intent here is high and the paid media earns the click, but for PPC, it relies on strong owned media to generate the lead. Remember this when investing in paid media. How the enquiry is taken and handled is just as important as generating leads cheaply on search engines or social media.

Where social media fits in Social can sit across all three types of media. These are your owned social channels, so you can control the message, but the artificial intelligence behind sites like Instagram, Facebook and Twitter show ‘personalised’ feeds, which will affect the visibility – organically you won’t see 100% of your social media audience viewing your post anymore.

Your social also competes on pages with ads, posts from other accounts (Facebook has 2.8 billion users and Instagram has 1.3 billion2) and suggested content based on a user’s interests. So, the part you own on social media, you no longer get to guarantee that a follower will see it.

Clinics can also pay to promote their social media, not just via ads; I find that guest posts and influencers are great for reaching new audiences. Working with influencers blends into owned, earned and paid types of media; you can be involved with the creation of the post, control the wording, pay for the promotion and tag in your business (the Advertising Standards Agency may catch up with you if you don’t), but it visually appears as earned media. Again, this content is at risk of being removed, and is harder to attribute leads to.

Combining owned, earned and paid media

A solid marketing plan may neglect the channels you already own in favour of social and PR efforts, but it’s my view that working on owned media should be a priority. Using the links in your social media bios strategically can drive traffic to your website, bookings and email sign-ups. It’s your choice depending on your goals or promotions, which page you send them to, or you can use a multi-link landing page such as Linkinbio. Growing traffic to your website will not only generate leads but improve your search engine optimisation (SEO), as it signals to search engines that this is a popular and useful website or specific page on the internet. This ranks your website higher than your competitors on Google, which grows traffic further, and generates leads. This is a positive feedback loop, so focus on driving traffic to the clinic website from social media wherever possible. A clinic mailing list can be so much more than a boring newsletter. Offering downloads and gifts for sign-ups, running giveaways via social media to grow this list and then delivering educational or inspiring content will lead to subscribers and potential patients and increased business. Even industry efforts like writing for publications such as the Aesthetics journal can be used to send traffic to a part of your website, despite the fact that you won’t own the copyright and will need permission to publish. If you’re interested in building an industry profile, having a professional section on your website to publish media on your terms is a great way to help brand awareness and secondarily generate leads through improved SEO.

Getting the mix right

Combining owned, earned, and paid efforts will generate the right digital marketing mix for any aesthetic clinic. Too much focus on one tactic, channel or distribution will leave a clinic at a disadvantage. There’s no one-size-fits-all approach to content marketing that suits an aesthetic clinic, so experimenting with different media channels, doing research and tracking leads allows you to learn where to invest your time and effort. Understanding owned, earned and paid media channels allows clinics to plan their marketing efforts. For servicebased businesses, owned media is often underestimated. Having a plan that covers all three and aims to drive traffic to your website and email list will increase brand awareness and generate enquiries.

Alex Bugg is a content marketer and industry educator, working for family-run web agency Web Marketing Clinic. Bugg is an Aesthetics Awards judge and speaks at events across the country. She received an MSc in Immunology from the University of Leicester in 2016.

REFERENCES

1. Glenday, J., 2021. Facebook’s six-hour outage costs an estimated $79m in ad revenue loss. The Drum. %26lt;https://www.thedrum.com/news/2021/10/05/facebook-s-six-hour-outage-costs-estimated79m-ad-revenue-loss%26gt; , 2021

2. Business Of Apps, Instagram Statistics, %26lt;https://www.businessofapps.com/data/instagramstatistics/%26gt;, 2022

3. Advertising Standards Agency, Influencers Guide, %26lt;https://www.asa.org.uk/resource/influencersguide.html%26gt;, 2020

4. WordPress, SEO, %26lt;https://www.wpbeginner.com/wordpress-seo/%26gt;, 2022

11 & 12 MARCH 2022 / LONDON

Alex Bugg will be speaking at the In Practice agenda at ACE on 11-12 March at the Business Design Centre, London Scan the QR code to register for free.!

It is my opinion and commonly agreed that content which educates, entertains and inspires works at every stage of the buying and selling process

Ultrasound is used throughout medicine as a convenient, painless, reliable and relatively inexpensive diagnostic tool. Ultrasound can determine anatomy, pathology, blood vessel flow and position, evaluate previously placed filler, guide filler injections and aid complication management.1-5 As a Merz Aesthetics Innovation Partner (MIP) I support practitioners in the effective use of Merz Aesthetics products. Along with my Merz Aesthetics colleagues we deliver face-to-face training and digital education for the E-Cademy and E-vents platforms. Merz Aesthetics support the United Kingdom & Ireland Faculty (the training and education team) by investing in our professional development, with the latest focus being ultrasound scanning. This investment will further enhance Merz Aesthetics teaching, driving standards for practitioners and the industry as a whole. As medics we would rarely diagnose a treatment plan without investigation using imaging and special tests. However, aesthetic medicine has lagged in this respect.

Having an interest in aesthetic medicine means you will instantly enjoy this learning; it complements everything you already know and do. I can definitely attest to this learning being fun! The use of ultrasound in small facial aesthetics is not new, however it is not routine. By taking steps to use this in my daily work I can hopefully encourage others to do the same by breaking down barriers which you may feel are making this step difficult. Your effort will be rewarded with enhanced clinical practice and satisfaction in personal learning as well as growth in you and your patient’s confidence.

