JANUARY 2022: The Body Issue

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VOLUME 9/ISSUE 2 - JANUARY 2022

DETAILS OF BEAUTY Unveiled on body

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CPD: Hydroxy Acids for Skin

Dr Kalpna Pindolia explores the clinical evidence behind hydroxy acids

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Treating the Body with Devices

Practitioners discuss non-invasive body contouring treatments

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Exploring Sclerotherapy for Leg Veins

Claire Judge outlines the treatment of thread veins in the leg

Marketing Your Calendar Aesthetics tells you the top dates to incorporate into your marketing strategy


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Contents • January 2022 08 News The latest product and industry news 18 News Special: Restricting Cosmetic Advertisements Aesthetics explores the new restrictions on advertising to under-18s

CLINICAL PRACTICE 23 Special Feature: Treating the Body with Energy-Based Devices Aesthetic practitioners discuss non-invasive body contouring 28 CPD: Understanding Hydroxy Acids in Skincare Dr Kalpna Pindolia explores the evidence behind hydroxy acids 33 Case Study: Treating the Male Jawline Dr Benji Dhillon explains how he used the TEOSYAL range for the

male jawline

35 Treating Leg Veins with Sclerotherapy Nurse prescriber Claire Judge describes treating thread veins in the leg

News Special: Restricting Cosmetic Advertisements Page 18

39 The 2022 Finalists! The Aesthetics Awards 2022 Finalists are announced 44 Owning Every Angle with Restylane Discover the ultimate 3D facial profiling technique with Restylane 47 Restoring the Nipple with Dermal Filler Dr Magdalena Szymanska-Bueno outlines how to add volume to the nipple

using filler

52 Case Study: Delayed Hypersensitivity Reaction Dr Saran Patter discusses hypersensitivity reactions to HA fillers 54 Introducing NEW Profhilo Body From face to body, all of IBSA Derma’s expertise are in the Profhilo Body Kit 56 Assessing the Ageing Nose Mr Samit Unadkat explores his approaches to nose assessment 58 The Revolutionary Approach in Body Shaping Dr Aggie Zatonska discusses her results using EMSCULPT NEO 59 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 60 The ACE 2022 Experience Discover first-class learning at the Aesthetics Conference & Exhibition 62 Marketing Your Calendar Aesthetics tells you the top dates to incorporate into your marketing in 2022 65 Building Resilience in Your Clinic Alan S Adams shares his strategies for maintaining resilience in your clinic 68 Starting Out Safely Natalie Haswell provides safety considerations when starting out in aesthetics 72 In Profile: Dr Tatiana Lapa and Mr Rishi Mandavia The husband-and-wife duo discuss their differing paths into aesthetics 74 The Last Word: Marketing Language Dr Parneet Sehmi explains why brands are responsible for language

in advertising

NEXT MONTH IN FOCUS: MALE TREATMENTS • Treating the Male Lower Face • Addressing the Male Tear Trough with Filler

Special Feature: Body Treatments with Energy-Based Devices Page 23

Clinical Contributors Dr Kalpna Pindolia is an emergency medicine and maritime medicine doctor and is director of education at Harley Academy as well as an aesthetic practitioner at Story Clinic, London. She is passionate about holistic aesthetic practice. Claire Judge is a nurse prescriber and a founding member and board member of the British Association of Sclerotherapy. She has 26 years’ experience in Sclerotherapy and clinics at the Royal Free Hospital, Hadley Wood Hospital and The McIndoe Centre. Dr Magdalena Szymanska-Bueno graduated in medicine at the Poznan University of Medical Sciences and is a specialist in dermatology and venereology at Heliodor Swiecicki Clinical Hospital. She is a fellow of the European Board of Dermatology-Venereology. Dr Saran Patter qualified from the University of Liverpool as a dentist. She runs her aesthetic practice from three clinics in Hungerford, Swindon and Cirencester. She is the owner of Bridge Street Skin Clinic and director of The Aesthetics Group Academy. Mr Samit Unadkat is a consultant ENT and facial plastic surgeon at the Royal National ENT and University College Hospital. He is also the director of My Nose London. He has a subspecialist interest in both cosmetic and functional rhinoplasty and complex sinonasal surgery.


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Editor’s letter As we begin afresh and start a new year, I am delighted to present some much needed good news – the Aesthetics Awards Finalists have been announced! We had a record number of entries this year with almost 400 applications received, so to become a Finalist Shannon Kilgariff really is a huge achievement. Dubbed ‘The Acting Editor & Oscars of Aesthetics’, the Aesthetics Awards Content Manager really is THE event to be at to celebrate and @shannonkilgariff be recognised for a year of achievements, and network with your industry. With so many challenges over the last year, a big congratulations to all the Finalists who are listed on p.39. Voting is now open in a select number of categories so be sure to go to our website to get your votes in by February 1! Some other good news, with the sad departure of Mr Dalvi Humzah as the Clinical Lead of our Clinical Advisory Board, comes the exciting appointment of aesthetic nurse prescriber Sharon Bennett who has enthusiastically agreed to lead the board. I hope you will all join me in congratulating Sharon, and I am looking forward to working closely

with her to further progress the journal and the whole Aesthetics, CCR and Beauty Uncovered brands. Now, this month in the journal we focus on all things ‘body’. As we know, after the holiday period and over the winter months your patients may start to pack on a few extra pounds. This means, in the coming months they will likely be turning to you for solutions! As such, we have put together an interesting article on using energy-based devices for body contouring and fat reduction on p.23, where three practitioners talk about their preferred devices. We also have articles on treating leg veins with sclerotherapy on p.35, nipple volumisation using dermal fillers on p.47, Profhilo for optimising skin on the body on p.54, and how you can build muscle whilst simultaneously burning fat on p.58. I write this as the UK hits record high COVID-19 cases, so I hope that you all had a safe holiday period and I look forward to seeing you all again in the new year soon. Remember to let us know what content you enjoyed this month, and what you want to read more of by sending us an email: editorial@aestheticsjournal.com or tagging us on Instagram: @aestheticsjournaluk

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

Sharon Bennett, Clinical Lead 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.

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.

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

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

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

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

EDITORIAL Shannon Kilgariff Acting Editor & Content Manager T: 0203 196 4351 | M: 07557 359 257 shannon@aestheticsjournal.com Leonie Helm Acting Deputy Editor 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

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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.

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Regulation

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

#Aestheticsjournal Dr Ashwin Soni @thesoniclinic It is wonderful that I have another article published in the Aesthetics journal this month about the role of acoustic wave therapy in aesthetics

#Training Dalvi Humzah Aesthetic Training @d_h_aesthetic_training Presenting at the launch of Profhilo Body in the UK for @ha_dermauk! Sharing the virtual stage with @annabakerskinclinic and @frank_haderma

JCCP partners with sk:n clinics The Joint Council for Cosmetic Practitioners (JCCP) and clinic group sk:n have announced a partnership to enhance regulation in the aesthetics industry. Through this partnership, sk:n and the JCCP aim to raise awareness surrounding the dangers of having under-qualified practitioners carry out non-surgical treatments and continue to lobby the Government to introduce laws to regulate the industry. The JCCP launched a Ten Point Plan in 2021, whilst sk:n clinics have strict supplier protocols and standards set out by their Medical Standards Committee. The partnership hopes to accelerate regulation in the industry from the licensing of premises to the training and qualifications of practitioners. Professor David Sines, chair of the JCCP, commented, “The JCCP has established a very positive relationship with sk:n over many years. Experts from sk:n have been actively engaged since 2016 in assisting the JCCP to develop a number of its published standards and have contributed extensively to broader debates about regulation and patient safety. The JCCP is delighted to be able to formulise this relationship into a clear partnership where both parties can contribute to raising standards regarding patient safety, ethical practice and public protection as central tenets of our shared mission and values.” Survey

#Fillers Dr Dev Patel @drdevpatel1 A fun day teaching some London based aesthetic practitioners with my colleague @drkimbooysen at the Cranley Clinic

#Education Dr Raj Acquilla @rajacquilla Sneak peek behind the scenes in Amsterdam today filming six patients for our upcoming live show in Paris @imcascongress

#BeautyUncovered Mr Taimur Shoaib @shoaib_plasticsurgeon Delighted to be in the inaugural edition of Beauty Uncovered magazine! #patienteducation

BCAM unveils audit results The British College of Aesthetic Medicine (BCAM) has revealed the results of the 2021 Annual Clinical Review. The BCAM has been collecting and sharing data since the association was founded in 2001, working with the Department of Health and Social Care (DHSC) to provide insights to guide and inform government thinking, explains BCAM. The 2021 audit covers under 299,000 individual treatment episodes conducted by 340 healthcare professionals, including 147,000 for botulinum toxin, which was found to be the top treatment conducted throughout the year, outlines the College. The audit has been expanded to ask more detailed questions regarding members’ patients and treatments. The review highlighted the issues which BCAM members face when treating complications from procedures carried out by non-healthcare professionals. The audit showed that members reported 600 complications from other practitioners, with 77% caused by dermal fillers, 13% from botulinum toxin, 6.7% from laser and 3.2% from threads. According to the audit, the top five treatments performed by BCAM members were toxin injections, hyaluronic acid dermal fillers, mesotherapy, platelet-rich plasma and laser and IPL treatments. BCAM president Dr Uliana Gout said, “In our 20th anniversary year, we are delighted to share the results of the 2021 BCAM Annual Clinical Review. The College is pioneering data collection, sharing insights and trends with stakeholders including the DSHC to pursue its charitable aims of patient education and safety. We are proud to be leading with facts not opinions, making evidence-based decisions about BCAM’s strategies and informing the wider aesthetic medicine community about our members’ clinical activity.”

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Conference

ACE rebrands business agenda At the Aesthetics Conference & Exhibition (ACE), the much-loved Business Track has been renamed to the In Practice Theatre. After its successful debut at CCR in October, the In Practice theatre sponsored by Enhance Insurance will feature the latest business insights and advice from healthcare professionals in the aesthetics specialty. Speakers include Dija Ayodele from the Black Skin Directory, aesthetic practitioner Miss Sherina Balaratnam, business coach Alan Adams, web marketing specialist Alex Bugg, business consultant Danny Large, consultant, plastic and reconstructive surgeon and trainer Mr Dalvi Humzah, PR consultant Julia Kendrick, plus many more. Event manager of ACE and CCR, Courtney Baldwin, said, “After a successful CCR event in October, we felt that the ‘In Practice’ agenda encompassed our business talks more and correlated with the Aesthetics portfolio as a whole. With some great speakers already announced, it’s the perfect place for aesthetic practitioners to learn about business strategies which they can implement into their clinics or for those who are thinking of taking the plunge and launching their own business.” ACE will take place at the Business Design Centre, London on March 11-12. You can register for free now through the ACE website. Injectables

Vital Statistics 51% of 2,271 UK adults feel pressured to have a certain body type, with women in their 20s and 30s feeling the most pressure (YouGov, 2021)

In a survey of 5,065 consumers, 43% purchase more due to a post on social media (Cheetah Digital, 2021)

Less than 20% of 2,000 adults have found the ‘perfect’ skincare routine for their skin type (Medovie, 2021)

Profhilo Body hits the UK market Distributor and training provider of the IBSA Derma portfolio in the UK and Ireland, HA-Derma, has introduced the Profhilo Body Kit to the UK market. The virtual launch occurred on December 2, 2021 with consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah and nurse prescriber Anna Baker. According to IBSA Derma, the new Profhilo Body kit aims to treat specific body areas where practitioners would usually offer patients non-invasive body treatments, explains HA-Derma. The injectable is designed to improve skin laxity, surface hydration and elasticity to the face and body. The new kit contains two Profhilo Body injectable treatments, one pack containing four Profhilo Figura Body Patches and one 150ml Profhilo Figura Body Cream. Iveta Vinkler, sales and marketing director at HA-Derma, said, “Profhilo has unquestionably led the skin injectable market since it launched in 2016. Although mainly used to treat the skin laxity of the face and neck, experienced practitioners have been treating the body for some time. Profhilo Body can be used in combination with energy-based devices, and it is also recommended for patients who are happy with their results on their face or neck and are ready to address skin laxity in areas such as their arms and abdomen.” To learn more about the Profhilo Body Kit, turn to p.54.

Online searches for ‘cheap lip fillers’ are up 150% year on year and ‘lip fillers Groupon’ are up by 35% since last year (UTH Aesthetics, 2021)

Salicylic acid was the most searched skincare ingredient in 2021 with 73,000 monthly searches (New Nordic, 2021)

87% of 813 video marketers say video has helped increase sales

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022

(Wyzowl, 2021)


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Events Diary 27th-29th January International Master Course on Aging Science imcas.com

11th-12th March Aesthetics Conference and Exhibition 2022 aestheticsconference.com

12th March Aesthetics Awards 2022 aestheticsawards.com

15th-16th September The BACN Autumn Aesthetic Conference www.bacn.org.uk Devices

New FDA clearance for SUPERB technology The SUPERB technology by aesthetic medical device company Sofwave Medical has received clearance by the US Food and Drug Administration (FDA). The technology has been given clearance for lifting the eyebrow, lax submental tissue and neck tissue whilst its previously been cleared by the FDA for a non-invasive dermatological treatment to improve facial lines and wrinkles. Sofwave Medical conducted a multi-site clinical study which evaluated the safety and effectiveness of the technology to lift the eyebrow, lax submental and neck tissue. A total of 80 subjects received treatments at five sites in the US. A total of 467 facial areas were treated. Dr Shimon Eckhouse, co-founder of Sofwave Medical, said, “The FDA clearance represents another major achievement for the Sofwave platform and showcases the company’s ongoing focus on innovation and clinical advancements in energy-based technology.”

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Skin

SkinCeuticals releases skincare kits Professional skincare and antioxidant company SkinCeuticals has launched new Daily Duo skincare kits. The Phloretin CF Kit is suitable for normal, combination and discolouration-prone skin, containing vitamin C serum Phloretin CF which works to prevent free radical damage and help to correct discolouration, fine lines and wrinkles, explains SkinCeuticals. According to the company, the Daily Duo C E Ferulic Kit is suitable for normal, dry and mature skin, containing the vitamin C serum C E Ferulic and H.A Intensifier, which aims to address dehydrated skin and discolouration. The Daily Duo Silymarin CF Kit is suitable for normal, oily and blemish-prone skin, containing the vitamin C serum Silymarin CF, which aims to prevent future breakouts whilst helping with blemishes. Lydia Davey, retail brand manager for SkinCeuticals, said, “In our latest instalment of SkinCeuticals kits we are focusing on our ‘prevent’ and ‘correct’ pillars, expertly curating three kits that each pair with one of our three iconic triple-antioxidant serums with cult-favourite HA intensifier to improve signs of ageing, blemishes and discolouration. Each kit is formulated to be sold based on skin type and concern and can be suitable for use post-injectable treatment, once the skin has healed, to improve natural hyaluronic acid concentration.” Body contouring

Cutera launches new muscle building device Laser manufacturer Cutera has launched the new truSculpt flex+. According to the company, the new device has a 15-minute no downtime, muscle building mode and can treat eight areas of the body simultaneously, compared to the truSculpt flex device. The device has been cleared by the Food and Drug Administration (FDA) for the improvement of abdominal tone, strengthening of the abdominal muscles and development of a firmer abdomen. It has also been cleared for the strengthening, toning and firming of the buttocks and thighs, explains Cutera. Tim Taylor, UK country manager, said, “We are proud to introduce the fastest muscle-sculpting treatment that is capable of replicating 54,000 crunches in only 15 minutes. This new muscle stimulation mode gives equal results to a 45-minute session, offering a new experience for practitioners and patients, putting their needs and wants at the heart of our business.” Injectables

New dermal filler enters UK market Aesthetic distributor Novus Medical has launched Hyafilia to the UK market. The range, manufactured by South Korean brand CHA Meditech, is a hyaluronic acid (HA) gel crosslinked with 1,4-butanediol diglycidyl ether (BDDE). Hyafilia has three products in the range. Hyafilia S is used to correct shallow and superficial wrinkles, Hyafilia M is used for the treatment of wrinkles and to increase lip volume, and Hyafilia V has the highest density to increase the volume of lips, cheekbones, chin, and cheeks, explains the company. Dr Rory Boud, an aesthetic practitioner who uses Hyafilia in his practice, said, “Hyafilia has set the bar high with their hyaluronic acid injectable dermal filler. A safe, reliable, and consistent filler that matches other market leaders. It’s hard not to be impressed with the quality and results of this filler.”

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Advisor

Aesthetics announces Sharon Bennett as new Clinical Lead Aesthetic nurse Sharon Bennett is the new Clinical Lead for the Aesthetics Clinical Advisory Board (CAB). The CAB comprises members of various professions within the aesthetics specialty, who share their expertise and experiences to ensure the latest clinical updates and standards are passed on to readers. Bennett is a renowned aesthetic nurse prescriber who has been practising aesthetics for more than 20 years and nursing for more than 30. In 1996, she flew to Sweden with a colleague to clear the UK distribution for a promising new product, which we all know today as Restylane. She is the co-founder and chair of the British Association of Cosmetic Nurses and she has represented the UK for standards in Europe, and worked tirelessly to develop the education, training and regulation of aesthetics across the UK. As part of her Clinical Lead role, Bennett will further support the clinical direction of the Aesthetics journal, as well as the Aesthetics Awards, Aesthetics Conference and Exhibition, CCR, Beauty Uncovered magazine and Beauty Uncovered Live patient educational event. Acting editor and content manager of Aesthetics, Shannon Kilgariff, said, “I have been working with Sharon for the past six years and she has been an invaluable asset to the Clinical Advisory Board, providing us with the latest industry insights and helpful ideas for progressing our content and supporting our loyal readers. I am absolutely delighted that she has accepted this position and I am looking forward to working closely with her and the rest of the CAB to further progress the brand and be the leading resource for medical aesthetic practitioners in the UK.” Bennett said she is delighted to take the lead to support the clinical direction of Aesthetics. “I have always enjoyed working with the Aesthetics team to ensure the community stays updated with the latest innovations, news and clinical and business insights from a trusted resource. The current CAB team are all experts in their own sector and I am looking forward to progressing the journal alongside them and also the events. Shannon and I, alongside the rest of the Aesthetics editorial team, will be working on some exciting things for 2022, so stay tuned!” Virtual

Merz introduces new digital platform Global pharmaceutical company Merz Aesthetics has launched a virtual events platform called Merz Aesthetics Events. According to the company, the platform enables practitioners to have instant access to a range of on-demand webinars, whilst also being able to enrol onto live webinars featuring live Q&A discussions. Industry professionals in medical aesthetics will be speaking on a range of topics including how to grow and develop your aesthetic clinic as well as practical tips and techniques for administering products. Webinars which took place in December involved aesthetic practitioners Dr Simon and Emma Ravichandran who walked users through individual approaches to treatment, from the initial consultation and facial assessment to designing a treatment plan. The webinar was offered in two instalments to ensure practitioners gained an understanding of patient consultation, explains Merz. You can catch up on the webinars through the Merz Aesthetics Events page by browsing the calendar, signing up and enrolling to ‘replay’ webinars.

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

BACN REGIONAL MEETINGS The long awaited BACN regional meetings are back! The BACN is hosting 14 regional meetings that will take place nationwide in 2022. The all-day meetings include a networking lunch, whilst featuring talks and presentations from industry partners who work directly with the BACN. These talks can range from injectables and skincare to business support and insurance concerns. Regional meetings create a space for businesses to interact with aesthetic nurses and showcase new and innovative products, whilst BACN members can learn about the latest developments happening in aesthetics. These events are free for members to attend, and guests are welcome to attend at a cost of £50. Members are encouraged to come to as many events across the UK as they would like. The day is a fantastic opportunity to network with nurses in their local area, learn something they may not have already known, and feel a little bit more connected after such a long time apart. Excitingly, these will be the first meetings attended by many of the new BACN regional leaders!

UPCOMING DATES Bristol – 24th January Cardiff – 28th January Southampton – 31st January Nottingham – 4th February Cambridge – 7th February Birmingham – 11th February Maidstone – 14th February Liverpool – 18th February Leeds – 3rd March Newcastle – 18th March Glasgow – 21st March London – 25th March Belfast – 28th March Manchester – 1st April All BACN meetings can now be booked via the BACN website. For more information, please contact Laura Watt, event coordinator, at lwatt@bacn.org.uk This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Alopecia

VIVACY launches new lip balm Aesthetic product manufacturer VIVACY Laboratories has released its latest addition to the Dermo-Cosmetic range, the Lip Protect. According to the company, the product aims to nourish and moisturise, giving a hydrated look to the lips. Ingredients include ricin oil and shea butter, and small spheres of hyaluronic acid which has been used in the VIVACY Beauty range as well as the STYLAGE dermal filler. In a clinical study conducted by VIVACY, 31 volunteers aged between 19 and 65 years old applied the product twice a day for 28 days. Participants noticed visibly rehydrated lips after 28 days of application. Terina Denny, national sales manager at VIVACY Laboratories, commented, “This is a great product to protect your patients’ lips after a lip treatment with STYLAGE Lips Plus for example, or simply to keep your patients’ lips hydrated during the cold winter.” Education

New training programme introduced A new mentorship and training programme named Aesthetication is due to launch in early 2022 to help aesthetic doctors to advance their independent practice. Established by aesthetic practitioners Dr Selena Langdon and Dr Paris Acharya, the programme is designed to build on the existing practical knowledge of trainees and guide them through a structured programme to develop aesthetic skills. The first intake to the programme will be focused on training doctors with an existing knowledge of aesthetic procedures, through a series of nine modules covering different advanced topics such as patient assessment, consultations, surgical skills, complications, injectable product selection, devices, skin health, business matters and suppliers. The programme also allows graduates ongoing support through the alumni network and enables trainees to access career and business opportunities. Aesthetic clinic Berkshire Aesthetics will offer graduates opportunities to take up either employment or operate new sites which are being established. Dr Langdon commented, “In developing my career, it was a real challenge to take the disparate skills learnt in the various short courses and apply these in a meaningful way which could do more for patients beyond a one-off treatment. The programme is designed to help those who have taken meaningful steps to establish themselves in aesthetics to develop into well-rounded aesthetic practitioners and clinic owners.” Ageing

New antiageing supplement launches Vitamin and supplement manufacturer HINNAO has released a new glutathione liquid supplement. According to the company, the supplement is taken orally and the HINNAO high-stability liposomal technology enables glutathione to be absorbed through the mucous membrane into the bloodstream, bypassing the gastrointestinal tract. Sophie Reed, co-founder at HINNAO, said, “We are excited to launch our HINNAO high stability liposomal glutathione into the UK and Europe, offering practitioners the opportunity to treat their patients with glutathione. Since 2013, we have been developing our technology with the main focus being clinically proven bioavailability.”

New hair loss treatment introduced UK pharmaceutical company Acre Aesthetics Ltd has launched a new hair loss treatment to the UK. According to the company, the QR 678 Neo is a hair regrowth therapy which treats the signs of male pattern baldness, hair loss in women, alopecia, and androgenetic causes of hair loss. The product has been approved by the US Food and Drug Administration (FDA) for all the above conditions and contains synergistic biomimetic peptides. The treatment involves dermarolling and then applying the product to the scalp. The treatment was invented by facial plastic, oculoplastic and cosmetic surgeon Dr Debraj Shome and consultant dermatologist Dr Rinky Kapoor from Mumbai, India. The hair therapy has been undertaken in multiple clinical trials with published results in the Journal of Cosmetic and Laser Therapy and Journal of Cosmetic Dermatology. In one trial, 1,000 patients were given intradermal injections into the scalp skin once every three weeks for a total of eight sessions. Hair pull test was performed before every session. A significant reduction in hair fall was seen in 83% of the patients on hair pull test. 75% of the patients believed that the hair injections were aiding the treatment of their hair loss. Dr Shome said, “Launching the product to the UK market has always been a milestone in our timeline for the product and we couldn’t have picked a more perfect company to do this with. After global success, we hope the UK market sees the uniqueness of the product and buys into the simplicity of the treatment journey. Now is the right time to launch the product, with hair loss being even more topical due to more recent recognised symptoms of long COVID-19 coming into play. We have taken time to not only develop the product but also ensure it comes with a catalogue of clinical studies with irrefutable results to assure patient confidence.” The treatment is now available to clinic owners in the UK.

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Awards

Aesthetics Awards 2022 Finalists announced Voting and judging for the premium awards ceremony in the UK aesthetics field – the Aesthetics Awards – has commenced. With almost 400 entries this year, it has been our busiest and most entered Awards so far. A huge congratulations to all deserving Finalists, which are listed on p.39 and on the Aesthetics Awards website. Users registered on the Aesthetics website are able to vote for a winner in the three product categories, as well as energy device, manufacturer, clinic support, professional initiative, distributor and the two training provider categories. Each individual can only vote once in each category and multiple votes under the same name or email address will be discounted from the final total. These categories will also be assessed by our judging panel and voting makes up 20% of the final score. An expert panel of more than 70 judges appointed by Aesthetics will review the Finalists. Voting and judging will close on February 1, so make your vote count! We are also pleased to announce four new Aesthetics Awards sponsors. Aesthetic manufacturer Croma-Pharma is sponsoring the Reception Team of the Year Award, RELIFE is supporting the Award for Best New Clinic, UK and Ireland, clinical distributor AestheticSource is sponsoring the Best Clinic North England Award and antimicrobial solution Clinisept+Skin is the sponsor of the Independent Training Provider of the Year Award. Acting editor and content manager Shannon Kilgariff, said, “This year has marked our highest number of entries yet! Congratulations to all our Finalists and I can’t wait to celebrate all the fantastic achievements of the aesthetics specialty that have taken place over the past year in March.” The Aesthetics Awards will take place on the evening of March 12, at the Royal Lancaster Hotel, London following the second day of ACE. Event

The BACN relaunches annual conference The British Association of Cosmetic Nurses (BACN) is relaunching its Autumn Aesthetic Conference in 2022. The event was last held in November 2019 and is exclusively for nurses working within medical aesthetics whilst bringing together BACN members from across the country. The event allows members to network, listen to key opinion leaders cover a range of topics, and also has a full exhibition space for companies to show new product launches and interact with potential customers. Gareth Lewis, BACN operations manager, said, “We are so excited to announce that we have date in the diary for our biggest event as an association, especially as it’s at a brand new location that allows us to run the most professional and dynamic conference yet.” The conference will take place on September 15-16, at The Eastside Rooms in Birmingham.

THE ACE 2022 EXPERIENCE Discover first-class learning at the longawaited Aesthetics Conference and Exhibition on March 11-12, 2022. Curation and plans are underway for what is set to be an incredible return for this leading event after so long, and we are delighted to announce that the new year brings a new announcement for the ACE 2022 agenda. The much-loved Business Track has a new name. After its successful debut as one of the most popular stages at CCR, the Business Track will retain its former glory as it becomes the In Practice Theatre. The new agenda will feature the latest business insights from experts across the field of aesthetic medicine. Expect business tips and industry updates from leading KOLs including award-winning practitioner Miss Sherina Balaratnam, PR guru Julia Kendrick, business coach Alan Adams, founder of the Black Skin Directory Dija Ayodele, web marketing specialist Alex Bugg, reconstructive surgeon and trainer Mr Dalvi Humzah, plus many more. To ensure we deliver only the latest content in the In Practice Theatre, we are proud to be working with Enhance Insurance. Business development executive of Enhance Insurance Sharon Allen said, “The whole team are really excited to be getting back to exhibiting. We have all missed the interaction with our clients, delegates and other exhibitors. Historically ACE has always been a fantastic event which we have always enjoyed attending!” At ACE 2022, you will attend the sessions that suit your learning needs the most and contribute to your career and clinic development, whether that involves laser treatments, body contouring methods, skincare approaches or business strategy. Further details on the agenda will be revealed soon with some sessions with limited places available taking bookings, including clinical sessions from aesthetic giants TEOXANE, Allergan, Galderma and more. Register now for exclusive priority access to these sessions and the chance to secure your place early.

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Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Education

Hygiene

Clinisept+ becomes skin prep partner at ACE Clinisept+, an antimicrobial solution from product manufacturer Clinical Health Technologies, will be the skin prep partner at the Aesthetics Conference & Exhibition (ACE). As a skin prep partner, Clinisept+ will be providing 2,000 bottles of Clinisept+ Prep + Procedure within delegate show bags. Ross Walker, director at Clinical Health Technologies, said, “We are very proud to be standard setters in clinical care and to have made a significant contribution to the UK aesthetics sector. Hopefully, our presence at ACE will remind attendees that best practice and patient safety have to be at the forefront of all aesthetic practices.” Threads

Amedica Group releases two new products Medical aesthetics company Amedica Group has added the new Nordyx threads and Light Eyes Ultra mesotherapy treatment to its portfolio. The threads use PLACL material which combines polycaprolacton (PCL) and polylactic acid (PLLA) together. The threads aim to stimulate the production of collagen, elastin, capillaries and hyaluronic acid within the skin due to the PLACL material, resulting in restored facial volume and smoother deep lines and wrinkles. The company has also introduced the Light Eyes Ultra, a mesotherapy treatment to help rejuvenate and refresh the under-eye area. The injectable aims to increase circulation and brighten the area, targeting concerns such as eye bags, wrinkles and dehydrated skin. Ingredients include vitamins, amino acids and minerals to improve dermal elasticity and the periocular area. Linn Emilie, managing director of Amedica Group said, “At Amedica, we want our practitioners to feel safe and know that they can treat their patients safely year after year using our products. Improving their patients’ skin quality and slowing down the ageing process without any long-term side effects.” Recruitment

Julie Scott joins Interface Aesthetics training faculty Aesthetic training provider Interface Aesthetics has welcomed independent nurse prescriber Julie Scott as a clinical trainer. Scott has more than 20 years of experience in the industry and is the owner and director of Facial Aesthetics in Essex. Scott will be the first nurse practitioner to join the injectables training team along with other surgeons, dentists and doctors training across foundation, advanced, masterclass and Level 7 diploma courses. Mr James Olding, Interface Aesthetics director and oral and maxillofacial surgery registrar, said, “Scott is highly regarded in the specialty, and has extensive experience in injectables, skincare and is a plastic surgery nurse. We are thrilled to have her as part of our growing team, which now has representation across all the key professions.”

New skincare pyramid created Skincare brand Swissline has produced an interactive animated tool named the Perfect Formula Pyramid that aims to offer patients an understanding of skincare, including when and how to approach ingredients for different skin concerns. The pyramid does not offer an in-depth look into every ingredient on the market, but instead provides an overview of the key ingredients, and which ingredients aim to help with certain skin concerns, from ageing to hydration. According to the pyramid, inflammation, hydration and UV protection are at the bottom and should be addressed first. Next, patients can address issues with the skin barrier and its defences with ingredients including amino acids, ceramides, vitamin C and probiotics. Then, patients should consider targeting signs of ageing with collagen, hyaluronic acid, and peptides and aim to improve cell turnover with retinol and AHAs. Finally, the top of the pyramid involves addressing cellular youth. The pyramid can be viewed on Swissline’s website along with suitable products for each skin concern. Research

Study indicates microneedling can help melasma A recent literature review has suggested that microneedling with topical therapy is safe and effective for the treatment of melasma. The review was discussed at the American Society for Dermatologic Surgery virtual meeting on November 19-21, 2021. Researchers had conducted a combined systemic review and meta-analysis of 12 eligible studies, which included 459 patients from seven countries. Topical therapies used included topical tranexamic acid, vitamin C, platelet-rich plasma, non-hydroquinonebased depigmentation serums and agents. The study showed that combining microneedling with topical medications saw a moderately positive effect at week eight (standardised mean difference at 0.45, 95% CI, 0.04-0.86) and a large effect at week 12 (difference of 1.04, 95% CI, 0.6-1.48). It had a similar efficacy to fractional CO2 laser and intradermal microinjections with topical therapies. Marcus Tan, dermatology resident at the University of Ottawa, said, “Our review found that microneedling alone, without any topical treatments, results in a 23% to 29% improvement in melasma. Adding topical treatments in general to microneedling resulted in greater improvements in melasma severity.”

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Patient education

HydraFacial announced as Beauty Uncovered Live Headline Sponsor Aesthetic manufacturer HydraFacial will be the Headline Sponsor for the patient-focused event, Beauty Uncovered Live. Organised by CCR and Aesthetics, Beauty Uncovered Live will allow patients to discover new products and aesthetic treatments, watch live demonstrations, and learn about the latest technology and trends in aesthetics. The two-day event aims to educate patients on making safe and ethical choices when seeking practitioners and treatments, promoting positivity and building trust amongst consumers. Lauren Gibson, UK country manager at HydraFacial, said, “We are delighted to be the Headline Sponsor for Beauty Uncovered Live! We cannot wait to attend the event and are looking forward to sharing why the original HydraFacial experience is the best option for your skin to glow.” Beauty Uncovered Live will take place on May 7-8 at the Business Design Centre, London, and registration will be open in early 2022. Body contouring

New multi-use device launches Aesthetic device company Deleo has introduced a new three-pronged treatment. The Deleo Cristal body layering concept has three functions to help target volume, tonicity, and firmness. The company explains that the Cristal Pro, the first phase in the Cristal body layering procedure, works on fat by removing adipocytes by using cryolipolysis. The second phase is the Cristal Fit which aims to build up the silhouette by toning and sculpting the muscles by using electromagnetic muscle stimulation technology, and the final step is the Cristal Skin which aims to improve firmness by minimising lax skin, through its multipolar radiofrequency technology. The Cristal Pro comes with a range of applicators, four of which are simultaneous. The device allows for the treatment of four areas at the same time. Co-founder of Deleo, Andre Fournier, said, “At Deleo, we pride ourselves on delivering innovative solutions to meet the needs of practitioners and the end-consumer. We knew that there was an opportunity to create a state-of-the-art machine with all three functions using the very best in technology whilst ensuring safety and efficacy.” Environment

IBSA Derma promotes sustainability Pharmaceutical company IBSA Farmaceutici Italia has published its third sustainability report. The report details the objectives, performances and activities relating to the environmental, economic and social sustainability of the company. IBSA explains that within the report, a growth in industrial production was recognised, the transition towards non-fossil fuels has accelerated and the renewable component in the energy mix supplied by industrial partners has increased. Director of HA-Derma, the exclusive distributor of IBSA in the UK and Ireland, Iveta Vinkler, said, “It’s a privilege to be representing a company like IBSA who are not only leading the way in the hyaluronic acid innovation, but despite the global success the company has been experiencing in the recent years; they are not blind to the effects this can have on the environment and are already taking actions towards a more sustainable business.”

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News in Brief Galderma signs agreement with ALASTIN Skincare Pharmaceutical company Galderma has acquired skincare brand ALASTIN Skincare. ALASTIN skincare provides daily skincare regimens and peri-procedural use with its TriHex technology, a mixture of peptides and active botanicals to support the appearance of rejuvenated skin. The acquisition is subject to customary closing conditions and necessary regulatory approvals, explains Galderma. BTL Aesthetics recruits new UK head of division Device manufacturer BTL Aesthetics has appointed Lee Brine as the new head of the UK Division. Brine began working in the medical device industry more than 30 years. He has has worked with BTL for eight years. Brine commented, “Throughout my career I have worked with the leading global names in aesthetics, but I have never seen anything comparable to the rise of BTL. The introduction of EMSCULPT and EMSCULPT NEO has transformed the medical aesthetic body contouring sector and I am delighted to take the brands forward within my new role.” New fat targeting device launches British medical device company Gelida Medica has introduced the Waves 21 device to its portfolio. According to the company, the device targets subcutaneous and visceral fat by using a combination of techniques, including metameric stimulation. A sinusoidal waveform is emitted to stimulate the metameres through the nervous system, helping to improve and reduce the specific problem whilst targeting visceral fat, explains the company. The device can be used on all areas of the body, except breast tissue and treatment benefits include removal of stomach fat and cellulite and skin tightening and firming. iS Clinical recognises Harpar Grace for successful distribution UK aesthetics distributor Harpar Grace International has been named iS Clinical’s third most successful distributor in 2021. Harpar Grace has been the exclusive distributor for iS Clinical for eight years and secured the achievement at the annual global conference which took place virtually due to the pandemic. Alana Chalmers, director of Harpar Grace, said, “We are delighted to secure recognition as the third largest iS Clinical distributor in the world at the recent global conference. We have achieved this success within the pandemic and being one of the youngest distributors with the most refined number of accounts.”

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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IMCAS 2022 Preview Aesthetics outlines the scientific agenda taking place at IMCAS 2022 The 23rd International Master Course on Aging Science (IMCAS) World Congress will return on January 27-29, 2022, at Palais des Congrès in Paris. The event aims to deliver an intensive educational conference covering themes in dermatology, plastic surgery and ageing science, with evidence-based research and the latest techniques outlined. Within the scientific programme this year, there will also be new topics and talks taking place. Ultrasonography as an essential ally for aesthetic procedures will be explored along with a cadaver workshop which gives an in-depth look at the use of ultrasonography after the use of injectables. The latest trends and innovations for artificial intelligence and robotics in aesthetics will be outlined, as well as updates on how to manage complications and an exploration of female and male patients in 2022. Additional topics taking place will be body surgery, which will pay attention to buttock augmentation, from implants to fat graft, abdominoplasty, and full body surgery from arms to thighs. Lasers

UKI-RES-2100180 DOP December 2021

and energy-based device (EBD) discussions will analyse a selection of clinical cases to help delegates learn from other practitioners’ experiences, whilst assessing, avoiding and managing complications with lasers and EBD. Hair restoration sessions will be taking place, discussing surgical hair techniques, as well as complex alopecia, medical therapies for hair loss and hair transplantation, alongside a wide variety of other aesthetic sessions on toxins, injectables, threads, cosmeceuticals, peels, body shaping, platelet-rich plasma and genital treatments. Speakers from across the globe will be attending the Congress this year including aesthetic practitioner Dr Raj Acquilla and consultant dermatologist Professor Firas Al-Niaimi from the UK, plastic surgeon Mr Tunc Tiryaki from Turkey, phlebologist Dr Leonie Schelke from the Netherlands and gynaecologist Dr Labib Riachi from Lebanon, plus many more. The event will take place in-person (Government restrictions permitting) and there will be an option to live stream the full congress online.

Adverse events should be reported. For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for Yellow Card in the Google Play or Apple App Store. For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Website: www.hpra.ie; Adverse events should also be reported to Galderma (UK) Ltd, Email: Medinfo.uk@galderma.com Tel: +44 (0) 1923 208950

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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during or adjacent to programmes commissioned for, principally directed at, or likely to appear particularly to under-18s.2 Examples of cosmetic interventions that the new restriction is intended to cover include, but are not limited to, breast augmentation or uplift procedures, breast reduction, abdominoplasty, blepharoplasty, rhinoplasty, labiaplasty, rhytidectomy, hair restoration surgery, skin rejuvenation treatments such as injectable treatments, chemical peels, microneedling, non-ablative laser treatments, laser or light treatments, teeth whitening treatments and micropigmentation.4 With these new restrictions coming to light, we spoke to senior media relations officer at the ASA Toby King, aesthetic practitioner Dr Steven Land, and vice president of the British Association of Aesthetic Plastic Surgeons (BAAPS) Mr Marc Pacifico to gain an insight into the new regulation and what this means for the aesthetics specialty.

Addressing body image issues According to the ASA, these new restrictions have been implemented because children and young people are subject to body image pressures and negative body image perceptions which can impact their self-esteem, wellbeing, mental health and behaviours.2 In a 2017 survey conducted on 11-16-year-olds in the UK, 79% said how they look is important to them, and 52% often worry about how they look.5 King explains, “The ASA has previously ruled against irresponsible cosmetic intervention advertising that exploited young people’s body insecurities. However, these new targeting rules will appropriately limit young people’s exposure to these ads during stages of their lives where they Aesthetics explores the new restrictions on particularly vulnerable to body image-related advertising to under-18s and what this means are pressures and negative perceptions.” for the specialty After campaigning since 2012 for a ban on cosmetic surgery advertising for under-18s due to body Regulation in the aesthetics field has always been a hot topic image and psychological issues, BAAPS welcomes the new ruling.6 of conversation amongst practitioners. With the Botulinum Toxin Mr Pacifico states, “The new rulings have come into force after and Cosmetic Fillers (Children) Act coming into force in October years of campaigning, and due to the intervention of the MP Laura last year, making it illegal to administer botulinum toxin or dermal Trott who restricted botulinum toxin and filler cosmetic procedures fillers to anyone under 18 in England,1 regulation ruling in aesthetics to under-18s through the Children’s Act, the UK is finally starting to is slowly beginning to emerge, even if a fully regulated industry will address some of the longstanding serious issues that have existed still take some time. for years. It’s been a real wakeup call for the industry. Advertising In November, it was announced that on May 25, the Advertising should be honest, legal, decent and truthful. It should be applied Standards Authority (ASA) is introducing new targeting across the industry not just for specific groups who are considered restrictions which prohibit cosmetic interventions from being vulnerable. The BAAPS fully supports this more recent measure and advertised to under-18s.2 Following a public consultation last had been calling on this for years. We are pleased that the CAP has year, the Committee of Advertising Practice (CAP) and Broadcast had a review and its ruling correlates with the law.” Committee of Advertising Practice (BCAP) decided to introduce the new restrictions. Within the new restrictions, adverts must Monitoring ads not appear in non-broadcast media (such as newspapers and To comply with the new regulations on advertising, the ASA warns print publications) directed at under-18s or in other non-broadcast that aesthetic practitioners must ensure their adverts are responsibly media where under-18s make up more than 25% of the audience targeted. King emphasises, “It’s worth noting that the General Medical (this applies where the likely audience cannot reasonably be Council (GMC) registered doctors who practice cosmetic interventions determined from a simple assessment).3 For broadcast adverts (such and practitioners who are members of the Joint Council of Cosmetic as television, radio, and social media), adverts must not appear Practitioners (JCCP) and Save Face already abide by similar targeting

Restricting Cosmetic Advertisements

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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restrictions through the respective Codes of Practice. However, there are several different tools on numerous platforms that will allow advertisers to avoid targeting children. The ASA does not prescribe the ways in which advertisers may do so, but we have CAP guidance on age-restricted ads online.” Although the new ruling is a step towards advertising regulation, Dr Land remains unsure on the policing of these adverts and believes that under-18s will still be able to gain access to these ads if they want to. He explains, “I hope that the new restrictions help as the pandemic has uncovered a frightening amount of body image issues that practitioners are beginning to see. However, people will find ways to see these adverts if they are looking – not targeting under-18s is not the same as not being available to under-18s. Instagram simply asks if you are over the age of 18 before allowing you access to certain pages so it’s not exactly a robust challenge. Advertising guidance and rules are only as good as the policing. The ASA announced two years ago that they would be taking more action against botulinum toxin advertising by actively monitoring feeds and sending warnings/ prosecutions to those not abiding. However, I haven’t seen much change in this area and many clinics are still doing this.” The new advertising regulation will be monitored by the ASA, King assures, to ensure practitioners are complying with the updated restrictions. King states, “We will continue to monitor the impact of the rules and there will be a 12-month post-implementation review to ensure that there aren’t any unintended consequences from the new rules. We have several mechanisms for monitoring ads, including the use of bot profiles, and we’ll continue to keep a close

eye on the situation. If someone does breach these restrictions, the ASA have a number of sanctions available. In the first instance, we ban ads outright, removing them from circulation. We can also work with media providers to have ads removed and can flag problem ads to our statutory backstops for further statutory action.”