Equipment

The first step is to invest in an ultrasound scanner. I use a GE V-Scan Air.6 This is

In

Introducing Ultrasound into Your Aesthetic Practice

a rechargeable, pocket size handheld wireless scanner. This gives precise imaging for facial aesthetic analysis and treatment. It is simple to set up and connects to your phone or tablet for visualisation and storage of images or videos. In addition it has doppler to view and trace blood vessel activity which is amazing to see. At any stage the company representatives are extremely helpful with the technical set up and support in use. You will also need ultrasound gel, sterile gel and probe covers if you intend to use your scanner during procedures.

Training

Having learnt the basics of my scanner I attended a Merz Aesthetics sponsored training event for the Merz Aesthetics Innovation Board Members and Partner team. This was run in collaboration with Cutaneous Safe and Sound Ultrasound Training.7 Cutaneous is an Amsterdam based company headed by leaders in the field; Leonie Schelke and Peter Velthius. Leonie is a cosmetic doctor in Amsterdam and with Peter, a dermatologist, founded a filler complications clinic at the Erasmus University in Rotterdam over 10 years ago. Both have a contagious passion for ultrasound and optimal patient outcomes. This was a mostly hands-on practical learning experience with expert guidance at all times. The facial zones were taught in a step by step way learning how best to use the scanner and create meaningful images and relate this to our patients. As we became more comfortable with basic anatomy and tissue layers we then added doppler to examine the flow and course of blood vessels. The enthusiasm of the Cutaneous experts and scope for where this could enhance our clinical

work made everyone really excited at the opportunities ahead.

Implementation Plan for return to practice with a view to immediately being able to use your new skills. In my case I ensured my diary had time to scan a few patients a day. Leonie and Peter advised it would be better to spend a short time getting used to the equipment, finding the best positions to achieve good images and recognise anatomy. With time you can progress to identifying existing filler or using ultrasound to guide your injections. Don’t be discouraged, the learning curve is steep and with short sharp exposure to Ultrasound you will feel more confident very quickly.

Capture the momentum Revision, study group discussion and training will support your progress. Merz Aesthetics organised continued learning with Cutaneous group to provide support to the MIB and MIP team through e-learning, webinars and Instagram posts. Together Merz Aesthetics and Cutaneous have encouraged connections and collaboration within our Faculty to drive discussion for future learning and advancements. I took advantage of all the above as well as having the unique opportunity to spend two days with Leonie and Peter observing their complication referral clinic in Rotterdam. This further improved my anatomical knowledge, ability to recognise different types of filler in the facial tissue and complications management. The advantages were obvious as I returned to my clinic able to scan patients before, during and after treatments with more confidence and clinical relevance. Using ultrasound will reward you by igniting

Dr Paula Mann describes her journey incorporating ultrasound into her aesthetic and teaching practice

with layers we examine the vessels. Cutaneous where this work excited at the with a view to use your ensured my few patients advised it short equipment, to achieve recognise anatomy. to using injections. learning short sharp you will feel quickly.

Rotterdam. This further improved my anatomical knowledge, ability to recognise different types of filler in the facial tissue and complications management. The advantages were obvious as I returned to my clinic able to scan patients before, during and after treatments with more confidence and clinical relevance.

discussion and progress. continued group to and MIP webinars Together Cutaneous connections and Faculty to learning advantage having the spend two observing clinic in

a fire of interest as you learn to further improve your outcomes. Your patients are both fascinated and appreciative of your extra skills. They will never want to go anywhere else.

Rotterdam. This further improved my anatomical knowledge, ability to recognise different types of filler in the facial tissue and complications management. The advantages were obvious as I returned to my clinic able to scan patients before, during and after treatments with more confidence and clinical relevance.

Academy in Glasgow and in my role as a Merz Aesthetics Innovation Partner. Delegates are interested and excited at prospect of using ultrasound. Our training sessions are elevated by giving visual confirmation of written learning, helping to connect anatomy with injection technique which is so much more meaningful when we see them in real time.

Rotterdam. This further improved my anatomical knowledge, ability to recognise different types of filler in the facial tissue and complications management. The advantages were obvious as I returned to my clinic able to scan patients before, during and after treatments with more confidence and clinical relevance.

Very quickly ultrasound has been advantageous in many aspects to my daily work. The first is treatment planning, having decided where I want to inject I can determine if there is any existing product, and where it has been injected, I can also use doppler to determine the position of blood vessels which may affect my plan and injection technique. Further to this I can use ultrasound to guide my needle or cannula into position while injecting my dermal filler, suddenly the unknown is so much less ambiguous.

Using ultrasound will reward you by igniting a fire of interest as you learn to further improve your outcomes. Your patients are both fascinated and appreciative of your extra skills. They will never want to go anywhere else. Very quickly ultrasound has been advantageous in many aspects to my daily work. The first is treatment planning, having decided where I want to inject I can determine if there is any existing product, and where it has been injected, I can also use doppler to determine the position of blood vessels which may affect my plan and injection technique. Further to this I can use ultrasound to guide my needle or cannula into position while injecting my dermal filler, suddenly the unknown is so much less ambiguous.

Using ultrasound will reward you by igniting a fire of interest as you learn to further improve your outcomes. Your patients are both fascinated and appreciative of your extra skills. They will never want to go anywhere else. Very quickly ultrasound has been advantageous in many aspects to my daily work. The first is treatment planning, having decided where I want to inject I can determine if there is any existing product, and where it has been injected, I can also use doppler to determine the position of blood vessels which may affect my plan and injection technique. Further to this I can use ultrasound to guide my needle or cannula into position while injecting my dermal filler, suddenly the unknown is so much less ambiguous.