A step towards regulation Regulation within aesthetics offers a continuous debate and discussion amongst the industry. New rulings and laws demonstrate a positive step towards safety for patients. Dr Land notes, “I think the next step needs to be increased policing of the rules that already exist. Why create more rules and regulations if they aren’t being followed up? It would be nice to see the ASA potentially working with more associations and stakeholders to ensure regulation is abided by.” REFERENCES 1. UK Parliament, ‘Botulinum Toxin and Cosmetic Fillers (Children) Act 2021’, Private Member’s Bill, 2021, <https://bills.parliament.uk/bills/2620> 2. Advertising Standards Authority, ‘Strict new rules for ads for cosmetic interventions’, CAP News, 2021, <https://www.asa.org.uk/news/strict-new-rules-for-ads-for-cosmetic-interventions.html> 3. Advertising Standards Authority, ‘Media placement restrictions: protecting children and young people’, Advertising Guidance, 2017, <https://www.asa.org.uk/static/uploaded/45f254d5-299b-4afb947b00bcdab55821.pdf> 4. The UK Code of Non-Broadcast Advertising and Direct and Promotional Marketing (CAP), ‘Cosmetic interventions’, Advertising Guidance (broadcast and non-broadcast), 2021, < <https://www.asa.org. uk/uploads/assets/815e71f5-4ce7-4f03-82c85387a23295b3/CAP-Advertising-Guidance-CosmeticInterventions-2021-update.pdf> 5. Be Real, ‘Sombody Like Me: A report investigating the impact of body image anxiety on young people in the UK’, 2017, <https://www.berealcampaign.co.uk/research/somebody-like-me> 6. BAAPS, ‘Mary had a little lipo? Protect children from surgery ads’, 2012, <https://baaps.org.uk/media/press_releases/1374/mary_had_a_little_lipo_protect_children_from_ surgery_ads>

Connecting the World to Expert Subspeciality Pathologists Diagnexia connect clinics to a global network of renowned pathologists supporting the highest quality of care and the achievement of diagnostic confirmation objectives.

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diagnexia.com Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Treating The Body With Energy-Based Devices Aesthetic practitioners discuss non-invasive body contouring According to the NHS, people seeking help to lose weight through its weight loss programme are, on average, five pounds heavier than before the COVID-19 pandemic.1 It’s been suggested by many practitioners in medical aesthetics that the pandemic has led to an increase in people seeking aesthetic help to reduce fat and contour their bodies. This is likely due to the limitations of the pandemic in terms of gym closures and the impact on people’s mental health, as well as a lack of understanding on the inadequate effects of diet and exercise after a certain age. As the demand for these treatments increases, with their relatively lower costs compared to surgical alternatives, lower risk of complications and side effects, and shorter recovery times, it is no surprise that business consulting and market research company DelveInsight estimates that the global energy-based aesthetic devices market will be valued at US $4.96 billion by 2026, up from $3.09 billion in 2020.2 Aesthetics spoke to three aesthetic practitioners to get an overview of the body treatment landscape.

Emerging trends Desire drives the market, and as the interest in minimally-invasive body treatments increases, the energy-based body contouring industry is going from strength, to strength and making huge innovative strides. “With years and years of focusing on injectables and rejuvenating the face, people are now turning to their aesthetic clinicians for help with their bodies too,” says aesthetic practitioner Dr Nestor Demosthenous. “I think in recent years and with innovations in the non-invasive body contouring industry, people have begun to look to aesthetics for a helping hand in the body fat and muscle department.” As Dr Demosthenous points out, energy-based body contouring is the third most popular aesthetic treatment in China after skin and facial rejuvenation and facial contouring,3 and it’s set to grow at a compound annual growth rate of 16.3% globally.4

“I would say the most important trend in recent years is the use of multitasking devices,” says aesthetic practitioner Dr Galyna Selezneva. “10 years ago, this section of the device industry was more about fat loss alone, but now patients are more educated and are seeking out a more holistic approach whilst looking for a treatment that not only tackles fat, but also builds muscle and improves the skin.” In the past, multiple devices were necessary, “And now,” she adds, “These machines are multifaceted and they’re growing in popularity.” Dr Munir Somji agrees that combination treatments are on the rise, stating, “I don’t find people coming in asking for specific treatments as much anymore, they’re looking for a combination of things, for example fat reduction at the same time as muscle stimulation, and we could use a combination of energy-based devices to suit different concerns.” He also asserts that wellness has become a popular trend in recent years, “People want help with superficial fat reduction, as well as visceral fat. This is the fat that wraps around organs deep inside the body, which can lead to serious health conditions like heart disease, breast cancer, and Alzheimer’s therefore, these treatments can make you healthier overall.”

Patient selection and the consultation Dr Somji comments that he is starting to see patients of all ages coming into the clinic for body contouring. “I tend to see 18-35-yearolds coming in asking about body contouring, whereas it used to be more 35-50-year-olds. In my experience the gender imbalance is levelling out. Before I would say it was about 70/30 female over male coming in, and now I’m seeing more of a 60/40 ratio. I’ve also started to see an increase in patients coming in for post-partum treatments, to help tighten up their muscles.” Although there are certain conditions that might make a patient unsuitable for body treatments which must be thoroughly deduced during the consultation, including heart problems and eating disorders, Dr Selezneva says, “The perfect patient does not exist and it is up to us as practitioners to find a solution to their problems. This is why we need a wide range of devices to personalise the treatment plan to each patient’s individual needs.” All practitioners interviewed are in agreement that there are certain conditions to look out for, highlighting the importance of identifying

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Figure 1: 38-year-old woman before and immediately after one truSculpt flex session. Image courtesy of Dr Nestor Demosthenous

Body Dysmorphic Disorder (BDD). “BDD is something we have seen a lot more of because people have been spending more time in the mirror and analysing themselves during the COVID-19 pandemic,” explains Dr Somji. “An important question to ask is ‘Is this the only area you want treated?’, and if they can’t specify a particular concern but want their whole body treated, then that is a definite red flag. If they are overly emotional during the consultation, then this also might be an indication that they are not emotionally stable enough. It’s our responsibility as practitioners to ascertain if there is an issue and if they will be happy with the results.” As a psychiatrist, Dr Selezneva, knows how to spot the signs of BDD. “I will always check their full medical history, discover if they have been refused treatment before or been shopping around to find a practitioner who will treat them, and assess whether the patient will be able to maintain and handle the results, and of course, if they come into the clinic grabbing handfuls of non-existent fat, further conversation is necessary before we decide to treat.” Dr Demosthenous agrees that an important part of the consultation is to assess where the patient is in their fat loss journey, and whether they will be able to maintain the results of a non-surgical aesthetic treatment. “It’s essential to find out what lifestyle changes they are making to aid and sustain their weight loss. Diet, Before

After

Figure 2: 32-year-old patient before and after Emerald Laser treatments. Image courtesy of Dr Munir Somji

exercise and lifestyle all need to be assessed prior to treatment and the patient needs to demonstrate that they are doing enough to be able to maintain the results, otherwise the treatment is pointless,” he says. Dr Demosthenous references a patient he once saw who was significantly overweight, “He informed me he had cut down his daily crisp consumption from four packets a day to two, and that he was going for fish and chips and a pint after our appointment. To him, this was obviously a step in the right direction, however much more is needed with regards to eating the right foods (and amounts), increasing physical activity, obtaining enough sleep etc. Sustainable changes to lifestyle are what is most important.” Before and after imagery The practitioners differ in their opinions on the use of before and after imagery when it comes to managing patient expectations of body treatments. “I think before and after imagery is very important, and I show my patients a range of results, some with dramatic changes and some with less significant results,” explains Dr Demosthenous. “It’s not possible to say exactly how the results will turn out,” he continues, “So I think showing before and afters is really useful in managing patient expectations.” It also depends on the patient’s size and perception of their own bodies, Dr Demosthenous continues, “Losing an inch off the waist might be loads for one person and barely anything for another.” Dr Somji agrees that before and after imagery is important and asserts the point that standardising the imagery is essential. “The images must be consistent so the patient can get a full picture of the results. 360-degree images are important and take measurements of circumferential changes from bony anatomy landmarks.” Dr Somji also agrees that showing an array of results is useful in managing patient expectations. “I show patients good, average, and minimal results so they can have a range of expectations, and I also show the good

effects when a patient has stuck to the aftercare and has maintained a healthy diet.” Dr Selezneva takes a different approach to the use of before and after imagery. “It’s a very personal and subjective process,” she says, “I don’t show my patients before and after images and prefer to speak to them about their own potential and manage their expectations that way, as every result is different.”

Choosing a device Dr Somji looks for three main factors when choosing a device for his clinic. “Firstly, I want innovative technology that will bring something new to my clinic to offer my increasingly educated patients,” he says, “Secondly, I look for a device that has a wealth of clinical studies behind it over a long period of time to ensure it’s as safe as it can be, and thirdly, it must have a proven level of efficacy,” he explains. “Science, science, science!”, agrees Dr Selezneva, “Safety is paramount and should always come before pricing considerations as we’re working on a human being here. We have 37 devices that can be used on the body in clinic, and I want to sleep at night knowing that they are all the best and most reputable devices from companies that offer support and a history of proven efficacy. I also use all the machines on myself first,” she continues, “So I can make sure they are effective and what we want in the clinic, and so I can accurately explain the process to the patient.” For more advice on choosing a device, read our online article.5

Popular treatments Here our practitioners discuss some of the technologies which they believe are effective and worth adding to your treatment portfolios. Dr Demosthenous on muscle stimulation Still an emerging treatment, muscle stimulation is fast becoming a popular and versatile option for a range of concerns. “The idea of being able to build muscle with a device fascinates me,” says Dr Demosthenous, “Non-surgical body treatments are now able to sculpt and define the body and the use and popularity of muscle stimulating devices is developing fast. There has been a big focus on body contouring for a long time now. We can only truly contour a body when the underlying structure (muscle) is addressed. I suppose it’s comparable to revolumising a face, we need the right volume in the right place. Building muscle builds a better body. The

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Figure 3: 30-year-old patient before and five months after one CoolSculpting treatment and four EMSCULPT NEO treatments on the abdomen, flanks, inner and outer thighs and buttocks. Image courtesy of Dr Galyna Selezneva

fitness industry has been singing from this hymn sheet for years.” Dr Demosthenous mentions his preferred devices include the electrical muscle stimulation (EMS) device truSculpt flex which induces muscle contractions using an electric current, for building muscle, used in combination with Cutera truSculpt iD radiofrequency device to remove fat. He explains, “The flex helps to build muscle with minimal effort and is great for people who struggle to get to the gym. Originally a 45-minute procedure, now condensed to a 15-minute session, I recommend four to six sessions over a two to three week period.” Another interesting innovation of muscle stimulation is how it can be used for injury rehabilitation. “More research is needed on the use of muscle stimulation for lower limb injuries,” explains Dr Demosthenous, “People who rapidly lose muscle due to disuse following injury could really benefit from this, not only to maintain muscle mass but also to strengthen the muscles and reduce recovery time, pre- and post-surgery.” Dr Somji on low level laser therapy Low level laser therapy (LLLT) employs non-thermal ablation of adipocytes for focal adiposity and skin tightening on the abdomen, thighs, flanks, and neck, according to Dr Somji, and patients need up to eight sessions for optimal affect. “When I looked at the Erchonia Emerald Laser,” says Dr Somji, “I thought this is probably the newest technology in terms of body contouring. It’s a cool laser and there’s no thermal release so no chance of burns or side effects.” The low chance of side effects makes LLLT an almost universal treatment, continues Dr Somji, “It works on patients who could benefit from circumferential fat reduction and even works on patients who are clinically obese, which has really opened up a new era of fat contouring.” Dr Somji asserts that the Emerald

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Laser can be used for reducing circumference as well as adapting shape, “We can now take a patient who is severely overweight, put them on a good exercise and diet plan, and reduce fat with LLLT before contouring, which is really exciting,” explains Dr Somji. Another advantage of the low-risk treatment is the ability to treat the arms and the calf/ ankle areas, which are a common trouble area for women, as Dr Somji points out. “These areas are very difficult to treat from a surgical perspective, so liposuction is not really an option, and this is where LLLT is a great treatment.” Dr Somji also recommends other body contouring treatments in his clinic, “Fat freezing is a great safe, non-surgical alternative to liposuction for the removal of localised fat in hard-to-shift areas, for example under the arms or chin. This is great in combination for radiofrequency skin tightening to improve skin laxity and reduce fatty deposits,” he explains. Dr Selezneva on cryolipolysis This process of fat freezing uses a high-pressured suction handpiece to target areas of the body which are cooled to negative temperatures to cause apoptosis of fat cells. These are then removed by lymphatic drainage.6 “We use a wide range of machines and technologies within the clinic,” says Dr Selezneva, “I like Cristal Cryolipolysis from Deleo, especially for men, due to its versatile applicator options and wide treatment area, making it possible to effectively target the upper and lower stomach, hips, inner and outer thighs, chest, and back, upper arms, calves, knees, buttocks and chin.” One session takes about 70 minutes, explains Dr Selezneva, “Your patients can just lie back and relax and can continue their normal day straight afterwards. There is a risk of paradoxical adipose hyperplasia, which has been in the news in recent months and affected the popularity of cryolipolysis, but it’s a very low risk at less than 1%.”7 As well as cryolipolysis, Dr Selezneva reshapes patients’ bodies with an array of other devices and will choose the best device for the individual patient. “I love using BTL Exilis and BTL Unison to target cellulite in combination with ULTRAcel to tighten the skin after fat removal. The key is to combine treatments to get the whole body looking it’s best!”, she says.

The future of body contouring With the steep interest in energy-based devices for body treatments, practitioners predict further developments and innovations.

“The demand for these procedures will certainly increase,” says Dr Selezneva, “And as the public becomes more aware of these treatments, I think there will be a higher demand for multitasking devices targeting different areas and concerns on the body. I genuinely believe the time of the single use device is over and we will move to a more personalised treatment protocol.” Likening it to injectable treatments, she continues, “With botulinum toxin, there’s a recommended dose of product, but you personalise it depending on the severity of the wrinkles and the results the patient wants – we can do the same with multitasking devices.” Dr Somji agrees that combination treatments are the way forward and adds that, “I also believe the introduction of nutritional information is imperative.” Dr Demosthenous also agrees that there will be a significant increase in the popularity of energy-based body treatments. “I see the public becoming more and more interested in these treatments as they evolve and develop, and people realise they can get rid of stubborn pockets of fat in a minimally invasive non-surgical way.” In terms of muscle stimulation, Dr Demosthenous feels as though society hasn’t quite caught on yet. He says, “People feel that by removing fat they will have a better body. This isn’t necessarily the case. Increasing muscle will have both aesthetic and health benefits, far greater than removing fat. I also don’t think we’ve seen the true potential of muscle stimulation devices yet,” he adds, “They’re relatively new in their current form, and more research and studies are needed to understand the possibilities that are open to us with these devices. So, watch this space.” REFERENCES 1. NHS, ‘People seeking NHS weight loss help heavier than those before COVID new study finds’, 2021, <https://www.england.nhs. uk/2021/09/people-seeking-nhs-weight-loss-help-heavier-thanthose-before-covid-new-study-finds/> 2. Delve Insight, ‘The energy based aesthetic market’, 2021 <https://www.delveinsight.com/report-store/energy-basedaesthetic-devices-market> 3. Statista, ‘China popular medical aesthetics procedures’, 2021, <https://www.statista.com/statistics/1135411/china-popularmedical-aesthetics-procedures/> 4. Market Research.com, Global Body Contouring Devices Market – 2020 – 2027, 2021, <https://www.marketresearch.com/ DataM-Intelligence-4Market-Research-LLP-v4207/Global-BodyContouring-Devices-14595976/> 5. Bird, V, ‘Choosing a Device for Your Clinic’, Aesthetics Journal, https://aestheticsjournal.com/feature/choosing-a-device-foryour-clinic, 2021 6. American Society of Plastic Surgeons, ‘Non- surgical fat reduction, ASPS, What is Cryolipolysis?’, 2019, <https://www. plasticsurgery.org/cosmetic-procedures/nonsurgical-fatreduction/cryolipolysis> 7. Jalian H. R, Avram M. M, et al., ‘Paradoxical Adipose Hyperplasia After Cryolipolysis’, JAMA Dermatol, 150(3), 317-319, 2014, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4171727/>

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Understanding Hydroxy Acids in Skincare Dr Kalpna Pindolia explores the clinical evidence behind hydroxy acids and why they have become increasingly popular in skincare products The skin represents the interface between an individual and other members of society,1 as well as providing protective and physiological functions. Contemporary skincare has become increasingly popular over time for the promotion of skin health, prevention of ageing and the treatment of some skin conditions. It uses a variety of functional ingredients to cause multifaceted activity in restoring and repairing skin. Hydroxy acids are widely used and studied skincare compounds and have become increasingly popular ingredients in skincare for therapeutic and cosmetic applications.