Then there is the reaction of my patients, they are interested, amazed and grateful. Bearing in mind they have just been appraised of the pros and cons of a procedure and signed a consent form, knowing you are doing all you can to keep them as safe as possible enhances the patient-clinician relationship. Ultrasound has been an invaluable addition to the teaching I do in the Aesthetic Training Academy in Glasgow and in my role as a Merz Aesthetics Innovation Partner. Delegates are interested and excited at prospect of using ultrasound. Our training sessions are elevated by giving visual confirmation of written learning, helping to connect anatomy with injection technique which is so much more meaningful when

Then there is the reaction of my patients, they are interested, amazed and grateful. Bearing in mind they have just been appraised of the pros and cons of a procedure and signed a consent form, knowing you are doing all you can to keep them as safe as possible enhances the patientclinician relationship. Ultrasound has been an invaluable addition to the teaching I do in the Aesthetic Training

Then there is the reaction of my patients, they are interested, amazed and grateful. Bearing in mind they have just been appraised of the pros and cons of a procedure and signed a consent form, knowing you are doing all you can to keep them as safe as possible enhances the patientclinician relationship. Ultrasound has been an invaluable addition to the teaching I do in the Aesthetic Training

Academy in Glasgow and in my role as a Merz Aesthetics Innovation Partner. Delegates are interested and excited at prospect of using ultrasound. Our training sessions are elevated by giving visual confirmation of written learning, helping to connect anatomy with injection technique which is so much more meaningful when we see them in real time.

Using ultrasound will reward you by igniting a fire of interest as you learn to further improve your outcomes. Your patients are both fascinated and appreciative of your extra skills. They will never want to go anywhere else. Very quickly ultrasound has been advantageous in many aspects to my daily work. The first is treatment planning, having decided where I want to inject I can determine if there is any existing product, and where it has been injected, I can also use doppler to determine the position of blood vessels which may affect my plan and injection technique. Further to this I can use ultrasound to guide my needle or cannula into position while injecting my dermal filler, suddenly the unknown is so much less ambiguous.

we see them in real time. Anyone who uses ultrasound will appreciate how it can aid in complications management. It has been an awakening of sorts to see where filler has been injected as opposed to where we think it has been injected. The realisation that this may lead to unsatisfactory results, potential changes in blood flow, or migration of product has opened all our eyes to considering how we could improve our technique in the future. Even for the most experienced injectors, being able to see in real time tissue spaces before during and after a treatment is satisfying and adds a layer of greater patient care to our clinic work. Consider also with experience you can use ultrasound to dissolve problematic HA if necessary with precision and monitor recovery.

Academy in Glasgow and in my role as a Merz Aesthetics Innovation Partner. Delegates are interested and excited at prospect of using ultrasound. Our training sessions are elevated by giving visual confirmation of written learning, helping to connect anatomy with injection technique which is so much more meaningful when we see them in real time.

Anyone who uses ultrasound will appreciate how it can aid in complications management. It has been an awakening of sorts to see where filler has been injected as opposed to where we think it has been injected. The realisation that this may lead to unsatisfactory results, potential changes in blood flow, or migration of product has opened all our eyes to considering how we could improve our technique in the future.

Anyone who uses ultrasound will appreciate how it can aid in complications management. It has been an awakening of sorts to see where filler has been injected as opposed to where we think it has been injected. The realisation that this may lead to unsatisfactory results, potential changes in blood flow, or migration of product has opened all our eyes to considering how we could improve our technique in the future.

Anyone who uses ultrasound will appreciate how it can aid in complications management. It has been an awakening of sorts to see where filler has been injected as opposed to where we think it has been injected. The realisation that this may lead to unsatisfactory results, potential changes in blood flow, or migration of product has opened all our eyes to considering how we could improve our technique in the future.

Even for the most experienced injectors, being able to see in real time tissue spaces before during and after a treatment is satisfying and adds a layer of greater patient care to our clinic work. Consider also with experience you can use ultrasound to dissolve problematic HA if necessary with precision and monitor recovery.

Then there is the reaction of my patients, they are interested, amazed and grateful. Bearing in mind they have just been appraised of the pros and cons of a procedure and signed a consent form, knowing you are doing all you can to keep them as safe as possible enhances the patientclinician relationship. Ultrasound has been an invaluable addition to the teaching I do in the Aesthetic Training

Finally, as practitioners we can collaborate. As more of us use ultrasound we can share our experiences and findings. We can stimulate discussion and research in how best we should place product into different tissue layers. Thus taking the next steps into the future of injectables and what could be safer, more effective treatments. I am so pleased I was given the opportunity to embrace the power of ultrasound even after several years working in aesthetic medicine, it certainly is better late than never. When I talk to my colleagues we agree it is not how you could incorporate ultrasound into your clinic, it is how could you not?

Even for the most experienced injectors, being able to see in real time tissue spaces before during and after a treatment is satisfying and adds a layer of greater patient care to our clinic work. Consider also with experience you can use ultrasound to dissolve problematic HA if necessary with precision and monitor recovery.

Even for the most experienced injectors, being able to see in real time tissue spaces before during and after a treatment is satisfying and adds a layer of greater patient care to our clinic work. Consider also with experience you can use ultrasound to dissolve problematic HA if necessary with precision and monitor recovery.