What are hydroxy acids? Hydroxy acids in skincare include alpha hydroxy acids (AHAs), polyhydroxy acids (HAs), beta hydroxy acids (BHAs), aldobionic HAs (BAs) and aromatic hydroxy acids (AMAs).2 They have been shown to reverse the effects of photoageing and improve wrinkles, skin elasticity, tone and hydration.3 Since their introduction to dermatology around 40 years ago, it has been found that applied topically, via the detachment of the hyperkeratotic stratum corneum, hydroxy acids also provide beneficial effects for conditions like ichthyosis, dry skin, keratoses and warts, as well as follicular hyperkeratosis, including that occurring in acne.4,5,6

Exfoliation and hydroxy acids The stratum corneum of the superficial epidermis comprises of corneocytes surrounded by the intercellular lipid lamellae attached by the corneodesmosomes. Tight junctions attaching to the lateral walls of the keratinocytes in the upper part of the stratum granulosum, as well as the intercellular lipids, such as cholesterol, ceramides, and free fatty acids create a barrier which also prevent transepidermal water loss.7 Exfoliation, the process of removing excess corneocyte build-up, stimulates cell turnover, resulting in a more polished, smoother, and translucent skin surface.7 A complete renewal of the epidermis requires 40 to 60 days in the elderly compared with 28 days in young adults.8 Radiance diminishes as the epidermal cell turnover rate slows down. This results in the build-up of defunct keratinocytes in the stratum corneum and follicular ostia, creating the appearance of rough, dry skin, and enlarged pores.9 Regular exfoliation has been shown to increase dermal matrix hyaluronic acid and glycosaminoglycans (GAGs), improving dermal thickness.10 Chemexfoliation can be rapid and predictable using specific agents to achieve uniform effect at the desired cutaneous depth. This results in wound healing and skin rejuvenation to occur, whilst simultaneously minimising complications, such as scarring and

pigmentary change.11 This is unique to hydroxy acids and is not found with other chemical or mechanical exfoliants, which work by solely removing the top layers of the skin.4

The ageing skin The earliest obvious harbingers of the ageing process are manifested in the deterioration of the skin morphology and physiology.12,13 Changes include dermo-epidermal junction thinning due to a decrease of laminin, loss of collagen, glycosaminoglycans (GAGs) and subcutaneous fat.14 There is impairment of barrier function, decreasing epidermal cell turnover, keratinocyte and fibroblast proliferation, and reduction of the vascular network responsible for delivering oxygen and nutrients to the tissues.15,16 Visible changes of intrinsic ageing of the skin include thinning, atrophy, fine lines, and dryness.17 Extrinsic ageing manifests as stratum corneum thickening, mottled pigmentation, dullness, dryness, wrinkles, and laxity.18

Alpha hydroxy acids Many AHAs are derived from fruit, so are called ‘fruit acids’. Frequently used AHAs include glycolic, lactic and mandelic acid. Others include malic acid (apples), citric acid (citrus fruits) and tartaric acid (fruit and grape wine). They thin the stratum corneum by reducing cohesion and speeding up the normal process of skin cell regeneration and exfoliation.19,20 They also weaken intercorneocitary cohesion and stimulate desquamation by interfering with the establishment of ionic bonds and desmosomes by inhibiting transferases and kinases. This leads to a reduction of the polarity of sulphate and phosphate groups on the corneocyte membrane.21 Desquamation occurs, promoting cell renewal, as well as stimulating collagen synthesis at the deeper dermal level, increasing skin thickness. At deeper layers of the stratum corneum, AHAs can also reduce pH contributing to desmosome dissolution. In the dermis, AHAs cause an increase in glycosaminoglycan deposition and collagen synthesis contributing to the biomechanical properties of skin.21 AHAs also improve the keratinocyte maturation process,4 reverse basal cell atypia and even out the distribution of melanin in photodamaged skin.22,23 At higher concentrations of 25%, AHAs can cause increased epidermal or papillary dermis thickness, increased acid mucopolysaccharides, improved quality of elastic fibres, and increased collagen density.22 The papillary dermis increases in thickness and the rete pattern (or dermal papillae) becomes more prominent. This effect has been shown to persist for months without further topical application.24,25

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AHAs also can promote increased gene expression of collagen and hyaluronic acid in the dermis and epidermis.26,27 UVB radiation encounters the uppermost epidermal keratinocytes and regulates crucial biological responses in skin cells, such as reactive oxygen species accumulation, apoptosis, DNA fragmentation, and inflammation. The different concentrations of AHAs have therapeutic and cosmetic benefits as an integrated system that serves as a physical and immunological barrier to harmful external factors and prevents DNA breakage.28 Glycolic acid Glycolic acid comes from sugar cane and can be synthetically produced. It is the smallest and simplest AHA in terms of chemical structure. It has the greatest bioavailability of all the AHAs.29 It is usually avoided with sensitive skin, as its small molecular size aids penetration but can cause irritation, and increased sun sensitivity.30 Glycolic acid is used at concentrations of 5% or above for exfoliation and improves fine lines and wrinkles, pigmentation, skin texture, size of pores, collagen content, tone and brightness.4 Sustained daily treatment with low concentrations of glycolic acid brings about a normal stratum corneum with increased resiliency, and enhanced cell renewal, as well as a plumper, firmer skin matrix.4,26 Lactic acid Lactic acid is derived from sour milk and tends to be used on sensitive and dehydrated skin. A larger particle size facilitates less skin reaction, due to shallower penetration of skin. Concentrations over 2% for hydration and 5-10% for exfoliation are used to provide antiageing benefits, including smoother, even-toned skin, with a reduction in the appearance of fine lines and wrinkles.22 It may also improve the skin microbiome, as it is a component of the skin’s natural moisturising factor.22 Lactic and mandelic acids have recently emerged as a popular agent due to their equivalent efficacy compared to gold-standard glycolic acid, with relatively mild discomfort profiles, minimal associated downtime, and risk.29,31-37 Lactic acid is structurally identical to glycolic acid, with the exception of an additional methyl group at the β-carbon end, a lower pKa and thus a lower pH than glycolic acid at equivalent concentrations, allowing for efficient chemexfoliation at lower concentrations.38-41 Lactic acid can provide comparative efficacy as standard glycolic acid peels for the treatment of photodamage, superficial hyperpigmentation, and fine rhytides.4 As lactic acid has a lower pH than glycolic acid, a lower concentration is often used to achieve an equivalent depth of keratocoagulation compared to glycolic acid, which allows a favourable side effect profile and recovery time.4 In particular, lactic acid has been reported to have repaired artificially UV damaged human dermal fibroblast cell lines by enhancing the amount and integrity of elastin fibres, whilst some derivatives of lactic acid have been widely used due to their hygroscopic and emulsifying properties.42,43 Mandelic acid Mandelic acid is soluble in both water and polar organic solutions, which results in a more uniform penetration through lipid-rich areas of skin.38-41,44 It is sourced from bitter almonds and wild cherries, and improves the appearance of skin texture, fine lines and wrinkles.45 It is an oil-controlling AHA with reported antibacterial and anti-inflammatory effects that may be beneficial for the treatment of oily, acne prone skin.45 There is also demonstrated efficacy in the treatment of

superficial erythema and dyspigmentation as well as in the reduction of cutaneous sebum production.46,29 Comparatively, the results of mandelic acid peels are more subtle than that of superficial glycolic acid peels; however, the side effects and subsequent downtime of mandelic acid are less. Patients often experience minimal desquamation, and reepithelialisation is often complete within three to five days.4 Citric acid Originating from citrus fruit, citric acid is a unique hydroxy acid as it contains a single hydroxyl group relative to three carboxylic acid functional groups in both alpha and beta positions, making it an alpha and beta hydroxy acid. It improves skin texture and the appearance of fine lines and wrinkles and has antioxidant benefits, helping to minimise the damaging effects of the sun and pollution on skin.23 Concentration vs pH In low concentrations, hydroxy acids are components of many non-prescription skincare promoted as being effective for ameliorating skin ageing. In higher concentrations, preparations can be used as chemical ‘peels’ to treat indications like calluses, keratoses, acne, psoriasis, and photoageing.47 Concentrations more than 10-15% in the case of AHAs require professional administration due to potential side effects and complications associated with skin irritation.48 AHAs used in a product must be available in their free acid form to penetrate the skin.49 Lower pH increases the amount of acid that can be absorbed, but also come with increased irritation and potential chemical burns. This means that the pH is important as concentration and products formulated in the pH range of 3.5 to 4 tend to be safe for home use.50

Poly hydroxy acids PHAs have been described as second generation AHAs and bionic acids have been more recently marketed as third generation AHAs (Table 1). AHAs contain one hydroxyl group, while PHAs, like

At higher concentrations of 25%, AHAs can cause increased epidermal or papillary dermis thickness, increased acid mucopolysaccharides, improved quality of elastic fibres, and increased collagen density

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Bionic acids Lactobionic and maltobionic acids are examples of BAs often used in skincare.58,59 The ‘third generation’ Glycolic, lactic, First generation AHA Normal, hyperkeratotic citric, mandelic poly-AHA – lactobionic acid – is suitable for all skin Second Sensitive, barrier compromised, types.60 It conserves AHA capacity to promote cellular PHA Gluconolactone generation acne prone, rosacea prone turnover, enhancing the stratum corneum exfoliation process, but also exerts a deeper moisturising, thus Lactobionic acid, Third generation Bionic acids (BAs) maltobionic acid, All having a humectant effect. Such properties make them cellobionic acid specific for the treatment of ageing signs and wrinkles of sensitive skin.21 Table 1: Types of AHAs This acid is made by a polyhydroxy acid, gluconic acid, which is present in cells as an acid form of gluconolactone (gluconic acid lactone) and lactobionic acid contains gluconolactone, together with a sugar molecule, galactose, which two or more hydroxyl groups and bionic PHAs have an additional is a natural component of GAG.20 Lactobionic acid exerts a very 7,51 carbohydrate monomer. Their molecular size is larger, but they can strong antioxidant action and it has an important moisturising effect.60 penetrate skin well. Water-binding and gel matrix formation properties Topically applied, this contributes to the improvement of skin tone provide both moisturisation, protection and soothing effects.12,52 and to the reduction signs of ageing, especially wrinkles, both Hydroxy acids like gluconolactone, lactobionic acid and maltobionic clinically and histologically.60 It works to protect the skin against 51 acid are potent antioxidants. They help to strengthen the skin’s photoageing by inhibiting destructive MMP enzymes which degrade barrier function and serve as antioxidant chelating agents, absorbing the skin’s structure and strength.61 9 free radicals generated by ultraviolet exposure. They offer the Maltobionic acid is also a potent humectant and antioxidant. It has benefits of AHAs without irritation, making them suitable for use on antiageing benefits like improving skin texture, clarity and roughness, sensitive skin, rosacea, and after cosmetic procedures. They also providing similar benefits to lactobionic acid.58,59 9 provide additional barrier strengthening, and moisturising effects. Generation

Ingredient

Example

Skin type

Beta hydroxy acids Gluconolactone Gluconolactone is a very commonly used PHA. Its structure keeps the keratolytic property of AHAs, but also adds a stronger moisturising action with the attraction of water. Due to the lactonic structure, this agent hides its acid nature, being suitable even for sensitive skin and for particular skin areas like the periorbital skin and lip contours.21 Concomitant use of gluconolactone-containing products with prescription azelaic acid is used for the treatment of rosacea. This improves therapeutic outcomes compared to medication alone, including erythema and the appearance of telangiectasia, with improved tolerability of the prescription medication.53 It is also a natural antioxidant, contributing to the enhancement of anti-wrinkle efficacy, and antiageing actions in general.54,55 It works on all levels of the skin to smooth the surface, even skin tone, plump and hydrate.56 As well as data to support the claim that PHAs have the same benefits as AHAs, further antiageing effects of PHAs that have been demonstrated histologically, such as increased GAGs, increased viable epidermal thickness, antioxidant activity and reduced matrix metalloproteinase enzymes (MMP) activity.52,57 Benefits have been demonstrated on various Fitzpatrick skin types, with studies looking at African-American, Asian, Hispanic and Caucasian skin types.52,57

Treatment planning tips Considering the literature referenced throughout this article, below are some of my personal treatment planning tips for using hydroxy acids: • The consultation is crucial to develop truly effective long term treatment plans • Discuss that some skin ‘flaws’ are normal • Exclude contraindications, for instance, allergy to salicylates

Beta hydroxy acids (BHAs) include β-hydroxybutanoic and salicylic acid (SA). For BHAs, an over-the-counter product with a concentration of 1-2% is effective.49 Some BHAs are a combination of AHA and BHA; for example, malic acid is an AHA and a BHA, and citric acid can also be categorised as a BHA.49 Salicylic acid Salicylic acid can be synthesised artificially. Natural sources include willow bark, sweet birch, and wintergreen leaves. It is lipid soluble, making it appropriate for oily skin and acne, and miscible with epidermal lipids and sebaceous gland lipids in hair follicles. When used for chemical peels, it removes intercellular lipids, which are linked covalently to the cornified envelope surrounding the surface epithelial cells.62 SA also decreases adhesion of corneocytes and causes loosening of these cells and their subsequent detachment.63-65 As a desmolytic agent, SA disrupts cellular junctions by extracting desmogleins causing dehiscence of epidermal cells leading to exfoliation.66 Therefore, it is not true as a keratolytic agent, as it disrupts cell cohesion rather than breaking keratin filaments.67 The concentration at which the anti-inflammatory action of SA is most pronounced is between 0.5-5%.68-70 The aromatic benzene ring in

• Consider skin type, Fitzpatrick grade and ethnicity • Discuss realistic expectations, downtime and timescales for change • Prime skin with a ‘go slow and grow’ to improve tolerance and reduce the incidence of irritation with lower concentrations of product to reduce skin reactions • Topical AHAs can increase sun sensitivity.30 Integrate sun protection

into the treatment plan and assess compliance • Educate the patient about the importance of skin barrier function and how not to ‘over comply’ and induce negative outcomes • Consider combination treatments with peels and other modalities • Choose a skincare line that caters for your patient’s bespoke needs and budget to promote compliance

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the salicylate converts ultraviolet radiation into longer wave radiation, which is felt as heat, explaining the mechanism of action in sunscreen preparations.71 SA also has antimicrobial and antifungal properties72 and an anaesthetic effect, which is seen during the peeling procedure and increases the patient’s ability to tolerate the procedure.73 The properties and indications of SA are dependent on the concentration used. For instance, 0.5-10% in acne and 20-30% in superficial peels is sufficient.74 Salicylic acid decreases dermal thickness rendering its use in antiageing formulations limited.5,23 It can be used as a therapeutic option for comedonal acne, and can be an adjunctive modality for treating open and closed comedones, post-acne erythema, and hyperpigmentation.75 It also decreases secretion of sebum in patients with acne74 and has been reported to decrease sebocyte lipogenesis, reduce inflammation, and decrease the cell viability of SEB 1.76 The efficacy of SA in the treatment of photoageing and acne has been described in patients with Fitzpatrick skin types I–III as well as in skin types V and VI.77 It is suggested that care needs to be taken with BHAs to avoid hyperpigmentation in Fitzpatrick skin types IV, V and VI.78,79 SA is absorbed readily when applied topically to the skin.71 A small study of nine patients conducted the relative bioavailability of SA following dermal application of a 30% SA skin peel preparation, and concluded that facial peeling using the 30% formulation should

Aesthetics Clinical Advisory Board Member and consultant ophthalmologist Miss Elizabeth Hawkes says… This is an excellent overview of hydroxy acids in topical skincare and chemical peels for medical and cosmetic applications. The article describes the different types of hydroxy acids, their

Dr Kalpna Pindolia is an emergency medicine and maritime medicine doctor and is director of education at Harley Academy, as well as an aesthetic practitioner at Story Clinic, London. She is passionate about holistic aesthetic practice using skin and injectable approaches for ageing well. Qual: MB, BCh, MCEM, L7 Injectables

not pose any significant risks to the systemic health in patients.80 Used in combined modalities, evidence has been found that sustained application of AHAs and BHAs results in the biosynthesis of glycosaminoglycans (GAGs), collagen, and improved quality of elastic fibres.22

Hydroxy acids and pregnancy The literature suggests AHA peels can be used safely in pregnancy.81 Studies examining the use of glycolic acid during pregnancy have not been conducted; however, it is suggested that using topical glycolic acid should not be of concern, as only a minimal amount is expected to be absorbed systemically.82,83 Overall, the use of lower concentrations appear more sensible as any negative reactions may be associated with exaggerated pigment responses. Use of SA peels are not recommended during pregnancy as the structure is closely related to that of aspirin.74,84

Summary Skincare is a fundamental pillar of holistic aesthetic treatment plans. Whilst one product cannot address all the changes that ageing brings, use of hydroxy acids can promote skin health, and improve some skin conditions for a range of skin types. Hydroxy acids form a class of compounds with benefits to the epidermal and dermal components of skin and in the right patient, can restore and maintain skin confidence.

derivates and physiological action. Within the aesthetic community it is agreed that good skincare is paramount for skin rejuvenation in addition to injectable treatments. The author shares some practical tips when using hydroxy acid. Of importance, there is discussion about the concentration strength of hydroxy acids in relation to the pH value, which is important for preventing chemical burns. This article is a good introduction for practitioners wishing to incorporate chemical peels into their practice.

Questions

a. b. c. d.

2 days 8 days 28 days 40 days

2. Which of the following acids are derived from fruit?

a. b. c. d.

Lactic acid Tartaric acid Beta hydroxy acid Azelaic acid

3. Which of the following statements are true?

a. AHAs must be in the free acid form to penetrate the skin b. Lower pH products can be associated with skin irritation c. Glycolic acid is a small molecule which easily penetrates the skin d. All of the above are true

4. Which of the following statements are false?

a. Lactic acid has comparable efficacy in the treatment of superficial hyperpigmentation b. Mandelic acid is sourced from bitter almonds and wild cherries c. Lactobionic acid is only suitable for combination skin d. Citric acid has antioxidant benefits

5. Which of the following statements about BHAs are true?

a. Salicylic acid is a desmolytic agent b. Salicylic acid has poor activity against Cutibacterium acnes c. B-hydroxybutanoic acid is a BHA d. All of the above statements are true

1.

Complete renewal of the epidermis occurs within how many days in the average young adult?

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Test your knowledge!

Possible answers

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

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

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Case Study: Treating the Male Jawline Cosmetic surgeon and aesthetic practitioner Dr Benji Dhillon explains how he used the Teosyal® range of fillers to re-masculinise the male jawline Assessment, ageing and anatomy A 39-year-old male patient came to see me at my clinic concerned that his face, and specifically his jawline, lacked the masculine look and the definition he had enjoyed when he was younger. He was particularly concerned that he had a ‘weak’ looking profile. I conducted a thorough consultation and review of his medical records which demonstrated no contraindications for potential dermal filler treatment. A key factor to take into consideration during any consultation is whether the patient had any prior aesthetic treatment. Having never had fillers before he needed a bit of encouragement to help him understand that well placed fillers were in no way likely to feminise his face, but instead could be used to enhance male features with a natural looking result. I showed him before and after images of previous male patients I had treated with filler, which reassured him that we would be able to achieve his desired result. As we age, our face loses volume across multiple anatomical layers and actually increases in volume in other areas, and therefore the external appearances of age begin to appear. I chose to treat this patient with filler as I believed it was the best option to replace the volume loss and give a natural, yet more defined result. Before

After

Before

After

Before

After

Patient before, and five months after jawline treatment with Teosyal® Ultra Deep and Teosyal® RHA 4

Advertorial Teoxane

Technique and product selection I used a total of 5ml of filler distributed throughout the jawline and chin, as well as a small amount in the cheeks. I started with 0.4ml of Teosyal Ultra Deep filler in each cheek to define the contour of the cheek bone then I injected a total of 0.6ml of Ultra Deep into the chin area using a needle to create the desired anterior projection. Teosyal Ultra Deep was also used in 0.4ml boluses with a needle at each gonial angle. Finally, I used a total of 1.8ml of Teosyal RHA 4 with a cannula superficially along each jawline and vertically at a subcutaneous level along the border of the ramus of the mandible to create definition. The science behind these two products from Teosyal can’t be argued with, and they’re based on great technology. The RHA range uses a longer chain of hyaluronic acid (HA) which is more like our naturally occurring HA, so we can use it more superficially as it moves with the face, resulting in the most natural outcome you can achieve. The Ultra Deep can be used at a deeper dermal layer which is great for pure structure and definition. I use it to project and in a male face it’s fantastic for adding those angles we want to achieve. I do not use topical anaesthetic, but I make sure the patient is comfortable at all times, taking a gentle and methodical approach to the treatment, explaining what I’m doing and treating one side of the face first and assessing the results before moving on to the next. The patient was over the moon with the results. He was thrilled that his face had regained some of the masculine definition and the results were natural looking. I routinely advise that the patient applies no topical creams or lotions on the face, or exercise for 12 hours after treatment. I also get a member of my team call after three weeks for a check-up. The patient needed no follow-up treatment.

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Aesthetics | January 2022

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33


Your patients have the will. You can offer them the way. Patients achieved significant and sustained weight loss, in conjunction with reduced calorie intake and increased physical activity, in 1-year and 3-year trials vs placebo1,2* Similar to natural glucagon-like peptide-1, Saxenda® works to decrease appetite and thereby reduce food intake3†

This is not a real patient but only an illustration.

This material only relates to adult indication only. Please refer to SmPC for full indication. Adults: Saxenda® is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of ≥ 30 kg/m2 (obesity) or ≥ 27 kg/m2 to < 30 kg/m2 (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea.

If you would like to request a visit from a representative please contact us on obesityuk@novonordisk.com For all product related enquiries please contact Novo Nordisk Customer Care Centre on 0800 023 2573.

The exact mechanism of action is not entirely clear.

* In the 1 year trial patients taking Saxenda® (n=2487) had a baseline body weight of 106.2 kg. Completers’ (n=2437) mean weight loss at week 56 of treatment was 8.4 kg. Patients taking placebo (n=1244) had a baseline body weight of 106.2 kg. Completers’ (n=1225) mean weight loss at week 56 of treatment was 2.8 kg1, p<0.001. In the 3 year trial Patients taking Saxenda® (n=1505) had a baseline body weight of 107.5 kg. Completers’ (n=1472) mean weight loss at week 160 of treatment was 6.5 kg. Patients taking placebo (n=749) had a baseline body weight of 107.9 kg. Completers’ (n=738) mean weight loss at week 160 of treatment was 2.0kg2, p<0.0001. References: 1. Pi-Sunyer X, Astrup A, Fujioka K, et al; for the SCALE Obesity and Prediabetes NN8022-1839 Study Group. A randomised, controlled trial of 3.0 mg of liraglutide in weight management. N Engl J Med. 2015;373(1):11-22. 2. le Roux CW, Astrup A, Fujioka K, et al; for the SCALE Obesity and Prediabetes NN8022-1839 Study Group. 3 years of liraglutide versus placebo for type 2 diabetes risk reduction and weight management in individuals with prediabetes: a randomised, double-blind trial. Lancet. 2017;389(10077):1399-1409. 3. Saxenda® Summary of product characteristics, NI&GB. Bagsvard, Denmark: Novo Nordisk A/S.