Finally, as practitioners we can collaborate. As more of us use ultrasound we can share our experiences and findings. We can stimulate discussion and research in how best we should place product into different tissue layers. Thus taking the next steps into the future of injectables and what could be safer,

Finally, as practitioners we can collaborate. As more of us use ultrasound we can share our experiences and findings. We can stimulate discussion and research in how best we should place product into different tissue layers. Thus taking the next steps into the future of injectables and what could be safer,

Finally, as practitioners we can collaborate. As more of us use ultrasound we can share our experiences and findings. We can stimulate discussion and research in how best we should place product into different tissue layers. Thus taking the next steps into the future of injectables and what could be safer,

aesthetic medicine, it certainly is better late than never. When I talk to my colleagues we agree it is not how you could incorporate ultrasound into your clinic, it is how could you not?

more effective treatments. I am so pleased I was given the opportunity to embrace the power of ultrasound even after several years working in aesthetic medicine, it certainly is better late than never. When I talk to my colleagues we agree it is not how you could incorporate ultrasound into your clinic, it is how could you not?

WE BRING THE EXPERTS TO YOU.

more effective treatments. I am so pleased I was given the opportunity to embrace the power of ultrasound even after several years working in aesthetic medicine, it certainly is better late than never. When I talk to my colleagues we agree it is not how you could incorporate ultrasound into your clinic, it is how could you not?

WE BRING THE EXPERTS TO YOU.

Merz Aesthetics

References: 1. A guide to doppler ultrasound analysis of the face in cosmetic medicine part 1 :standard positions Velthius p et al Aesthetic surgery jn 2021, 1-12 2. A guide to doppler ultrasound analysis of the face in cosmetic medicine part 2: vascular mapping Velthius p et al Aesthetic surgery jn 2021, 1-12 3. Early

SLA (Superior labial artery) OOM (Orbicularis oris muscle)

SLA OOM

Teeth

This advertorial is sponsored by Merz Aesthetics UK & Ireland

the latest techniques in aesthetics, the best skincare and the most effective combination therapies with them to maximise their results? How can you share this unless you are ‘selling’ the solution to their problems; a solution that leads to fantastic results and a happy patient? Potentially reducing clinical outcomes because you don’t want to tell patients about a great new serum for fear of being ‘salesy’ is a limiting belief pattern that needs acknowledging so you can move away from it.

The consultative sell

Understanding Consultative Selling

Sales and selling are the lifeblood of any successful business, however many of us view selling as unethical, unnecessary or in some way dishonest, especially as we work in medical aesthetics. Author Daniel Pink conducted a survey where he asked people to state the first word that came to mind when they heard the word ‘sales’ or ‘selling’. 80% of those words had negative connotations.1 That’s why so many people resist selling to others –perhaps you or your team believe patients will recoil in horror and run away if sold to, or maybe you feel awkward about how to approach selling without damaging the relationship of trust you developed with your patients? This negative mindset directly affects your ability to provide a more comprehensive treatment plan for patients, restricts clinical outcomes and negatively impacts turnover.

If you are frustrated because your business isn’t seeing the success and growth you hoped for, and you can’t significantly increase turnover no matter what you try, then continue reading to discover ways to change your mindset and find a new style of selling that feels natural and ethical.

Changing your mindset

Before taking any other steps, you first need to overcome your own negative view of selling. You can do this by adjusting your mindset and focusing on your ‘why’. Why do you want to provide a treatment or product that can help this person, other than to increase your turnover? Once you understand what drives you to want to provide a solution, it’s easier to overcome a reluctance to sell.

But how do you discover your ‘why’? Take a step back and reflect! What made you choose to work in aesthetic medicine? Most likely it was a desire to help people feel better about themselves by providing safe and effective aesthetic treatments – what a great motivator that is. Your passion for aesthetics means you are always researching the best new products and the most up to date techniques in order to bring the best solutions to clinic. It feels great to help someone and make them happy, which is essential for job satisfaction. This is your ‘why’.

Remember that everything you do should be done in the best interests of the patient you are treating. You have a wealth of knowledge and experience so why wouldn’t you want to share

Now you understand your ‘why’, be open to developing subtle yet effective selling skills to get your message across to your patients in a way that feels natural. One of the most effective ways of doing this is by using the consultative sales approach; a type of sales technique where you adopt the role of advisor more than salesperson, and recommend solutions based on what the buyer needs. It is focused on the customer, and your relationship with them, rather than on the product being sold.2

Critical communication skills

If you want to be good at the consultative sell, it helps to hone your critical communication skills. In terms of sales and building those important relationships, being a strong communicator means being not only a good listener, but being good at asking questions so you understand your patients’ needs. When someone shows interest in you by listening to what you say you feel appreciated and good about yourself, so by actively listening we make a conscious decision to try to understand things from the patient’s point of view. Listen for the total meaning and don’t interrupt. What words were used? What is their overall mood? Happy and excited or nervous and upset? Listening for the language used is helpful but understanding how your patient feels about something gives full value to the message.

It’s also important to use questions to find out more information and to make the patient feel cared for. Summarise what they said by using these questions for clarification. ‘Do you mean you want both treatments at the same time?’ Open questions encourage others to talk, give detail or explain something so by asking open questions we can fact-find and also determine if the patient has understood what we said. Examples of open questions

Business consultant Vanessa Bird shares her soft-sales techniques

include ‘How does your acne make you feel?’, ‘What part of the procedure do you still have questions about?’ and even ‘‘Do you have a budget in mind?’ Using customer-focused questions help us build common ground and allows us to discover the wants and needs of the patient by showing that the focus is on them. While we may know this is always the case, practitioners don’t always phrase their speech in a way that shows this. For example, they may say ‘I think you need this product or device because I always get great results with this’, making it seem about them and their expertise. Instead, say something like ‘How do you feel we can help you with this?’ – adapting your language in this way can help them to trust in you and your recommendations.

Dealing with objections

Objections happen at all stages of the sales journey, even when carrying out a consultative sales process, and are usually an emotional response to something heard, a misunderstanding, or used as a way to slow down the process because the patient feels too ‘rushed’ into making a decision. Remember, objections are a natural part of the decision-making process and can actually be a sign of interest – often you only ask questions if you’re interested in knowing more. Occasionally you may encounter ‘false objections’ which tend to happen early on in a patient relationship or sales journey. False objections aren’t really genuine objections and are often a knee jerk reaction as they don’t want to feel rushed. It is usually an objection to your approach rather than to what you are saying. Examples of false objections include ‘It’s not the right time’, ‘Send me some information’ or ‘I need to discuss it with my partner.’ Whether it’s a genuine or false objection, you can utilise the above critical communication skills to smooth over the process and show you’re acting in the patient’s best interests.

1. Listen. Are you clear about what the objection is? You cannot address it unless you understand it.

2. Acknowledge. Summarise the objection back to the patient and acknowledge their point so they know they’ve been heard.

3. Respond. This is another opportunity to sell the features and benefits of your product or treatment, demonstrating why it is the right solution for their needs, or put forward other solutions the patient may feel more comfortable with.

4. Ask for feedback. ‘Are there any more questions you’d like to ask?’ If other objections pop up, you can retrace your steps and respond to them accordingly – it also shows that you value what they have to say.

Handling price objections

Price objections develop if your patient fails to see the value of what you’re offering versus the cost, so be sure to talk about the benefits in relation to wants and needs. Build value by highlighting any additional extras included in the price, how long-lasting the results will be or how preventative treatment now will save money in the future. They are paying for your experience, high-quality products and clinically-proven treatments, so explain this to them. If they understand why your pricing is higher and that lower prices elsewhere may be down to less experienced practitioners with substandard equipment or products, they will be more accepting of your pricing. Be open and honest about pricing and provide two or more options to accommodate different budgets. Once they understand the benefits and how your service is of value to them, they will emotionally connect and they will move forwards.

Buying signals

Patients start to give signals when they are ready to buy, and this can happen at all stages of the consultative sales process. You need to learn to recognise these signals and engage with them, rather than taking the hard sell approach and pushing at the end. For example, they may begin to interact more, asking questions and wanting to see before and after photos or testimonials. Or, it can often be as subtle as positive body language, leaning forwards, increasing eye contact, nodding and changing their energy to something more positive, excited or enthusiastic. Be open to these subtle signals. Noticing their buying signals should give you confidence to start moving towards the next stage of the process, known as ‘closing the sale’.

Closing the sale

Remember, when you are using a consultative selling style the selling has been happening at all stages of the journey, so this final step isn’t the hurdle you think it might be. If you’ve used critical communication skills and consulted throughout with the patient, closing the sale should be a natural next step. Avoid

directly asking them if they’re going to buy what you’re selling and instead act as if the customer has already decided to buy (if they have given you the signals outlined above). Say something like ‘Would you like me to check the diary and book you in?’, or perhaps ask them to select their preferred package, for example whether they want the injectables package or the energy-based package. This is known as ‘the alternative close’ where you are offering an ‘either-or’ solution. A decision made for one or the other is a ‘yes’ to the sale.3 You can even ask whether they wish to pay by cash or card –when they tell you how they wish to pay it is their way of saying yes to the sale. Often, a simple ‘When would you like to start?’ is all that’s needed and your patient will appreciate the no-pressure approach.

Start your new sales journey!

Utilising the consultative sales approach means that prior to closing the sale you will have carried out a thorough consultation, established patient wants and needs, offered a number of possible solutions and helped them decide on their preferred choice. This means that the process flows naturally and is not high pressure – rather, the sale is the destination you both reached together. When you close that sale, your business and your patients will thank you for it.

Vanessa Bird is the founder of The Aesthetic Consultant. She has more than two decades of experience working in sales and selling capital equipment, teaching her to recognise key areas for partnership development between the sales rep and the customer.

REFERENCES

1. Daniel H. Pink, ‘To Sell Is Human’, <https://www.danpink.com/ books/to-sell-is-human/>

2. Richardson, Defining Consultative Selling, 2017, <https://www. richardson.com/en-gb/sales-resources/defining-consultativesales/>

3. Adam Wiggins, How to Close a Sale, 2019, <https://blog. hubspot.com/sales/sales-closing-techniques-and-why-theywork>

Crafting Your Online Advertisements

Digital

When it comes to the word ‘offers’, most clinics shriek and immediately worry it will be cheapening their brand. However, it doesn’t have to be this way. The Cambridge Dictionary defines the word ‘offer’ as ‘to ask someone if they would like to have something or if they would like you to do something’.1 Not as scary as it sounds, right?

On social media, you’re up against big companies who have spent millions on creating the perfect advertisement. Think of these brands as ‘genetically modified’ opponents who are bred specifically for online ads. If you’re going into the social media ads arena without a clear strategy in place, your ad budgets are going to be wasted. You need to think ahead!

However, there is some light at the end of the tunnel. After running adverts online for more than 75 clinics, we’ve found a bulletproof five-step formula that will ensure your ads don’t get swallowed up online. Plus, it doesn’t require you to hugely discount your services... let’s dive in!

Step 1: Decide on the treatment you want to advertise

Firstly, you need to decide on the specific treatment that you want to advertise. Now I know this is extremely obvious, but we need to step back and look at it from an outside perspective. As clinic owners, you’ll have

lots of popular treatments that your patients love. A mistake I see often is that clinics try to launch an advert showing all the treatments that they offer. However, the audience you’re showing your adverts to don’t yet know, like, or trust you! We don’t want to shove every treatment that you offer down their throat as it won’t be specific to their needs and could lead to an information overload.