Prescribing Information Please refer to the Saxenda® summary of product characteristics for full information. Saxenda® Liraglutide injection 3 mg. Saxenda® 6 mg/mL solution for injection in a pre-filled pen. One pre-filled pen contains 18mg liraglutide in 3mL. Indication: Adults: Saxenda® is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of ≥ 30 kg/m² (obesity) or ≥ 27 kg/m² to < 30 kg/m² (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea. Adolescents (≥12 years): Saxenda® can be used as an adjunct to a healthy nutrition and increased physical activity for weight management in adolescent patients from the age of 12 years and above with obesity (BMI corresponding to ≥30 kg/m2 for adults by international cut-off points) and body weight above 60 kg. Posology and administration: Saxenda® is for once daily subcutaneous use only. Is administered once daily at any time, independent of meals. It is preferable that Saxenda® is injected around the same time of the day. Recommended starting dose is 0.6 mg once daily. Dose should be increased to 3.0 mg once daily in increments of 0.6 mg with at least one week intervals to improve gastro-intestinal (GI) tolerability. Treatment with Saxenda® in adults should be discontinued after 12 weeks on the 3.0 mg/day dose if patients have not lost at least 5% of their initial body weight. Daily doses higher than 3.0 mg are not recommended. No dose adjustment is required based on age but therapeutic experience in patients ≥75 years is limited and not recommended. No dose adjustment required for patients with mild or moderate renal impairment or mild or moderate hepatic impairment but it should be used with caution. Saxenda® for adolescents from the age of 12 to below 18 years old a similar dose escalation schedule as for adults should be applied. Treatment with Saxenda® in adolescents should be discontinued and re-evaluated if patients have not lost at least 4% of their BMI or BMI z score after 12 weeks on the 3.0mg/day or maximum tolerated dose. Saxenda® is not recommended for use in patients with severe renal impairment including endstage renal disease, or severe hepatic impairment or children below 12 years of age. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Special warnings and precautions for use: There is no clinical experience in patients with congestive heart failure New York Heart Association (NYHA) class IV and Saxenda® is not recommended for use in these patients. It is also not recommended in patients with eating disorders or treatment with medicinal products that may cause weight gain. Use of Saxenda® is not recommended in patients with inflammatory bowel disease and diabetic gastroparesis since it is associated with transient GI adverse reactions including nausea, diarrhoea and vomiting. Acute pancreatitis has been observed with the use of GLP-1 receptor agonists, patients should be informed of the characteristic symptoms. If pancreatitis is suspected, Saxenda® should be discontinued. If acute pancreatitis is confirmed, Saxenda® should not be restarted. In weight management clinical trials, a higher rate of cholelithiasis and cholecystitis was observed in patients on Saxenda® than those

Saxenda® is a trademark owned by Novo Nordisk A/S. 2021 © Novo Nordisk A/S, Novo Allé, DK-2880, Bagsvæd, Denmark

on placebo, therefore patients should be informed of characteristic symptoms. Thyroid adverse events such as goitre have been reported in particular in patients with pre-existing thyroid disease. Saxenda® should be used with caution in patients with thyroid disease. An increased risk in heart rate was observed in clinical trials. For patients who experience a clinically relevant sustained increase in resting heart rate, treatment with Saxenda® should be discontinued. There is a risk of dehydration in relation to GI side effects associated with GLP-1 receptor agonists. Precautions should be taken to avoid fluid depletion. Patients with type 2 diabetes mellitus receiving Saxenda® in combination with insulin and/or sulfonylurea may have an increased risk of hypoglycaemia. Episodes of clinically significant hypoglycaemia have been reported in adolescents (≥12 years) treated with liraglutide. Adolescents should be informed about the characteristic symptoms of hypoglycaemia and the appropriate actions. Fertility, pregnancy and lactation: Saxenda® should not be used during pregnancy. If a patient wishes to become pregnant, or pregnancy occurs, treatment with Saxenda® should be discontinued. It should not be used during breast-feeding. Undesirable effects: Very common (≥1/10); nausea, vomiting, diarrhoea, constipation. Common (≥1/100 to <1/10); hypoglycaemia, insomnia, dizziness, dysgeusia, dry mouth, dyspepsia, gastritis, gastro-oesophageal reflux disease, abdominal pain upper, flatulence, eructation, abdominal distension, cholelithiasis, injection site reactions, asthenia, fatigue, increased lipase, increased amylase. Uncommon (≥1/1,000 to <1/100); dehydration, tachycardia, pancreatitis, cholecystitis, urticaria, malaise, delayed gastric emptying Rare (≥1/10,000 to <1/1,000); anaphylactic reaction, acute renal failure, renal impairment. The Summary of Product Characteristics should be consulted for a full list of side effects. MA numbers and Basic NHS Price : 5 x 3 ml pre-filled pens £196.20 NI: EU/1/15/992/003 GB : PLGB 04668/0409 Legal category: POM. Full prescribing information can be obtained from: Novo Nordisk Limited, 3 City Place, Beehive Ring Road, Gatwick, West Sussex, RH6 0PA. Marketing Authorisation Holder: Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark. Date last revised: October 2021

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Novo Nordisk Limited (Telephone Novo Nordisk Customer Care Centre 0800 023 2573). Calls may be monitored for training purposes. Saxenda® is a trademark owned by Novo Nordisk A/S.

December 2021 UK21SX00423


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Treating Leg Veins with Sclerotherapy Nurse prescriber Claire Judge explains the treatment of thread veins Microsclerotherapy is a cosmetic procedure used for the treatment of unsightly thread or spider veins on the leg. These are abnormally dilated superficial veins (CEAP class 1)1 that can cover wide areas of the legs. Generally, they are asymptomatic, but they can cause itching, swelling and discomfort and can affect more than 40% of the female population over the age of 50.2 Men are thought to be less susceptible to thread veins due to lower levels of the hormone progesterone, but in my experience, they can still be treated successfully. Patients of all skin tones can get thread veins, but they appear much more obviously with paler skin and the majority of patients presenting with thread/spider veins have a strong family history of the condition, and pregnancy and hormonal changes will aggravate their propensity.3 Many patients who are concerned about these veins will investigate potential treatments on the internet, and come to an initial consultation expecting overnight perfection following one treatment, after seeing a video of someone’s veins instantly disappearing. This article aims to clarify what the practitioner should be communicating to the patient about the treatment process, as patients who have their expectations managed at the outset will be far happier with the outcome.3

The consultation Patient selection is paramount and suitability must be established, predominantly by ascertaining whether they will be able to successfully keep up with the aftercare. Absolute contraindications include known allergies to the sclerosant, acute deep vein thrombosis or a pulmonary embolism, local

infection in the area of sclerotherapy or a severe generalised infection, pregnancy and breastfeeding and long-lasting immobility.4 Taking photographs pre-operatively shows patients the extent of change since treatment started, enabling them to see the progress made, rather than visualising an idealised image of how their legs could look.4

The treatment Sclerotherapy is a skilful technique which involves cannulating fine veins and injecting a sclerosing agent. The agent I use is Aethoxysklerol sodium tetradecyl sulfate, which I have been using for more than 25 years and have found it has less risks of side effects than other sclerosants, in particular staining and ulceration. The sclerosant liquid solution damages the lining of the vein walls causing swelling, hence the injected vein will swell and shut, so the blood is redirected to unaffected veins. This can cause the misleading results seen on social media that the treatment has immediate and final results. The affected veins form a fibrous cord that is absorbed over time.5 I use a 30 gauge needle with a 5ml syringe. A 10-30 degree bend is placed in the needle with the bevel up (Figure 1). Approximately 0.2ml of Aethoxysklerol 5mg/ml is injected into the vein. Whilst injecting, the skin should be stretched taut to ease cannulation and patient comfort. Pressure is applied to the skin, restricting the area of drug dispersal. Efficacy of the drug has been shown to diminish with increasing distance from the entry site so practitioners should only blanch a 2cm square area, and low pressure will also help reduce intra luminal trauma.2

Potential side effects and complications In my experience, legs often look worse before they improve and there are side effects that patients should be made aware of at the outset, including staining, lumpiness and tenderness over some areas, ulceration and failure of the treatment.6 Staining is a common side effect, occurring in 10-30% of patients in the short term and it usually settles within the year for around 80% of patients.7 It occurs due to deposits of melanin and haemosiderin pigment as a result of postinflammatory processes and haemosiderin deposition. If the drug is injected under high pressure into a superficial larger fragile vein, this may cause a higher incidence of staining due to rupture of these vessels. This causes the release of haemoglobin into the dermis which is degraded into haemosiderin. Thus, using larger volume syringes may help reduce this risk.7 Some patients will have innate tendency toward cutaneous pigmentation (total body iron stores and/or altered iron transport and storage mechanisms).7 There is no consensus as to whether there is a higher risk of staining with patients who have dark skin and dark hair, but this side effect has also been reported in these patients.6,8 Other rarer side effects can include allergic reactions and migraines.4 Another potential concern is extravasation of the drug, which can be caused by incorrect siting of the needle.4 If this occurs, the injection should immediately stop, and the resulting bleb should be massaged until the drug disperses.9 As the drug enters the vein often there is no discomfort; however, rarely, the patient my feel a slight stinging. Once completed the veins may feel slightly itchy (this is more common distally) and urticaria may occur as the earliest manifestation of perivascular inflammation.9 During this process I would spend time talking to the patient to both reassure and distract them. This is also an effective way to assess the patient’s tolerance and welfare throughout the procedure.

Post treatment

Figure 1: Using a cannula at an angle to treat thread veins with sclerotherapy

Figure 2: Patient after sclerotherapy treatment wearing compression socks and cotton wool on the entry points, which can be seen underneath

After treatment of larger flares or more substantial reticular veins, cotton wool balls provide immediate pressure to the area, held in place with micropore. On completion of treatment, I will tell the patient to remain lying flat, and will measure them for class 2 graduated compression stockings (30mmhg) from foot to thigh. Compressing the veins immediately is thought to be beneficial for reducing the risk of undesirable side effects such as post

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022



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Case study: the stages of recovery A 52-year-old female patient attended clinic with extensive dark thread vein webs covering wide areas of her legs bilaterally (Figure 3). She had one sclerotherapy treatment and kindly agreed to take regular pictures of her legs so as to document her treatment journey. DAY 0

Stockings stay in place continuously for 72 hours, at which point patients may remove them. All are advised that their legs will look bruised, the veins may feel lumpy and tender and there will be marks from the areas of cannulation (Figure 4). DAY 3

DAY 6 Before

At this point some of the bruising may be fading and patients would still be wearing

stockings during the day only (Figure 5). If some of the veins are very hard, lumpy and uncomfortable it may be possible to puncture the area and express the thrombus. Veins and staining are fading. Post sclerotherapy pigmentation commonly occurs after sclerotherapy whether treating large or the smallest of telangiectasia; it is defined as the appearance of persistent, increased pigmentation running the course of a treated ectatic blood vessel.4 DAY 21

As expected, the veins are fading well (Figure 6). It can take many months for the fading to settle, but as the patient DAY 50

Day 3

Figure 3: 52-year-old female Figure 4: Patient three patient presenting to clinic days after sclerotherapy with visible thread veins

Day 6

A useful treatment to help patients

The veins have significantly improved and the stains are fading (Figure 7). At this point the patient reassesses herself and decides if she wants follow-up treatment. This particular patient is planning to return for a followup treatment to further target any remaining visible veins. She has been delighted with the progress thus far. In one clinical study of 37 women with bilaterally symmetrical telangiectatic leg veins treated with post-sclerotherapy compression, spontaneous resolution in 70% of cases has been reported at six months.12 DAY 70

Day 50

Figure 5: Patient six days after treatment

sclerosis pigmentation, temporary ankle oedema and telangiectatic matting.10 It creates direct apposition of the vein walls producing effective sclerosis by limiting thrombus formation. This in turn may minimise telangiectatic matting.10 Compression is also useful as it can augment the body’s natural muscle pump.11 Although the need for compression for varicose veins is universally recommended, there is ongoing debate regarding the need to compress when treating thread veins.8 However, a significant number of thread veins are fed by larger reticular or varicose veins, thus, by reducing the blood flow through compression it is likely that blood flow to the smaller vessels will be more effectively sclerosed with a subsequent decrease in recanalisation.8 For the 52-year-old patient seen in Figure 2, I recommended she wear her stockings for 72 hours continuously, and then for a further three days during the daytime. This was due to the presence of large webs and flares and some reticular veins that I felt would benefit from extra compression. Moreover, the patient was a nurse and on her feet a lot, therefore there would be increased pressure on the veins.

is aware of this risk and can see the improvement she is happy with the progress seen at this stage.

Day 70

Figure 6: Patient 50 days after treatment

Figure 7: Patient 70 days after treatment

may take many months for the full outcome to be seen. The veins that have been treated will never return as the vein has collapsed, but new thread veins may appear. The images in this article are very typical of patients who are awaiting the results of their sclerotherapy treatment, and it is vital to manage patient expectations in terms of the length of the process. On browsing the internet, there are very few honest images to be found when researching how legs look in-between the before and after images. I think it is necessary for patients to fully understand that the treatment is not perfect and side effects are relatively common, albeit short term. Claire Judge is an independent nurse prescriber and a founding member f the British Association of Sclerotherapy. She has 26 years’ experience in Sclerotherapy. Quals: RGN, NIP, BEM

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Microsclerotherapy is an effective treatment for thread veins; however, it is not perfect. Although quick to undertake, the treatment

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Aesthetics Awards Finalists

THE 2 0 2 2 FI N A L I ST S! VOTE FOR YO UR WINNE RS ! After hosting an amazing virtual event last year, the Aesthetics Awards is gearing up for our first in-person ceremony since the pandemic so we are delighted to reveal the 2022 Finalists for the Aesthetics Awards! Established in 2011, the Aesthetics Awards is regarded as the most prestigious and longest-serving awards ceremony of its kind in the UK, recognising practitioners, clinics, suppliers, products and other aesthetic companies. Dubbed ‘The Oscars of Aesthetics’ we are delighted to yet again bring the industry together for a dazzling evening of recognition and celebration. With hundreds of exceptional, high-quality entries, not everyone can be shortlisted, so we want to extend a huge congratulations to everyone who has put in the time and effort to submit their applications. Feedback is available upon request via contact@aestheticsjournal.com and we encourage all entrants to apply again next year. Of course, a huge congratulations to this year’s Finalists and good luck at the ceremony on March 12! Certain categories will be partly judged by our esteemed judging panel, and partly voted-for by you, giving you the opportunity to

celebrate the products you value and thank the suppliers and companies who do so much to support the running of your practice. Not all categories can be voted for, so make sure you check below what Aesthetics Awards you can be involved in. Voting will consist of 20% of the final score in the applicable categories and you can submit your vote by logging into aestheticsawards.com by February 1 – remember your vote counts! Please note that voting is monitored through IP addresses and individuals can only vote once. Multiple votes under the same name will be discounted from the final total and multiple votes from within organisations will also be monitored.

HOW DOES THE JUDGING PROCESS WORK? Alongside the Aesthetics journal reader votes, we are proud to have an esteemed judging panel with a diverse range of skillsets consisting of more than 70 aesthetic professionals. Six judges will be assigned to each category and are chosen specifically for their knowledge and expertise in that area, as well as to ensure that conflicts of interest are avoided. For more information regarding the judging process, visit our Frequently Asked Questions page.

COMPANY F INALIS TS PRODUCT/PHARMACY DISTRIBUTOR OF THE YEAR – VOTE NOW! ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

AestheticSource Church Pharmacy Cosmeditech Innovations Ltd HA-Derma Harpar Grace International Healthxchange Group

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AESTHETIC TECHNOLOGY LTD BTL Industries Candela InMode UK Lumenis Lynton Sciton UK Skinade Teoxane UK VIVACY Laboratories

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PRODUCT F INALIS TS THE SKINCEUTICALS AWARD FOR ENERGY DEVICE OF THE YEAR – VOTE NOW! ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

BYONIK Pulse Triggered Laser (Pure Swiss Aesthetics Ltd) CoolSculpting Elite (Allergan Aesthetics) Dermalux Tri-Wave (AESTHETIC TECHNOLOGY LTD) Emerald Laser (Erchonia Lasers Ltd) ENDYMED 3DEEP Skin Science (AesthetiCare) Nordlys (Candela) Stellar M22 (Lumenis) Secret RF (Cutera UK) Thermage FLX (Solta Medical)

THE 5 SQUIRRELS AWARD FOR INJECTABLE PRODUCT OF THE YEAR – VOTE NOW! ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

DESIRIAL (VIVACY Laboratories) Juvéderm VYCROSS (Allergan Aesthetics) Profhilo (HA-Derma) Restylane (Galderma) Sculptra (Galderma) Teosyal RHA (Teoxane UK) WOW Fusion (WOW Facial)

SURGICAL PRODUCT OF THE YEAR – VOTE NOW! ⊲ Skinade MD Pre + Post Care Surgical Programme (Skinade) ⊲ Solutions for Scars (Science of Skin) ⊲ The Micro Adipose Processing System (AQ Therapeutics, Inc)

TOPICAL SKIN PRODUCT/RANGE OF THE YEAR – VOTE NOW! ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

AQ Active Serum (AQ Therapeutics, Inc) Heliocare 360 (AesthetiCare) Hyaluronic Acid Boosting Serum (PCA Skin) iS Clinical Cosmeceuticals (Harpar Grace) skinbetter science (AestheticSource) SkinCeuticals Silymarin CF (SkinCeuticals) Synergy 6 NX GEN SPF50 (Intradermology) The MATRIXYL SYNTHE’ 6 Range (AlumierMD) The Perfect Peel (Medica Forte Ltd) Your Signature Range (5 Squirrels) ZO Skin Health (Wigmore Medical)

FAST. EFFICIENT. SECURE.