A good way to find out the best treatment to advertise is to find one that hits most of the criteria:

• Has great results in a short space of time with little downtime

• Gets patients back for regular appointments (course of treatments, follow-ups)

• Quick treatment time/high profit (we don’t want to offer a long treatment with thin margins)

• Allows patients to ‘test’ treatment or have a free consultation for the treatment

If you can think of a treatment that matches these, you’ve got yourself a winner. Of course, there are so many different treatments available, from devices to topical skin treatments, and remember we can’t advertise prescriptive-only medicine (POMs) to the public as it is against the law.2

Step 2: Map out the value ladder!

As we’re showing adverts to new potential patients, we don’t want to be pushy or too salesy as it’ll just scare them off. Your end goal may be to sell your high-end packages which best solve your patients’ needs, however, you need to ease them in. Telling them it’ll cost £2,500 and a six-month commitment to hit their goals will terrify most people if this is the first thing they see on your advertisement with zero trust built.

My clients often say the most common objections when patients are concerned about price are:

• What if I don’t like the practitioner/therapist

• I’m not sure if I’m suitable for this treatment

• I’ve heard it’s painful

The best way to overcome these objections is to think of the easiest way to get them inside your clinic to meet the team and

build trust. Typically, this is pushing the initial consultation, or it could be giving them an introductory offer/treatment that can hook them in so they can experience the treatment for themselves.

It’s time to map out your value ladder (Figure 1). The value ladder shows that the higher the value, the more you can charge for your services.

The hardest part for any clinic running ads online is getting people through their doors. The value ladder will guide you on the easiest way to do this. The ladder helps you to meet new patients, discover where they are in their journey and build trust slowly without being pushy.

Start at the bottom of the ladder and input the beginning part of a new patient’s journey. This will be something that is low in price and doesn’t take up too much time for you/provide too much value, such as a consultation or skin assessment using an imaging device. We want it to be an easy way for the potential patients to experience your service and build trust. Once you give them an incredible experience, you can slowly move them up the value ladder to your more expensive treatments/packages. This will enable you to upsell them your higher end packages.

Figure 1 highlights a way to do this by using laser hair removal as an example. The goal is to sell a course of six to eight sessions of laser. However, if you go to push this straight away to a cold audience online, you might be met with some resistance. People will have objections and questions that they want answered before they commit to eight sessions.

Step 3: Map out what you do for your patients during this treatment

As clinic owners, you can be very influential when patients walk through your doors. The best way to show value to your patients is to map out everything your patient can get specifically from you when they visit. These

are ways that show your expertise and bits your competitors can’t copy! We need to show the value, not just price.

For example, when someone comes in for a skin consultation they get:

• 45-minute consultation with skin therapist/practitioner

• Complimentary skin analysis

• Custom roadmap to hit their skin goals

• Free skincare tips PDF

• Complimentary follow-up skin consults via phone call

• Exclusive offers in-clinic

Again, this is just an example and it’ll need to be tailored to your specific clinic and treatment offering. We need to show new patients how much value you provide and why they should visit you… not just a ‘complimentary consultation’. Even if it’s just the same as you always offer, the goal is to break it down so patients can clearly see what they’re getting.

Step 4: Value stack each item

Now that you’ve mapped out each aspect of your service (consult, treatment), it’s time to value stack each item! Go through each aspect and add a price amount to each service. You could say your skin analysis is worth £30, your skincare PDF is worth £9 for example. Add a price to each element (make it accurate and true!), and total that figure. It could be that it’s all together worth £99. So really, instead of them just thinking it’s a typical free consultation, it’s actually worth £99… thus increasing the perceived value of your services!

Step 5: Abide by advertising codes on time-limited offers

Once you’ve done all the above steps, you’re almost there! It’s now time to tie it all together to ensure your ads cut through the noise online. As we’re showing this offer to potential new patients, we need to get them to stop in their tracks online. Research shows that we only have 1.7 seconds to capture

their attention on Facebook.3 The best way to do this is to ensure the advert calls out their wants, needs, goals and fears! If they just read what’s included in their first visit with you but don’t understand how it solves their issue, they’ll scroll past. Remember to abide by the Advertising Standards Authority (ASA) guidelines on advertising, particularly regarding time-limited offers as if you are advertising a sales promotion, then you need to tread carefully.4

Within the first three sentences, you need to address exactly what this treatment solves. For example, ‘laser hair removal will help patients save hours of shaving, remove ingrown hairs and stop accidental razor cuts’. Make it simple to understand and talk about the benefits of the treatment, rather than just the treatment.

For structuring the advert, it’s best to keep it short and sweet. Typically, our best performing ads are around three to four short paragraphs. We want to cut straight into the benefits as discussed above. Make it more about what you can do for them, rather than just speaking all about you and the clinic. Having pictures of the treatment being done with smiling staff tends to get the most interaction (don’t use stock images!).

Try it yourself!

Creating an offer that cuts through the noise online can be really confusing and frustrating for clinics. However, as you’ve seen in this article, if you follow these five steps, you’ll ensure that your campaigns have the best chance of succeeding and gaining more potential patients for your clinic.