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THE DIGITRX BY CHURCH PHARMACY AWARD FOR PRODUCT INNOVATION OF THE YEAR

BELOTERO Revive (Merz Aesthetics) Definesse Threads (RELIFE) EMSCULPT Neo (BTL Aesthetics) Eternal (Luna Microcare) MaiLi (Sinclair Pharma) Profhilo Body and Body Kit (HA-Derma) Purifeyes (Face Restoration Ltd) Revanesse (Prollenium Medical Technologies) The Pollution Shield 5PF (Dr LEVY Switzerland)

TRAI NI NG P ROV IDE R F INALIS TS THE STERIMEDIX AWARD FOR SUPPLIER TRAINING PROVIDER OF THE YEAR – VOTE NOW! ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

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AestheticSource Training Cynosure Clinical Training Team HA-Derma Teoxane UK VIVACY Laboratories Wigmore Medical

THE CLINISEPT+SKIN AWARD FOR INDEPENDENT TRAINING PROVIDER OF THE YEAR – VOTE NOW! ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

Acquisition Aesthetics Avanti Aesthetics Academy Cosmetic Courses Dr. Uche Academy Inspired Cosmetic Training Interface Aesthetics Learna Limited Medical Aesthetics Training Academy Ltd (MATA Courses) Younique Aesthetics Academy

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R EGI ONAL CLINIC F INALIS TS THE AESTHETIC TECHNOLOGY AWARD FOR BEST CLINIC LONDON ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

Adonia Medical Clinic Cadogan Clinic Dr Leah Cosmetic Skin Clinics Juve Medical and Aesthetics LINIA Skin Clinic London Aesthetic Medicine London Professional Aesthetics Premier Laser Clinic UK Ltd The Centre for Advanced Facial Cosmetic & Plastic Surgery The Clinic by Dr Mayoni Vie Aesthetics

THE AESTHETICSOURCE AWARD FOR BEST CLINIC NORTH ENGLAND ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

THE HAMILTON FRASER AWARD FOR BEST CLINIC SOUTH ENGLAND ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

BEST CLINIC MIDLANDS AND WALES ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

Aesthetic Health Cliniva Medispa DD Clinical Discover Laser Ltd Dr Bejma Medical Clinic Dr Natalie Clinics Dr Sobia Medispa Lumiere Clinic MySkyn Clinic Ltd Novellus Aesthetics Paragon Aesthetics SDS REJUVENATE MEDISPA SkinHQ VL Aesthetics

Aspire Medical Group Ltd Atelier Clinic Finesse Skin Clinic Health & Aesthetics Hunar Clinic Illuminate Skin Clinic Koha Skin Clinics Perfect Skin Solutions River Aesthetics S-Thetics Clinic The Hartley Clinic The Shore Skin Clinic Ltd Weston Beauty Clinic

Air Aesthetics Clinic Freyja Medical Hampton Clinic MediZen Clinic Secret Aesthetics So Aesthetics The Beauty Medics

BEST CLINIC IRELAND & NORTHERN IRELAND ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

Beyond Skin Eden Medical Clinic Elite Aesthetics Clinic Ltd FaceTherapyNI Revive Clinic The Laser and Skin Clinic The New You Clinic Younique Aesthetic Clinic

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Clinetix Clinica Medica Ltd Dermal Clinic Dr Nestor’s Medical Cosmetic Centre Renu Skin Clinic The Canmore Clinic Aesthetics | January 2022

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OTHE R CLINIC F INALIS TS THE RELIFE AWARD FOR BEST NEW CLINIC, UK AND IRELAND ⊲ Ambra Aesthetics Clinic ⊲ Dr Grace Kelly Aesthetic Skin Clinic ⊲ Dr Joshua Harley Street Aesthetics ⊲ Dr Yusra Clinic ⊲ Harley Street Injectables ⊲ House of SAAB

⊲ ⊲ ⊲ ⊲ ⊲

Natali Kelly Clinic Natural Nurse Aesthetics Skinfluencer LTD Thames Skin Clinic The Aesthetic Treatment Rooms ⊲ The Dr Jenni Clinic ⊲ Yorkshire Skin Centre

THE HEALTHXCHANGE GROUP AWARD FOR BEST NON-SURGICAL RESULT ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

Dr Ana Mansouri (Kat & Co Aesthetics) Dr Andrew Kane (Dr Andrew Kane Aesthetics) Dr Dev Patel (Perfect Skin Solutions) Dr Ifeoma Ejikeme (Adonia Medical Clinic) Dr Linea Strachan (Dr Linea Medical) Dr Roxi Haasbroek (Fountain of Youth) Dr Rehanna Beckhurst (ifab clinic) Dr Rory Boud (RKB by Dr Rory) Dr Yusra Al-Mukhtar (Dr Yusra Clinic) Dr Vincent Wong (Vindoc Aesthetics) Dr Victoria Manning (River Aesthetics) Dr Rekha Tailor (Health & Aesthetics) Dr Sindhu Siddiqi (No Filter Clinic London) Dr Sonia Soopen (Hershem Dental Practice)

THE CROMA-PHARMA AWARD FOR RECEPTION TEAM OF THE YEAR ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

Adonia Medical Clinic Bank Medispa Cadogan Clinic Clinetix Cliniva Medispa Dr Sobia Medispa Hampton Clinic Health & Aesthetics Perfect Skin Solutions

⊲ ⊲ ⊲ ⊲ ⊲ ⊲

River Aesthetics Skinfluencer S-Thetics The Clinic by Dr Mayoni Vie Aesthetics Younique Aesthetic Clinic

BEST SURGICAL RESULT ⊲ Mr Daniel Ezra (Moorfields Eye Hospital) ⊲ Miss Elizabeth Hawkes (Cadogan Clinic) ⊲ Mr Julian De Silva (The Centre for Advanced Facial Cosmetic & Plastic Surgery) ⊲ Mr Muhammad Riaz (St Hugh’s Hospital)

C LI NI C SU PPO RT, CO M PANY OR ORGANIS ATIO N F INALIS TS BEST CLINIC SUPPORT PARTNER/PRODUCT OF THE YEAR – VOTE NOW! ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

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5 Squirrels Aesthetic Nurse Software Allergan Spark Delivering Demand EnquiryBot GetHarley Julia Kendrick PR MeTime Success in Aesthetic Business The Aesthetics Accountant

PROFESSIONAL INITIATIVE OF THE YEAR – VOTE NOW! ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

BACN Code of Professional Conduct BCAM 20th Anniversary Mindfulness and Wellbeing Initiative British Society of Aesthetic Examiners and Assessors In The Consulting Room by S-Thetics Clinic iS Clinical Cancer Care Programme MAP-IQ

Aesthetics | January 2022


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Aesthetics Awards Finalists

INDI VI DUAL PRACTITIO NE R F INALIS TS THE ALUMIERMD AWARD FOR RISING STAR OF THE YEAR ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

Mr Ashwin Soni (The Soni Clinic) Dr Aileen McPhillips (The Skin Health Clinic) Dr Ana Mansouri (Kat & Co Aesthetics) Dr Andrew Kane (Dr Andrew Kane Aesthetics) Stephen Humble (True Medispa) Dr Jemma Gewargis (Aesthetics by Dr Jemma) Jacqueline Cooney (Beautiform Aesthetics) Dr Joshua Van Der Aa (Dr Joshua Harley Street Aesthetics) Lauren Turner (Aesthetics by Lauren Turner) Dr Manav Bawa (Time Clinic Medical Aesthetics and Wellness) Dr Paula Mann (Clinetix) Dr Priya Verma (Phi Clinic) Dr Raquel Amado (Dr Raquel Skin and Medical Cosmetics Ltd)

THE SPRINGPHARM AWARD FOR BEST NURSE PRACTITIONER OF THE YEAR ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

Áine Larkin (Younique Aesthetic Clinic) Alice Henshaw (Harley Street Injectables) Claudia McGloin (The New You Clinic) Jacqueline Naeini (Cliniva Medispa) Jenny O’Neill (Aspire Medical Group Ltd) Julie Scott (Facial Aesthetics Ltd) Lisa Waring (FaceTherapyNI) Lucy Millar-Hume (LA Face Consultants) Sara Cheeney (Pure Perfection) Susan Young (Northern Institute for Facial Aesthetics) Natali Kelly (Natali Kelly Clinic) Yuliya Culley (Novello Skin)

Dr Anjali Mahto (55 Harley Street) Dr Anna Hemming (Thames Skin Clinic) Dr Bhajvit Kaur (Health & Aesthetic Clinic) Dr Beatriz Molina (Medikas Medispa) Dr Dev Patel (Perfect Skin Solutions) Dr Emma Ravichandran (Clinetix) Dr Ifeoma Ejikeme (Adonia Medical Clinic) Dr Mayoni Gooneratne (The Clinic by Dr Mayoni) Dr Sobia Syed (Dr Sobia Medispa) Dr Sophie Shotter (Illuminate Skin Clinic) Miss Sherina Balaratnam (S-Thetics) Dr Steven Land (Novellus Aesthetics) Dr Uliana Gout (London Aesthetic Medicine)

⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

Mr Adrian Richards (The Private Clinic) Mr Ali Ghanem (The Aesthetic Regenerative Clinic) Miss Elizabeth Hawkes (Cadogan Clinic) Mr Julian De Silva (The Centre for Advanced Facial Cosmetic & Plastic Surgery) Mr Naveen Cavale (Real Plastic Surgery Ltd) Miss Rachna Murthy (FaceRestoration) Mrs Sabrina Shah-Desai (Perfect Eyes Ltd) Mr Sotirios Foutsizoglou (SFMedica)

THE AWARD FOR OUTSTANDING ACHIEVEMENT IN MEDICAL AESTHETICS The exceptional accomplishments and significant contribution to the profession by an individual with a distinguished career in medical aesthetics will be recognised with the trophy for Outstanding Achievement in Medical Aesthetics. The winner of this category will be announced at the ceremony and is not open to entries. If you wish to nominate an individual for the Aesthetics team to consider, email contact@aestheticsjournal.com and clearly explain their achievements and why they are deserving.

JO IN US AT THE UK ’S M O S T E S TE E M ED AWARDS CE RE M O NY !

THE GETHARLEY AWARD FOR MEDICAL AESTHETIC PRACTITIONER OF THE YEAR ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

CONSULTANT SURGEON OF THE YEAR

To be a part of the most respected and esteemed event in the aesthetics calendar, book your tickets now as tables will sell out! The Aesthetics Awards 2022 will be taking place at our exciting new venue the Royal Lancaster Hotel, London, on March 12. Remember the event will be on the second day of the Aesthetics Conference and Exhibition, so you can spend the day learning and the evening celebrating with 800+ guests in the aesthetics specialty.

Individual ticket: £320 + VAT

Table of 10: £3,050 + VAT

WE CAN’T WAIT TO S EE YO U ALL THE RE AND GO O D LUCK TO ALL F INALIS TS !

Aesthetics | January 2022

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Advertorial Restylane

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Owning Every Angle with Restylane Discover the ultimate 3D facial profiling technique with Restylane Lyft, Volyme and Defyne When it comes to creating a holistic individualised facial profile, the timeless mantra of ‘use the right tool, for the right job, in the right way’ comes to mind. The pioneering Restylane brand by Galderma represents the gold-standard for dermal fillers in terms of clinical efficacy, practitioner trust and patient satisfaction. Within this diverse portfolio there are targeted products which lift, define and volumise the face, for a natural-looking, yet beautifully impactful 3D facial profile – with the cheeks, nose and chin acting as critical anchor points to the overall facial outline and ensure patients can own every angle. In this crowded, competitive industry, aesthetic practitioners can trust the unrivalled heritage and clinical backing of Restylane, which has grown and evolved over the last 25 years to become a globally recognised brand, with more than 50 million treatments now delivered worldwide.1

The professional view… “Restylane means something that has stood the test of time; something that is tried, tested and trusted. With Restylane – day in, day out for the last fifteen years, I’ve been able to deliver reproducible, reliable results for every single patient.” Dr Kuldeep Minocha, aesthetic doctor

Backed by unrivalled technology Restylane is the only dermal filler portfolio supported by two complementary hyaluronic acid technologies: NASHA (non-animal stabilised HA) and OBT (Optimal Balance Technology). • The NASHA range (encompassing the Restylane, Restylane Lyft and SkinBoosters) is designed for lifting and precision, with a firmer gel for targeted product integration which utilises the natural entanglement of the HA strands, hence less than 1% cross-linker is needed. NASHA is the closest to the natural composition of HA than any other filler. • The OBT range (comprising Restylane Kysse, Volyme, Defyne and Refyne) is designed for contouring and expression, with a more distributed product integration into the skin, and a softer gel texture for pronounced lifting capacity and movement. These pioneering Restylane HA-based gel technologies have been developed from Galderma’s understanding of the natural role of HA within the body. Each Restylane product can be defined by various physical properties that determine its clinical applications and expected aesthetic results. All Restylane products contain non-animal stabilised hyaluronic acid, alongside Lidocaine hydrochloride 3mg/ml for effective pain relief and a comfortable injection experience. By creating an integrated approach which leverages the unique benefits of both these HA technologies, Restylane’s 3D lift methodology delivers results which provide long-lasting support and definition to key facial structures, alongside preservation of movement and flexibility for a natural-looking result.

Empowering patients to #owneveryangle Patients often report that they only like photos being taken from a particular side or angle, due to embarrassment or concern about certain facial imbalances – such as receding chins, bumpy nose bridges or flat cheeks. Rather than chasing a point-by-point improvement 44

Aesthetics | January 2022

“Restylane is a unique filler brand with two contrasting technologies OBT and NASHA. Each technology has specific characteristics to suit a variety of patient needs. Combining both of these technologies you can create unique personalised outcomes for your patient.” Dr Munir Somji, surgical and non-surgical expert “Restylane are medically proven and have scientifically robust data out there to support all their fillers, which for me as a plastic surgeon is of paramount importance. The biggest impact Restylane has had in terms of my practice – it’s the versatility that Restylane brings to the practice. In my opinion the uniqueness of Restylane is the fact that it can complement any stage of ageing – for me, this translates into confidence for my patients!” Dr Priya Chadha, surgeon and trainer


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in facial features, the Restylane 3D profile method looks at the holistic balance and characteristics of the entire face. By using a targeted approach with these specially designed ‘tools’ from the Restylane portfolio, practitioners can confidently address these concerns in a universal approach.

Patient satisfaction, DELIVERED The long-term quality of results and positive patient feedback with these three treatment products have been well-established by Galderma’s satisfaction research: • Dare to Defyne – 100% of injectors said Restylane Defyne improved patients chin projection at 12 weeks, 96% still agreed at 1 year

• Stay true to their Volyme – 98% of patients were pleased with results at 18 months, offering a natural and expressive contour that 100% of respondents would recommend and have again

• Provide the precise Lyft – 96% of patients felt their treatment met or exceeded their expectations, with 99% saying they would recommend to a friend and 96% saying they would do the treatment again

Discover more For further information, look out for Galderma’s Webinar on February 14th, where Dr Munir Somji will be discussing all things Restylane, in partnership with the Aesthetics journal. To discover the Restylane range and how this diverse brand can amplify your treatment offerings, please contact INSERT DETAILS. For further details on Restylane product and anatomy training from the GAIN programme, please contact: INSERT DETAILS REFERENCES 1. Data on file (MA-33939) 2. Data on file (MA-43049) 3. Kablik J et al. Dermatol Surg 2009;35(Suppl 1):302–312; 4. Lundgren B et al. J Drugs Dermatol 2018;17(9):982–986; 5. Andriopoulos B et al. Poster presented at AMWC 2019 6. Edwartz C et al. Poster presented at IMCAS 2020. 7. Data on file (MA-34483). 8. Öhrlund Å. JCDSA. 2018;8:47-54.

9. Segura S, Anthonioz L, Fuchez F, Herbage B. J Drugs Dermatol. 2012;11(1 Suppl):s5-s8. 10. Lundgren B, Sandkvist U, Bordier N, Gauthier B. J Drugs Dermatol. 2018;17(9):982-986. 11. Nikolis A, Enright KM, Lazarova D, Sampalis J. Aesthet Surg J Open Forum. 2020;2(1):ojaa005. doi:10.1093/ asjof/ojaa005 12. Data on file (MA-42769). 43USCH1702 Clinical Study Report, 2020.

This advertorial was written and supplied by

Adverse events should be reported. For the UK, reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. For Ireland, suspected adverse events can be reported via HPRA Pharmacovigilance, www.hpra.ie; Adverse events should also be reported to Galderma (UK) Ltd. E-mail: Medinfo.uk@galderma.com Tel: +44 1 923 208950

Advertorial Restylane

Introducing the 3D facial profiling heroes The Restylane 3D Profiling technique uses three specific products from the range to create long-lasting support, definition and shaping, enabling patients to achieve a stronger facial profile whilst retaining their individual character. As the most diverse filler portfolio on the market, the individual products across both the NASHA and OBT technologies allow practitioners unprecedented control and artistry to enhance and perfect various elements of the facial structure. The 3D profile technique utilises: Restylane Lyft Restylane Lyft is part of the NASHA™ technology range and is the firmest gel in the portfolio – designed to deliver projection and structure for a pronounced effect. Lyft is suited for lifting the cheeks, enhancing the jawline and chin, or delivering non-surgical rhinoplasties and is proven to last up to 24 months with just one treatment. This hero precision product is supported by extensive clinical evidence and long-term treatment satisfaction, and importantly is intended to provide lift without volumising, thanks to the highe G’ prime and controlled particle size.2,3,4,5,6 Restylane Volyme Restylane Volyme creates volume and shape to the face and is a soft, flexible gel from the OBT™ technology range, which are designed to distribute naturally within the tissue post-injection and follow the animation of the face for natural expressions. Volyme is recommended for treatment of the cheeks, temples and chin. Restylane Volyme lasts up to 18 months, and the addition of Lidocaine provides a painrelieving effect during treatment.7,8,9,10,11 Restylane Defyne Restylane Defyne shapes facial contours and lifts to create definition. Another targeted treatment within the OBT technology range, it is recommended for redefining the shape of the cheeks, chin and jaw and lasts up to one year, again, with the pain-relieving benefits of lidocaine for a comfortable treatment experience.12 UKI-RES-2100181 DOP December 2021

Aesthetics | January 2022

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A safe solution

Restoring the Nipple with Dermal Filler Dr Magdalena Szymanska-Bueno outlines how to add volume to the nipple using dermal filler and presents a case study showing successful results Breast reconstruction is an important factor to consider when women are gaining a full recovery from breast cancer. Patients who undergo a breast mastectomy are very often seeking for full reconstruction, including in the nipple-areola complex (NAC).1 In this article I will present a case study evidencing how aesthetic practitioners can meet the expectations of patients looking to obtain nipple projection after areola reconstruction, through the use of dermal filler.

Main issues of the NAC The reconstruction of the nipple-areola complex is the final step in the breast reconstruction process. Whenever possible, the surgeon will spare the NAC, otherwise, it will be surgically removed together with the cancerous breast tissue.2,3 The reconstruction of the NAC is usually performed between four and six months after the breast reconstruction. It plays a very important anatomical part for the woman and the reconstruction has considerable aesthetic and psychological impact.4 Women attach great importance to the presence of a three-dimensional nipple in the process of the breast reconstruction. Patients expect from NAC reconstruction symmetry in position, size, shape, texture, and colour.5 However, regardless of the technique, loss of nipple projection can be expected as the skin used often gets necrosis or becomes flat, lessening the appearance of a natural nipple. There are different techniques for NAC reconstruction, but the most common are: the arrow flap, the C-V flap and the C-H flap. The main issue is maintaining the nipple’s projection over time since the new local flap tends to flatten.4,6,7 The reconstruction of the areola can be performed with a skin graft from areas such as the inner thigh skin, the axillary region or the labia minora skin. The first areola reconstruction using a full-thickness skin graft (FTSG) from the labia minora was described in 1949.8 This technique is easy to perform, and the healing process is generally fast. The main issue associated with FTSG for the areola reconstruction is the loss of pigment over time. In some cases, there is an indication to perform the skin graft again, one to two years after the initial one.9 It is also reported that tattooing the nipple has been associated with a decrease in nipple projection.10

The loss of the three-dimensional contour of the NAC following surgical breast reconstruction is a technical challenge for the physician and a psychological burden for many breast cancer patients. In 2005, a study established that nipple projection is the main reason for unsatisfactory NAC reconstruction,11 and many techniques have been proposed to maintain projection of the reconstructed nipple. For 70 patients, 90 nipples were reconstructed using either a small wedge from the labia minora (n=70) or nipple sharing (n=20). Two months after reconstruction, each reconstructed nipple was injected with the hyaluronic acid filler DermaLive. Second and third injections were performed two and five months later. The described method is simple and safe, and it provides precise projection with no need for intraoperative forecasting of tissue reabsorption. The result was better for the labia minora wedge patients, perhaps because of their higher distensibility.11 A 2019 study of 12 patients saw an average increase of 3.0mm in nipple height, with all results stable at a median of seven and a half months follow-up and there were no complications observed.12 Patients that have used dermal filler to treat the nipple have noted that they gained self-confidence from the treatment, that they felt more feminine, and were much happier when they looked in the mirror as their breasts no longer reminded them of what they went through during cancer treatment.11,13 As such, the use of injectable dermal fillers to enhance nipple projection can be considered a simple non-invasive procedure with immediate and adjustable volume results that positively impact patient satisfaction.

Potential complications More serious complications that can appear following dermal filler injection in this area are nipple necrosis, tip loss, wound infection and wound breakdown.14 In my experience nipple necrosis is a rare event, due to the dual nature of the local flap. In the case of previous postmastectomy radiation, the reconstruction of the nipple is associated with an increased complication risk. If an implant is used in breast reconstruction it might be associated with a higher rate of nipple reconstruction issues. Fading after tattooing or skin grafts is common over time; therefore, it is recommended to choose a darker pigment for the tattoo skin area as a place to harvest the skin graft.14,15

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Case study Patient overview and consultation A 39-year-old female patient was diagnosed with breast cancer on the left-hand side. Eight months later, after a course of neoadjuvant chemotherapy, a mastectomy was performed, followed by radiotherapy which lasted two months. A year later, a full reconstruction of the breast was completed. Another five months passed, and the patient had NAC reconstruction using the labia minora graft technique. The patient originally chose this technique as she wanted her reconstructed nipple to have a similar colour and look to the one on her right breast. She also suffered with hyperplasia of the labia minora which qualified for surgery, and this graft could be used in the procedure. The next step for a full recovery was a tattoo of the NAC. Although the breast reconstruction and tattoo gave a good result, the patient Before

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still was not satisfied with the final look. The patient came to my clinic to talk about the possibilities of improving the projection of the nipple, as it was flat compared to her healthy breast. During the consultation, we discussed the different treatment options available, and she emphasised that the most important factor for her was to obtain natural looking breasts. During the physical examination, the NAC was symmetric compared to the other breast, and the colour was matching, however I found that the nipple was slightly flat, and the volume was decreased. I proposed to perform nipple volumisation with dermal filler. Prior to treatment I informed the patient that this was an off-label use of the filler and got her to sign consent forms acknowledging she was aware of this. Treatment approach The treatment was performed using a cross-linked hyaluronic acid filler. After

Figure 1: 39-year-old female patient after tattooing of the areola, prior to HA filler

Improving patient confidence It is likely that aesthetic practitioners will see patients looking to restore their breasts following breast cancer, with many women particularly looking to volumise the nipples. By using hyaluronic acid to restore volume and nipple projection, we can help patients overcoming breast cancer to obtain the most natural looking NAC and help restore any lost confidence in their appearance. There is not a lot of published literature around different techniques for areola volumisation using HA, so this would be welcomed.