Richard Gibbons is the founder of Facebook advertising agency Boost My Customers and specialises in helping clinics generate bookings. He has been in the industry for four years and is the author of the book The Clinic Marketing Blueprint

REFERENCES

1. Cambridge Dictionary, ‘offer’, (2021) <https://dictionary. cambridge.org/dictionary/english/offer>

2. Advertising Standards Authority (ASA), ‘Healthcare: Prescriptiononly medicine’, (2015) <https://www.asa.org.uk/advice-online/ healthcare-prescription-only-medicine.html>

3. Facebook For Business, ‘Capturing Attention in Feed: The Science Behind Effective Video Creative’ (2016) <https://www. facebook.com/business/news/insights/capturing-attention-feedvideo-creative>

4. Advertising Standards Authority (ASA), ‘Cosmetic Advertising: Give your ads a nip and tuck’, CAP News, (2015) <https://www. asa.org.uk/news/cosmetic-advertising-give-your-ads-a-nip-andtuck.html>

The best way to show value to your patients is to map out everything your patient can get specifically from you when they visit

In The Life Of Dr Lee Walker

A varied training day…

I don’t really practice in my clinic B City Clinics in Liverpool anymore as my days are mainly focused on training and education, which I love! I have two working lives in aesthetics – one is where I work with my own training facility the Lee Walker Facial Aesthetics Academy in Liverpool, and the other is based around Teoxane, for whom I am a national and international trainer as well as a mentor. For a typical training day in Liverpool, I wake up at 7am. I arrive at 8:30am, starting the morning with a team talk about the upcoming day. We discuss the level of education we are going to pitch based on the delegates we have coming in. The official training day begins at 10am and finishes at 6pm. We keep the sessions small to focus on a high level of structured teaching. We also run an intense, evidence-based mentorship programme where 12 delegates take a sixmonth course, which I conduct once a month. It brings me a huge level of satisfaction and has a positive impact on my day. I finish work at 6pm and will reply to any messages, missed calls or emails before I go home. Depending on my schedule, I might have a virtual meeting or Zoom call, so will work my evening around this. If not, I will watch some sport or a documentary on the TV and finish off the day by reading a book before bed –mainly anything related to anatomy!

Being a KOL…

I have lots of other exciting work commitments which take up a lot of my time besides my training academy. I am a trainer for Teoxane, which allows me to speak and educate people in the UK and internationally which is a huge honour! I receive advanced notice on conferences, lectures and workshops which are scheduled into my diary – I’m full until November! The training with Teoxane is very different. We deliver a message which is based around the company’s key principles, anatomy, ageing, assessment, techniques and product choices. As travelling within the UK is easier now, I am able to go to various places including all the four nations and Ireland. This is a great opportunity to meet other practitioners and hear about their experiences in the industry. The international training is structured

Career if you weren’t in aesthetics…

I’d be a chef! I love to cook and I’m very experimental. When I was a student, we had competitions and the winner would be exempt from washing up for a week.

Favourite thing about your job…

Passing on knowledge and watching people develop into successful, safe and happy injectors!

Any hobbies…

I’m a huge Liverpool football fan, and I’ve also got a passion for CrossFit, so I try to keep myself active.

differently, as Teoxane will choose specific topics or subjects for me to focus on during my talks. There is a language barrier in some countries so I may have to work with an interpreter, which can make the days long as usually the medical education message is being repeated. Also, ethnic and cultural differences come into play, where practitioners treat the face differently due to the different proportions and features of the face. Speaking at international conferences is a great learning experience as I’m able to see what other practitioners are doing around the world and the different techniques they are using. Through this role, I’ve educated in more than 40 countries. I’m also a mentor for other KOLs in a programme called A Journey to Excellence with Teoxane. This allows me to take young KOLs through a process to help develop them into strong speakers for the

future. Being able to mentor and share my knowledge is paramount as we can craft the future of aesthetics and hopefully ensure it becomes a safer specialty.

Other work commitments…

Another work commitment is being the chair of the Complications in Medical Aesthetic Collaborative (CMAC), which was established in 2020 to support clinicians worldwide in diagnosing and managing complications in aesthetics. I have a phenomenal team with aesthetic practitioner and vice chair Cormac Convery, prescribing pharmacist Gillian Murray and nurse prescriber Dr Emma Davies, without whom this organisation wouldn’t be possible! We have a Zoom meeting every two weeks which can last between two to three hours. It’s quite intense, but there is a lot of work to be done. We also have a global WhatsApp group where we share ideas, thoughts, and cases with experts from around the world. Complications are rife in this industry, and not enough people are trained in how to manage them, so I enjoy being able to share my knowledge to ensure patients are safe.

Most memorable day…

I have two which stand out for me… The first is when I got to speak on the stage at the Aesthetic and Anti-Aging Medicine World Congress (AMWC) a couple of years ago on complications. I had always been one of the delegates sitting in the audience watching, but then suddenly, I was teleported into this position! My second would be publishing a book with aesthetic practitioner Dr Raul Cetto and Dr Toni Burke in 2021 named Facial Ageing and Injection Anatomy, which is being sold in 30 countries now!

Dr Lee Walker will be speaking at ACE. Register for free by scanning the QR code.