Figure 2: 39-year-old patient after the second treatment of HA filler to restore nipple volume

Dr Magdalena SzymanskaBueno practises in Poland and Spain. She graduated in medicine at the Poznan University of Medical Sciences in 2009 and is a specialist in dermatology and venereology at Heliodor Swiecicki Clinical Hospital at the Karol Marcinkowski Medical University in Poznan. Dr Szymanska-Bueno is a fellow of the European Board of Dermatology-Venereology, member of the Polish Dermatology Association and a member of the European Academy of Dermatology and Venereology. Qual: MD, EADV REFERENCES 1. Somogyi RB, Ziolkowski N, Osman F, Ginty A, Brown M. Breast reconstruction: Updated overview for primary care physicians. Can Fam Physician. 2018 2. Galimberti V, et al., ‘Nipple-sparing and skin-sparing mastectomy: Review of aims, oncological safety and contraindications,’ 2017 3. Yoon J.S, et al., ‘Modified C-H flap for simultaneous nipple reconstruction during autologous breast reconstruction: Surgical tips for safety and cosmesis’, Medicine, 2018 4. Goh S, et al., ‘Patient satisfaction following nipple-areolar complex reconstruction and tattooing’, J. Plast. Reconstr. Aesthetic Surg, 2011 5. Tanini S, Calabrese S, Lucattelli E, Russo GL. One injection for a great projection: a quick and simple procedure for nipple reconstruction. Arch Plast Surg. 2021

Specifically, I used Juvéderm Ultra 4 due to its density increase volume of soft tissue, which allowed me to obtain better nipple projection and volume. The filler was slowly injected using a needle, which is my preference over a cannula to be able to control the amount of product injected into this area, until the desired result was achieved. I chose to distribute around 0.25ml of the product. Two months later, the patient had a second areola tattoo, and she then returned to my clinic for a follow-up appointment to assess the results. She observed that after the filler, the pigment used for the tattoo was actually producing better results. I decided to add another 0.15ml of hyaluronic acid filler into the nipple because it had dissolved slightly, which achieved the desired projection and matched to the unoperated breast. This area of the body can be sensitive for the patient, and some bruising and swelling is to be expected in the first few days. In my experience, full results can usually be seen around two weeks after the treatment, when the side effects have settled. This patient reported that she was very happy with the result and noted that she felt more confident in her body. I advised her that in order to maintain the result she will need to come back for a top-up treatment once a year.

6. 7. 8. 9. 10. 11.

12. 13. 14. 15.

Guerra A.B, et al., ‘New Technique for Nipple Areola Reconstruction: Arrow Flap and Rib Cartilage Graft for LongLasting Nipple Projection’, Ann. Plast. Surg, 2003 Rubino C, et al., ‘A modified technique for nipple reconstruction: The ‘arrow flap’, Br. J. Plast. Surg, 2003 Jones G., Bostwick J., ‘3rd Nipple-Areolar Complex Reconstruction’, Nipple-Areolar Complex Reconstr, 2018 Sisti A, ‘Nipple-Areola Complex Reconstruction’, Medicina (Kaunas), 2020 Satteson E.S., et al., ‘An Analysis of Complication Risk Factors in 641 Nipple Reconstructions’, Breast J, 2016 Beahin E, ‘Decreased nipple projection following tattoo’, Presented at the Twenty-fourth Annual Meeting of the American Society for Reconstruction Microsurgery, Beverly Hills, CA, 2008 Seither et al., Use of hyaluronic acid filler for enhancement of nipple projection following breast reconstruction: An easy and effective technique, 2019 Braza ME, Sisti A. Nipple Areola Reconstruction. 2021 Jul 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Pizzonia G, Sasso A., Rossello C, ‘Alternative technique for nipple-areola complex reconstruction with poor skin condition’, ANZ J. Surg, 2015 Sisti A, ‘Nipple-Areola Complex Reconstruction’, Medicina (Kaunas), 2020

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


96% patient satisfaction with BOCOUTURE®, you can be confident of results that your patients come back for.1 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)2 References: 1. Prager W, et al. Clin Cosmet Investig Dermatol. 2012;5:53–58. 2. BOCOUTURE® (incobotulinumtoxinA) Summary of Product Characteristics. Merz Pharmaceuticals GmbH. M-BOC-UK-0444 Date of Preparation: December 2021


Free from complexing proteins (Botulinum toxin type A)


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Case Study: Delayed Hypersensitivity Reaction Dr Saran Patter discusses delayed hypersensitivity reactions to HA fillers and presents a case study on management Complications caused by hyaluronic acid (HA) fillers are rare, particularly those that have a delayed reaction. As aesthetic practitioners we must acknowledge that there is always a chance of them occurring and we need be proficient in recognising, diagnosing and treating them. HA filler complications can be difficult to diagnose, especially if the practitioner is not experienced in managing them.

Diagnosis Filler complications are typically divided into four categories: allergic, infection, late onset nodules/inflammation or vascular compromise.1 It can be difficult to diagnose delayed complications of HA fillers as signs and symptoms can often overlap. It can be particularly challenging to differentiate between a bacterial biofilm and a delayed hypersensitivity reaction as the physical signs such as swelling and erythema occur in both. Initially, they require different management as a biofilm will require antibiotic treatment, whereas a delayed hypersensitivity reaction requires immunosuppression.2 However, in both reactions the eventuality is that they will both require the HA filler to be dissolved.3 The clinical features of delayed hypersensitivity are characteristically erythema, tenderness, swelling, induration and occasionally nodules.2,4,5 It typically occurs within a day of the treatment but can present as late as several weeks or months.3,4 Using the Gell and Coombs classification system for hypersensitivity found in Table 1, delayed type IV hypersensitivity is mediated by T-lymphocytes rather than antibodies.6 It involves the interaction of T-cells, monocytes, and macrophages.4 However the aetiology related to HA filler hypersensitivity is not completely understood.5 There is suggestion that patients with pre-existing medical conditions such as particular autoimmune diseases or allergies are more susceptible to adverse HA filler reactions, and so it is at the discretion of the injector if these candidates are suitable for HA filler treatment.1 Other triggers can also be viral illnesses, bacterial infections, excessive UV exposure or vaccinations. These can activate an immune response to foreign body implants and create a delayed onset reaction even to those that have had dermal fillers years ago. 7,8,9 The possible side effect of the SARS-CoV-2 vaccination is currently relevant due to the large cohort of patients receiving it. Fortunately, there are not many reported cases

of vaccination related delayed hypersensitivity reactions, but if there is a suspected case the Aesthetic Complications Expert (ACE) Group World have published guidelines on the recommended treatment.9

Treatment options Hypersensitivity can persist indefinitely if left untreated and therefore it is best to remove the underlying cause by dissolving the HA filler.3 Antihistamines are known to have no impact on these reactions.2,3,4 Steroids are the initial mainstay of treatment, but long-term steroid use is not recommended due to the associated risks.11 If steroids have little impact then hyaluronidase is needed to dissolve the underlying cause.2-4, 11 If non-HA fillers are used then laser treatment, extrusion or, as a last resort, surgical excision is indicated.2 Current literature offers a plethora of suggested doses for hyaluronidase, but it is advised to use as much as deemed necessary as suggested by the ACE Group World guidelines.11 The type HA dermal filler used is an important consideration for how effective hyaluronidase will be, so it is worth considering this when selecting HA fillers for use in your practice. Some dermal fillers dissolve easier than others and some need a higher dose of hyaluronidase to be completely removed; which is partly down to the composition and degree of cross-linking.10,12

Case study This case report demonstrates a 54-year-old woman that attended for HA dermal fillers in her lower face. Six weeks after her procedure she developed a symmetrical diffuse swelling and induration over the injected areas which was treated as a type IV delayed hypersensitivity reaction. Hypersensitivity can be classified as acute or delayed dependant on time of onset, this is how a diagnosis of delayed type IV hypersensitivity was made.4

Presentation The patient attended the clinic for the first time with no previous history of non-surgical treatments. Medically, she was fit and well with no allergies and was not taking any regular medications. Her primary concern was ageing around her lower face. Although she was advised to have her mid-face volume addressed first, she wanted to focus the treatment on her lower face first Type Time frame Antibody or cell mediated as that was her main concern. Type I Usually occurs immediately Antibody mediated (IgE) The area was cleaned with a topical antiseptic prior to injecting. A topical anaesthetic cream with lidocaine Antibody-mediated cytotoxic reaction (IgG Type II Occurs within 24 hours was applied over the area and a sterile dressing or IgM) pack with sterile gloves were used. She had 5ml of Type III Occurs within 24 hours Immune complex-mediated reaction a high-concentration, high G-prime and cohesive HA filler injected into the pre-jowl area, chin, labiomental Delayed reaction which occurs Type IV Cell mediated crease, marionette and nasolabial folds. The after 12 hours typically treatment was solely carried out using a 25 gauge Table 1: Gell and Coombs Classification distinguishing immune responses6 38mm cannula and completed with no complications.

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Before

Two weeks after

Six weeks after

After hyaluronidase

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Figure 1: The patient before and two weeks after treatment, and then six weeks after treatment with signs of type IV delayed hypersensitivity reaction. The final image shows the patient after dissolving the HA filler

Post-procedure cream containing chlorhexidine designed to soothe and protect the skin was applied at the end of the procedure. The patient was seen after two weeks for a review and she reported no complications or concerns. She was very happy with the results and subsequently enquired about having her tear troughs treated, which was carried out another two weeks later, once again with no complications. The HA dermal filler used for the tear trough was of a lower HA concentration, G prime and cohesivity, due to the delicate nature of the area being treated. Four weeks after the tear trough treatment and six weeks after her initial treatment the patient suddenly developed generalised swelling and oedema to her lower face when she woke up in the morning. The tear trough region was unaffected at this point. On examination there was generalised indurated swelling in the treated areas of her lower face. The swelling was tender to palpate but not warm to touch. The overlying skin was unaffected and there were no clinical signs of infection. The patient did not have any recent illnesses that could have affected her immune system, nor had any trauma to the area. She did not have any recent dental procedures or infections. Nothing unusual was detected in the patient’s recent history to predispose her to such a response. As such it is not clear why this patient was affected in this manner.5 A delayed type IV hypersensitivity reaction was the diagnosis made due to the indurated swelling which is a key sign of this condition.2,5,11 The patient was understandably eager to have the issue addressed as soon as possible. Based on the ACE guidelines, steroids were prescribed (Prednisolone 40mg once a day for seven days).11 The plan going forward was to either taper off the steroid dose if there were signs of improvement or consider removing the HA filler with hyaluronidase. Unfortunately, after one week the steroids had little impact and we proceeded to dissolve the HA filler, removing the underlying factor causing the hypersensitivity.

Treatment A dose of 1,500 units of hyaluronidase was injected directly into the affected areas. Another course of Prednisolone was given to taper off the original dose, reducing the dose by 5mg each day until reaching 5mg as a final dose. The patient required a further two courses of hyaluronidase for the swelling to fully subside. This was administered two weeks apart each time to ensure any swelling that was related to the procedure of dissolving itself had settled. Due to the larger size of the affected area, 1,500 units were used in each of the three courses to completely dissolve the HA filler. After the second course of hyaluronidase, which was four weeks after the initial reaction, the indurated diffuse swelling had reduced significantly to localised firm and palpable nodules. Concurrently, a similar swelling appeared in the tear trough region two weeks after the first swelling appeared which was treated in the same fashion. This was expected and it was relayed to the patient that it would likely happen as hypersensitivity is a systemic response.10 All areas treated with HA dermal filler were dissolved successfully without further complication. After each treatment the patient was given aftercare advice alike to the advice given after any injectable treatment. The patient was reviewed regularly throughout the treatment. At the final review, two weeks after the third and final round of hyaluronidase, all swelling had settled, and no nodules were present. The patient was happy with the outcome. As it was not clear why the patient had such a reaction there is a possibility the patient would have a similar reaction to future HA filler treatments even with other types of HA brands. Therefore, I would not recommend repeat HA dermal filler treatment for this patient, but other fillers may be considered.

Conclusion Complications can happen to any practitioner regardless of their experience. It is probable that the more procedures you carry out the more likely you are to come across them. We need to be aware of delayed risks and ensure the patient is appropriately informed during the consent process. It is advisable to communicate with fellow aesthetic practitioners for advice and second opinions. If you do not feel confident in treating a particular complication, or do not have the experience in doing so it would be wise to refer the patient to a more experienced practitioner. We completed an adverse reaction form with the HA filler company to rule out any possible manufacturing issues and it was also discussed with one of the key opinion leaders of the HA brand, who agreed with our management plan. It is certainly worthwhile for clinicians to keep guidelines at their place of practice for quick reference if a complication should arise. Dr Saran Patter qualified from the University of Liverpool as a dentist. She is the owner of Bridge Street Skin Clinic in Hungerford, Berkshire and director of The Aesthetics Group Academy. Qual: BDS

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

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


Advertorial HA-Derma

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The launch of Profhilo® Body complements the energy-based body device treatments we offer at Dr Preema London clinic as skin laxity often required addressing after body sculpting treatments. I was delighted to be invited to generate case studies as part of the launch of the new Profhilo® Body and have been able to treat a selection of patients with excellent treatment outcome. The inclusion of the post injectable in-clinic sheet mask and home-use topical body cream creates a regime for patients between their treatments and maximises the final results – especially on dryer and thinner skin areas.”

Introducing NEW Profhilo® Body From face to body, all of IBSA Derma’s expertise with hyaluronic acid are in the new PROFHILO® BODY KIT: an all-round approach for treating skin laxity on the body Developed by IBSA Derma, the NEW Profhilo® Body kit presents an all-round approach from face to body, counteracting skin laxity, improving surface hydration and elasticity. Backed by an expertise in the field of aesthetic medicine and in the production of ultrapure hyaluronic acid, IBSA Derma identify and address an increased demand for body treatments, equal to those devoted to the face. In today’s aesthetic medicine market, the face and body have seemingly different weights of importance: the face is the area that absorbs most of the time and investment. In fact, according to a recent survey* conducted by IBSA Derma on a panel of experts and patients, the time dedicated to aesthetic treatments is divided about 80% spent on treating the face, while only the remaining 20% is dedicated to the body. Although the skin on the body is equally susceptible to chrono-ageing and photo-ageing, patients tend to focus their attention mainly to the face. The decision to treat the body only comes ‘later’, making this market from ‘prevention’ to ‘correction’ an already evident concern. The development of the Profhilo® Body Kit for specifically treating body areas has been driven by practitioners who wish to also offer patients non-invasive body treatments to enhance authentic beauty, as well as meet the demand from existing Profhilo® patients to treat skin laxity beyond the face and neck areas. In addition, alongside the launch and increased availability of new aesthetic body energy and advanced technology devices for patients, there has been an increase in demand for non-surgical treatments to address skin laxity. IBSA Derma wants to promote a better balance between face and body, encouraging both practitioners and patients to take better care of the body. To achieve this, IBSA Derma have designed a complete approach offering a new way of caring that combines in-clinic injectable treatments with home cosmetic treatments, with clinically tested efficacy to help maintain the results obtained. Dr Preema Vig commented, “There has been a growing demand for Profhilo® treatments in my practice and many of my patients regularly have treatments to their face, neck and décolletage. 54

Aesthetics | January 2022

Dr Alex Parys added, “Patients recognise and trust the Profhilo® name, and over the last few years we have seen the demand for Profhilo® treatments extend beyond the face to the neck, décolletage and even parts of the body such as arms, knees, and abdomen. The Profhilo® Body kit offers a complete treatment for patients to maximise results.” To provide further support to practitioners, IBSA Derma designed a ‘photographic laxity scale’ for the inner arms, a useful tool for practitioner-patient dialogue that will facilitate assessing the level of laxity and therefore the type of outcome to be expected. In addition, it is recommended for practitioners to use the BODY BAP stencil to mark out the areas to be treated for easier application. Two stencils are provided with each Profhilo® Body Kit. IBSA Derma wants to promote a better balance between face and body, with a targeted innovative product, encouraging both practitioners and patients to take better care of the body because for IBSA Derma “Each one of us is a Masterpiece.”

Profhilo® Body is the ONLY injectable treatment on the market specifically designed for the treatment of body skin laxity


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Profhilo® Body Kit contains PROFHILO® BODY, 2 x 3ml syringe (3.2% 96mg/3ml) The ONLY injectable treatment on the market specifically designed for the treatment of body skin laxity and is particularly recommended for the brachial area and abdomen. Profhilo® Body is characterised by high and low molecular weight Stable Cooperative Hybrid Complexes (HCC) of high concentration ultrapure hyaluronic acid, produced using a unique and innovative thermal production process patented by IBSA, the NAHYCO® Technology. The efficacy of PROFHILO® BODY on mild to moderate skin laxity and roughness of the abdomen and inner arm has been clinically proven***.

PROFHILO® FIGURA BODY PATCH (pack of 4 patches in a single sachet) Created to soothe and moisturise the skin of various areas of the body following aesthetic treatments, the Profhilo® Figura Body Patch contains high and low molecular weight hyaluronic acid, salvia haenkei - a patented plant extract with strong antioxidant properties, arnica montana - to soothe and provide relief, escin - to prevent excessive accumulation of liquids that can lead to the formation of oedemas and PINEAPPLE extract - to restore the skin’s natural condition. A clinical study has shown an increase of 33% in skin hydration and a decrease of 11% in skin irritation within an hour of use.

PROFHILO® FIGURA BODY CREAM (150ml airless bottle) This multi-active modelling and firming cream restores tone and elasticity whilst providing deep hydration. Formulated with a complex of low and high molecular weight hyaluronic acids in high concentration and Matrixyl 3000, the combination of two peptides promotes tissue re-modelling and helps restore the vitality of cellular functions. A clinical study has shown increased skin hydration (+42%), elasticity (R2 +6% and R5 +9%) and an improvement in skin firmness (52%) 28 days following start of treatment. Patients’ self-assessment ranged from very good to excellent on a number of efficacy metrics, including hydration (100%), elasticity (100%) and firmness (87%).

Profhilo® Body - Before

Profhilo® Body Case-Study Gallery Profhilo® Body - Before

Profhilo® Body - After

Profhilo® Body - After

Images courtesy of Dr Preema Vig, Dr Preema London Clinic

Images courtesy of Dr Alex Parys, SONÜ Medical Aesthetics

About Profhilo® Award winning Profhilo® is the first BDDE-free stabilised injectable hyaluronic acid based product for treating skin laxity. With the highest concentration of HA on the market it is not only boosting and hydrating the skin, but also remodels ageing and sagging tissue with stimulation of collagen and elastin. Profhilo® delivers great results as a treatment on its own or in combination with other aesthetic treatments currently on offer.