International trainer Dr Lee Walker details his varied working day and how he educates practitioners across the globe

The Last Word

When you think of team members who are indispensable to your clinic, I’m sure you rightly start with yourself and your qualified doctor, nurse, or dental injectors and practitioners (if they’re not one and the same). If you have a therapist, you probably consider them next. So, my question to you is: at any point, do your front of house staff cross your mind? I know many clinic owners for whom front of house staff are like a revolving door, changing every few months, and are never truly considered part of the ‘inner circle’ of the team, leading to a high turnover. In fact, according to an Allied Workforce Mobility Survey as many as 25% of new employees leave their company within their first year of employment,1 and according to O.C. Tanner’s Global Culture Report, the most cited reason for leaving a job is a lack of appreciation from their current employer.2 I firmly advise against viewing reception staff in this way, as valuing and investing in these team members can be of huge benefit for your business as a whole. In fact, according to LinkedIn’s 2019 Workforce Learning Report, 94% of employees noted that they would stay at a company longer if it invested in their careers.3

Utilise their assets

You should remember that your front of house staff are the first point of contact any patient has with your business, whether they are walking through the door, picking up the phone, or getting a response to an email. Of course you know this, which is why you recruited carefully, right? And in order to trust them with this huge responsibility, you’ve trained them. You’ve spent copious amounts of time and energy instilling your vision, methods and your ethos into your staff so they can confidently coordinate your business. Now, if you operate as a hierarchical practice, which I find so many practices do, and don’t invest in the people in these roles because they’re ultimately replaceable, what motivation do these people have to promote your business as if it’s theirs? By rewarding them and investing in them, you and your business will benefit. I also believe in taking this further. If you haven’t addressed this at the interview stage, it’s never too late to ask your front of house staff what other skills they have so you can develop talent in-house – which I think should be a priority for many business owners. Perhaps one of your team members has writing skills. In that case, don’t encourage them to stop at writing emails – instead ask them to try their hand at captions, website copy, promotional materials like flyers, etc. I find that when outsourcing social media, for example, it is very rare for a social media agency to truly understand my ethos, brand, and what I want to communicate. They may come up with a caption or post which is 90% there based on what information I’ve given them, but purely because they aren’t working with me in my business day-to-day, it can never capture 100% of what I want it to. Yet when I ask my clinic coordinator or my front of house to write a caption, it expresses exactly what I’m aiming for, and that’s how my social media has a personal touch that many patients comment on.

Between my two full-time employees who cover the front desk, they also entirely handle the clinic’s marketing, website, and more. They have designed my brochure, produced videos and presentations for me, and come up with some brilliant ideas to further the business, all whilst handling the day-to-day of patients and running clinics. This is why I recommend never overlooking your receptionists, bringing out each person’s strengths and capitalising on them. You’ll save money by keeping jobs in-house rather than outsourcing, and additionally your team feels more valued, increases their skill sets, and are encouraged to grow. This individual growth benefits your business in turn, because their understanding of your clinic’s ethos is much greater than that of someone who has been there for a long time, thus improving the patient experience.

You may read the above and be tempted to say, is this not too much to ask? Or alternatively, is this not shoving a square peg into a round hole – should each person not have their specific job and do it well? I have colleagues who prefer to outsource because if they’re not getting the results they want, they can simply move on to another supplier. I also acknowledge that this approach works better in a small team with a bespoke offering, and it may be difficult in a larger clinic with multiple front of house staff who may not perform at the same level, or may simply be on part-time hours. However, I am a firm believer that when you have the right team around you, they are excited to grow your business and take on a bigger job role, as long as they feel adequately valued. If you are expecting more from a person than what you’re paying them for, this won’t work, so I think it’s important to not take a hierarchical approach and treat everyone in your team, non-medic and medic, as equals.

Make your staff a family

Ultimately, this is my approach: make your front of house part of your brand, your business, and keep them close. People buy into people, so this method will not only serve you and your clinic, but your patients too –they will feel more comfortable knowing who to expect on the other end of the phone. Managing my team like this has served me very well thus far and I’d recommend it to any clinic owner weighing up who their next recruit will be!

Julie Scott is a registered nurse and independent nurse prescriber with more than 20 years’ experience in the aesthetics industry. She now practises from her own Essex clinic, Facial Aesthetics, and teaches for Interface Aesthetics in London. Scott is always happy to speak with fellow members of the aesthetics specialty about recruitment or any other aspects of running a clinic.

Qual: RGN, NIP

REFERENCES

1. Allied, Workforce Mobility Survey (2018) <http://hriq.allied.com/ pdfs/AlliedWorkforceMobilitySurvey.pdf>

2. OC Tanner, Global Culture Report (2022) ><https://www. octanner.com/content/dam/oc-tanner/images/v2/culturereport/2022/home/INT-GCR2022.pdf>

3. LinkedIn, Workplace Learning Report, (US: LinkedIn, 2019) <https://learning.linkedin.com/content/dam/me/business/en-us/ amp/learning-solutions/images/workplace-learning-report-2019/ pdf/workplace-learning-report-2019.pdf>

Nurse prescriber Julie Scott argues why clinic owners should value their non-medic staff as much as their medical injectors or therapists

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REFERENCES:

1. www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed September 2019 2. Ulthera

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

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

Refer to the Instructions for Use (IFU) for complete instructions on operating the Ultherapy® System The non-invasive Ultherapy® procedure is U.S. FDA-cleared to lift skin on the neck, on the eyebrow and under the chin as well as to improve lines and wrinkles on the décolleté. The CE Mark indications for use for the Ulthera® System include non-invasive dermatological sculpting and lifting of the dermis on the upper face, lower face, neck and décolleté. Reported adverse events from postmarketing surveillance are available in the Instructions for Use (IFU ). Please see the available IFU in your country for product and safety information, including a full list of these events. © 2018 Ulthera, Inc. The Merz Aesthetics logo is a registered trademark of Merz Pharma GmbH & Co. Ulthera, Ultherapy, DeepSEE, SEE THE BEAUTY OF SOUND and the Ultherapy logo are trademarks or registered trademarks of Ulthera, Inc., in the U .S. and /or certain foreign countries.

Merz Pharma UK Ltd, Ground Floor Suite B, Breakspear Park, Breakspear Way, Hemel Hempstead, Hertfordshire HP2 4TZ Tel: +44 (0) 333 200 4140