About IBSA Derma Scientific knowledge, continued research, technological development and modern production processes, retain IBSA Derma as a market leader in hyaluronic acid as they control the entire product life cycle of their HA, from the biofermentation raw material production to the finished product in pre-filled syringes. Aesthetics | January 2022

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For more information about Profhilo® Body please contact HA-Derma: info@ha-derma.co.uk * Kantar Health study conducted in 2018-2019 ** Product sheet *** “Aesthetic performance and tolerance evaluation of an Injective intradermal treatment for the skin roughness and laxity of Inner arm and abdomen”, submitted

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of cosmetic and functional concerns. Indeed, if function is their primary problem, this needs to be investigated further and referred appropriately to a rhinoplasty specialist. Specific questions to focus upon include the nature of the nasal obstruction, olfactory concerns, history of nasal trauma and any other symptoms of rhinologic disease. Patients need to be forthcoming about previous Mr Samit Unadkat explores his approaches to septal and/or rhinoplasty surgery as this would nose assessment for successful rejuvenation influence the treatment approach as well as requiring the tempering of patient expectations. Symmetry of the facial structures are key elements in the perception Comorbidities, too, become more relevant as patients age and of facial attractiveness. As the central structure of the face, the nose is this may have an impact on the suitability of general anaesthesia of particular importance.1,2 A crooked nose will exacerbate pre-existing should a surgical approach be required. facial asymmetries and the nasal septum itself plays an important In patients with an ageing nose, further considerations must be role in mid-face development.3-5 It is no surprise then, that rhinoplasty undertaken as to what is realistically attainable, and importantly, surgery remains in the top five most performed aesthetic surgical communicate these with the patient in depth through several procedures worldwide.6 meetings. One approach is to ask the patient their single biggest The majority of cosmetic rhinoplasty surgery takes place in the third concern that they wish to have addressed. decade of life, although increasingly, surgeons are reporting an older cohort of affluent patients seeking out cosmetic rhinoplasty Clinical examination surgery.7 Unlike their younger counterparts, older patients are more As per convention, following a thorough history, a detailed naso-facial likely to present with a deterioration in nasal function as well as analysis should be performed. This assessment should be performed aesthetic concerns. This article will seek to describe some of these systematically in order to identify deformities, evaluate anatomical changes and the relative considerations prior to embarking on relationships and establish goals for the treatment intervention.13 rhinoplasty surgery, which can also be considered for practitioners An experienced rhinoplasty surgeon will always assess the nose performing non-surgical interventions such as dermal filler, in relation to the rest of the face to ensure aesthetic harmony from botulinum toxin and threads. surgery. Patients can have a tendency to focus on specific perceived irregularities on the nose alone, but in reality, there may be other areas Considerations for the ageing nose on the face that need addressing; for example retrognathia giving the In my experience, treatment of the ageing nose necessitates a illusion of an over-projected nose. greater reliance on structural grafting due to the changes in support Facial asymmetries too are common but frequently overlooked by and skin quality. The techniques employed may necessitate a more patients and practitioners alike. Thus, patient expectations again need reconstructive than purely cosmetic approach. to be managed as corrective surgery or non-surgical interventions to According to Janeke and Wright, there are four areas involved in the nose may improve facial asymmetry, but it will not fully correct it. normal tip support:8 I find that capturing photography, preferably with morphing software 1. The fibrous connection between the upper and lower lateral early in the patient journey, is extremely useful in the initial assessment. cartilages (scroll area) Although morphed images are not a guarantee of post-operative 2. The sesamoid complex that attaches the lateral crura to the outcomes, they do allow patients to express what changes they would pyriform aperture like addressed to their nose and from the surgeon’s perspective, to 3. The fibrous connections between the domes of the lower lateral explain what is realistically achievable through surgery. cartilages 4. The attachments of the medial crura footplates to the caudal septum Receding hairline

Assessing the Ageing Nose

Forehead rhytids

As we age, these support mechanisms all weaken giving rise to distinctive changes to the nose and various different studies have been published highlighting the key hallmarks of the ageing nose.9-12 For example, in the ageing nose, the scroll area gradually begins to separate as the fibres weaken, giving rise to a ptotic (droopy) tip and a hanging columella. In terms of the bony nasal pyramid, unlike cartilage, its position does not change, but the bone quality deteriorates and becomes more brittle.9 When surgeons perform osteotomies to realign the nasal pyramid, care must be taken to not cause substantial trauma.

Glabellar rhytid Brow ptosis Upper lid dermatochalasis Malar fat descent Deepening of nasojugal fold Nasal tip ptosis Deepening of nasolabial fold Smokers creases Jowl formation Midneck hollowing

Initial consultation

Platysmal banding

Prior to examination of the nose, as with all consultations, it is crucial to first gauge the patient’s concerns through thorough history taking. Anecdotally, older patients have a tendency to have a combination

Figure 1: Common issues on the ageing face

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Next, it is important to assess the nose endonasally with both anterior rhinoscopy and where available, 1/3 endoscopically. Gross deviations of the nasal septum and valve collapse 1/3 can be elicited with anterior rhinoscopy i.e. 1/3 placing a speculum at the front of the nose, in each nostril with a strong light source. For more 1/5 1/5 1/5 1/5 1/5 posteriorly based and subtle deviations, including Figure 2: The ideal facial proportions14 at the internal nasal valve, the use of a rigid nasendosope provides a high-resolution image. This is particularly important when dealing with functional problems as well as in revision/secondary cases to exclude septal perforations which would not otherwise be apparent. Next, the nose is systematically assessed from a frontal, lateral, basal and skyline view, paying particular attention to its position with the rest of the face. The frontal view, in particular, will give details of any obvious nasal deviations and facial asymmetries. The ideal facial proportions consist of dividing the face into equal vertical fifths and horizontal thirds; vertical landmarks being the outer edge of the pinna, the lateral and medial canthus of the eyes; horizontal landmarks being the trichion, subnasale and mentum (Figure 2).14 The facial midline is constructed using two main landmarks. In a symmetrical face, a vertical line dropping from the glabella to midpoint of the chin should pass through the mid-philtrum of the upper lip (Cupid’s bow).14 Focusing then on the nose, any deviation of the upper, middle and lower third of the nose is assessed. Care should be taken to appreciate the dorsal aesthetic lines, nasal tip, alar rims and alar base. Dorsal humps, tip projection and rotation are best appreciated from the right and left lateral views. Standard rhinoplasty assessments can then be carried out to assess the nasal dorsum, supratip, tip rotation, nasofrontal and nasolabial angles. It is essential to compare both lateral views as the alar-columellar relationship may be different from each side. Congenitally twisted medial crura are best assessed via the basal view, which can in turn give rise to nostril asymmetry. Caudal septal dislocations, previous scars and columella-to-lobule ratio are all best picked up on basal view.

Considering ageing of the full face The face as a whole also undergoes numerous changes with age which are not always symmetrical or uniform, meaning that facial asymmetry can become more apparent with age. These include forehead and glabellar rhytids, brow ptosis, upper lid dermatochalasis, malar fat descent and deepening of the nasolabial folds. Bony changes take place too, most notably in the maxilla.15 For example, around the periorbita, the orbital aperture increases in size with age due to bony resorption, but this may take place at differing rates between both sides of the face.16 An area often overlooked is the skin. All too frequently, the focus is on the underlying nasal skeleton, without due consideration given to how the skin will react to underlying changes. As we age, the dorsal

skin over the bony pyramid, in particular, becomes thinner and any structural changes may become more apparent, including contour irregularities. The effect of soft-tissue dissection may also exaggerate telangiectasias over the dorsum, particularly in Fitzpatrick skin types I and II.9 More caudally, however, the skin will thicken with age, and in turn can further down-rotate the tip. The lower lateral cartilages and dilator naris also weaken and so external nasal valve collapse becomes more apparent.9 Hence, older patients will often have concurrent aesthetic and functional symptoms.

A thorough understanding Rhinoplasty surgery is widely accepted as the most challenging of facial plastic surgery operations as it combines technical skill, an eye for detail as well as management of patient expectations and psychology. As the central structure of the face, any surgical or non-surgical intervention to the nose must be balanced with the rest of the patient’s facial features. Increasingly there has been a rise in older patients seeking out procedures. In the ageing patient, additional challenges exist due to skin changes and soft tissue and bony resorption, frequently leading to both functional and aesthetic problems compared to younger patients. Techniques that may be suitable for younger patients may not be applicable for the ageing nose. Ultimately, rhinoplasty, or non-surgical interventions, in the ageing face can be very successful with a thorough understanding of facial anatomical changes and a nuanced approach. Mr Samit Unadkat is a consultant ENT and facial plastic surgeon at the Royal National ENT and University College Hospital, London. He is also the director of My Nose London. He has a subspecialist interest in both cosmetic and functional rhinoplasty and complex sinonasal surgery. Qual: BSc (Hons), MBBS, DOHNS, FRCS (ORL-HNS) REFERENCES 1. Yi JS, Jang YJ. ‘Frequency and Characteristics of Facial Asymmetry in Patients With Deviated Noses’, JAMA Facial Plast Surg, 17(4):265-9, 2015 2. Chatrath P, De Cordova J, Nouraei SA, Ahmed J, Saleh HA, ‘Objective assessment of facial asymmetry in rhinoplasty patients’, Arch Facial Plast Surg, 9(3):184, 2007 3. Carvalho B, Ballin AC, Becker RV, Berger CA, Hurtado JG, Mocellin M, ‘Rhinoplasty and facial asymmetry: Analysis of subjective and anthropometric factors in the Caucasian nose’, Int Arch Otorhinolaryngology, 16(4):445-51, 2012 4. Meeuwis J, Verwoerd-Verhoef HL, Verwoerd CD, ‘Normal and abnormal nasal growth after partial submucous resection of the cartilaginous septum’, Acta Otolaryngology, 113(3):379-82, 1993 5. Bernstein L., ‘Early submucous resection of nasal septal cartilage. A pilot study in canine pups’, Arch Otolaryngology, 97(3):273-8, 1973 6. International Society of Aesthetic Plastic Surgery (ISAPS) international survey on aesthetic/cosmetic procedures performed in 2018. <https://www.isaps.org/wp-content/uploads/2020/10/ISAPS-GlobalSurvey-Results-2018-1.pdf. Accessed 21 September 2021> 7. Ishii LE, Tollefson TT, Basura GJ, et al., ‘Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty’, Otolaryngology Head Neck Surgery Journal, 156(2), 205-219, 2017 8. Janeke JB, Wright WK, ‘Studies on the support of the nasal tip’, Arch Otolaryngology, 93(5):458-64, 1971 9. Romo T 3rd, Soliemanzadeh P, Litner JA, Sclafani AP, ’Rhinoplasty in the aging nose, Facial Plast Surg, 19(4):309-15, 2003 10. Krmpotić-Nemanić J, Kostović I, Rudan P, Nemanić G. Morphological and histological changes responsible for the droop of the nasal tip in advanced age’, Acta Otolaryngology, 71(2):278-81, 1971 11. Ries WR, Rathfoot CJ, ‘The aging nose in rhinoplasty for facial rejuvenation’, Facial Plast Surg, 12(2):197-203, 1996 12. Toriumi DM, ‘Surgical correction of the aging nose’, Facial Plast Surg, 12(2):205-14, 1996 13. Rohrich RJ, Villanueva NL, Small KH, Pezeshk RA, ‘Implications of Facial Asymmetry in Rhinoplasty’, Plast Reconstr Surg, 140(3):510-516, 2017 14. Ricketts RM, Divine proportion in facial aesthetics, Clin Plast Surg, 19(4):401-22, 1982 Mendelson B, Wong CH, ‘Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation’, Aesthetic Plast Surg, 36(4):753-60, 2012 15. Kahn DM, Shaw RB Jr, ’Aging of the bony orbit: a three-dimensional computed tomographic study’, Aesthet Surg J, 28(3):258-64, 2008

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The Revolutionary Approach in Body Shaping for Muscle & Fat Dr Aggie Zatonska discusses her results using EMSCULPT NEO The new innovative EMSCULPT NEO goes beyond the imaginable, introducing new opportunities for clinics and patients. Using a unique combination of synchronised radiofrequency (RF) and HIFEM+ technologies in one treatment, it is now possible to treat both muscles and fat simultaneously in one session. As such, it is a faster and more profitable solution than combining multiple procedures. With more than 40 peer-reviewed publications, EMSCULPT NEO’s proprietary HIFEM technology has also become the most intensively researched modality used in non-invasive body shaping. The device has been recognised by peers around the world as well as by various international awards, such as the Best Body Sculpting Treatment by Instyle or the newest recognition by Safety in Beauty, Diamond Awards, in the category ‘The Body Hero of the Year’.

Practitioner experience Dr Aggie Zatonska, the founder and the medical director of Atelier Clinic in Egham, Surrey, has 13 years of experience in the non-surgical aesthetic sector and specialises in delivering the most subtle, natural results. The clinic is not only offering exclusive facial treatments, but it has expanded and balanced their offer of services with EMSCULPT NEO, which helps them target more body related concerns. “This allows our patients to become more confident and stronger. My patients want to feel well, stay fit, look their best, in the most natural way,” she explained. “Devices are increasingly becoming an integral part of our daily practice. They complement injectable treatments and allow to take skin and body care to the next level,” shared Dr Zatonska. “Patients’ expectations have evolved and trends are towards more holistic treatments and results. EMSCULPT NEO blends together the benefits of modern technology perfectly; by combining RF and HIFEM in a single treatment it allows us to address multiple patient concerns during a single treatment session. It is a perfect fit for the modern world: better results in less time,” she added. “Lockdown has resulted in an inactive year, we had to pause the gym and become more static. Many of our patients report that EMSCULPT NEO helped them improve their workout routines. It provides patients with an opportunity to focus on their body and to Before

EMSCULPT NEO is a perfect fit for the modern world: better results in less time start the process of change they’ve been meaning to implement,” Dr Zatonska commented, adding, “The patients enjoy how versatile EMSCULPT NEO is, it targets muscle and fat in one treatment that can be performed on nine areas of the body including abdomen, buttocks, arms, thighs, and even calves,” Dr Zatonska shared. The course of the treatment typically consists of four 30-minute sessions, scheduled one week apart. “We perform on average between six and 10 treatments per week and we recommend the treatment to be complemented together with evidencebased dietary recommendations. My favourite thing about EMSCULPT NEO is that it delivers consistent, empowering results that benefit patients’ health and wellbeing,’’ Dr Zatonska added.

After

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42-year-old male patient before and 2 months after the last treatment on two areas (abdomen and buttocks, to improve the core strength). Courtesy of Dr Aggie Zatonska.

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A summary of the latest clinical studies Title: Experience of Abdominoplasty and Analysis of the Risk Factors Authors: Montesanti B, et al. Published: Acta Chirurgica Belgica, December 2021 Keywords: Abdominal, Complications, Surgery Abstract: We performed a retrospective study of patients who underwent abdominoplasty to determine the predisposing factors for complications. Between 2013 and 2016, 235 patients underwent abdominoplasty at the Brugmann University Hospital. The risk factors for the complications studied were sex, body mass-index (BMI)≥30, active smoking, diabetes, high blood pressure, previous abdominal surgery, weight loss, other associated surgical procedures, liposuction, muscle diastasis correction and the duration of presence of the suction drains. Complications were divided into three groups: major complications requiring a second intervention within the first 15 days, minor complications only requiring local treatment and aesthetic complications corrected at a later stage. Complications were observed in 46.5% of the patients: 19% major complications, 69% minor complications and 12% aesthetic complications. Risk factors for complications were BMI ≥30, weight loss, associated surgical procedures and suction drains left in place for more than three days. We also analysed combinations of risk factors and found that certain combinations such as active smoking and previous abdominal surgery increased the risk. In our study, a high complication rate was observed, because our population was mostly obese, and many needed an additional procedure. Risk factors should be taken into consideration and explained to the patient beforehand. Title: Fractional Carbon Dioxide Laser or YAG Laser Assisted by Topical Application/Intradermal Injection of PRP for Post-Acne Scars Authors: Chen J, et al. Published: Plastic and Reconstructive Surgery, December 2021 Keywords: Acne Scars, Platelet-Rich Plasma, YAG Laser Abstract: Fractional carbon dioxide or erbium:yttrium-aluminumgarnet (YAG) laser combined with platelet-rich plasma (PRP) has been used for post-acne scars. There is limited evidence on its use because of the small size of studies. Randomised controlled trials comparing carbon dioxide or YAG laser combined with PRP to laser alone were searched for using PubMed, Embase, Web of Science, Cochrane Library, and Google Scholar databases. 13 studies involving 672 cases were included. The degree of clinical improvement favoured PRP combined with carbon dioxide laser (mean difference, 0.55; 95 percent CI, 0.40 to 0.70) or YAG laser (mean difference, 0.63; 95 percent CI, 0.31 to 0.96). The use of carbon dioxide laser combined with PRP was effective in both greater than 50% improvement of acne scars and greater than 75% improvement of acne scars, compared with laser alone. YAG laser combined with PRP was effective in greater than 75% improvement of acne scars compared with laser alone. Moreover, patient satisfaction was higher with PRP combined with carbon dioxide laser (OR, 2.98; 95 percent CI, 1.72 to 5.16) or YAG laser (OR, 2.88; 95 percent CI, 1.33 to 6.21) compared to laser alone. This metaanalysis provides evidence that fractional carbon dioxide or YAG laser combined with PRP is an effective and safe combination therapy for post-acne scars.

Title: Safety and Effectiveness of Hyaluronic Acid Filler, VYC-20L via Cannula for Cheek Augmentation Authors: Jones D, et al. Published: Dermatological Surgery, December 2021 Keywords: Cheek Augmentation, Cannula, Filler Abstract: Using cannulas to deliver facial fillers may reduce adverse events (AEs) compared with needle injection. This study aims to evaluate the safety and effectiveness of VYC-20L (20 mg/ mL hyaluronic acid gel with lidocaine) via cannula for midface age-related volume deficit. This multicentre, evaluator-blind, randomised, controlled study enrolled adults with moderate to severe Mid-Face Volume Deficit Scale (MFVDS) scores. VYC-20L was administered in one cheek via cannula (with optional needle use in the zygomaticomalar region) and in the other cheek via needle. The primary effectiveness end point was the mean (95% confidence interval) paired difference between treatments in MFVDS score change from baseline to month one; an upper CI limit of less than 0.5 determined noninferiority. Injection-site responses (ISRs), procedural pain, and AEs were assessed. Of 60 randomised and treated subjects, the mean change in MFVDS score from baseline to month one was -1.8 with cannulas and -1.9 with needles, providing a mean (95% CI) paired difference of 0.1 (-0.05 to 0.25). Most ISRs were mild/moderate and resolved within two weeks. Procedural pain was minimal, and no serious AEs were reported. VYC-20L for cheek augmentation was safe and effective using a cannula and noninferior to needle injection. Title: Social Media as a Tool to Educate Plastic Surgeons on Patients’ Concerns Before and After Cosmetic Breast Surgeries Authors: Shaul N, et al. Published: Aesthetic Plastic Surgery, December 2021 Keywords: Breast Augmentation, Plastic surgeon, Social Media Abstract: The rapid evolution of the social media platform has a major effect on the field of medicine. To identify patterns, trends and patients’ concerns before and after aesthetic surgeries involving breast implants, by analysing social media posts. We examined comments posted on popular Israeli online public forums between January 2019 and May 2021, regarding breast augmentation, mastopexyaugmentation and breast implant removal. 561 comments were posted on the three forums investigated: 165 pre-operative and 396 postoperative. In the pre-operative period, the main interests were implant size, type and location, as discussed in 69 posts (42%). During the first two months post-operative, questions reflected concerns regarding post-operative instructions, wound management, and asymmetry: 76 (43%), 59 (34%) and 27 (16%). These topics continued to be in focus up to one-year post-operative. Beyond the first post-operative year, main interests were breast implant-associated anaplastic large cell lymphoma (28%), capsule formation (26%) and systemic effects (26%). Social media harnessing to identify patterns, trends and patient concerns pre- and post-aesthetic breast surgeries is a novel approach. Misinformation was common, particularly in comments posted more than one-year post-operative. Four topics that concerned patients in the immediate and late post-operative period were asymmetric results, breast implant-associated anaplastic large cell lymphoma, capsule removal and systemic effects.

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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The ACE 2022 Experience Discover first-class learning at the long-awaited Aesthetics Conference and Exhibition on 11 & 12 March 2022 New year, new discoveries Curation and plans are well underway for what is set to be an incredible return after so long without this leading event, and we are delighted to announce that with the new year brings a new announcement for the ACE 2022 agenda. After the success and enjoyment at CCR 2021, brands, KOLs and medical professionals across the UK are poised to return to events, to catch up with friends, share the latest learnings and rediscover how extraordinary the aesthetic specialty is.

Business advice at the In Practice Theatre For the ACE 2022 comeback, the much-loved Business Track has a new name. After its successful debut as one of the most popular stages at CCR, the Business Track will retain its former glory as it becomes the In Practice Theatre. Many clinicians excel in the clinical aspects of their job, however, are often challenged by the unknowns of the business world. The In Practice agenda, sponsored by Enhance Insurance, will feature the latest business insights and advice from experts across the field of aesthetic medicine. Boosting your clinical skills and knowledge isn’t the only thing that will help you gain and retain patients to further progress your aesthetic career. The In Practice agenda will feature the most effective practical tips to help grow your practice, revealed by industry leaders, trainers and experts. How can you operate a successful clinic on a budget? Gain effective press coverage? Set achievable KPIs? Understand VAT? Or recruit and retain a team? Providing their best business tips and industry updates will be Dija Ayodele from the Black Skin Directory, awardwinning practitioner Miss Sherina Balaratnam, business coach Alan Adams, web marketing specialist Alex Bugg, reconstructive surgeon and trainer Mr Dalvi Humzah, PR guru Julia Kendrick, founder of Harley Academy Dr Tristan Mehta, business consultant Danny Large, Sharon Allen and VAT advisor Veronica Donnelly plus many more.

“ACE has always been such a fantastic event which we have always enjoyed attending”

Enhancing the ACE learning experience To ensure we deliver only the very best and latest content for the In Practice Theatre we are proud to be working with Enhance Insurance. Enhance protects healthcare businesses by providing specialist holistic assistance and advice and they are bringing this to ACE and to the In Practice Theatre. Business development manager of Enhance Insurance Sharon Allen said, “The whole team are really excited to be getting back to exhibiting. We have all really missed the interaction with our clients, delegates and other exhibitors that events such as ACE 2022 deliver. Historically ACE has always been such a fantastic event which we have always enjoyed attending and this year in addition to sponsoring the In Practice Theatre we have a new purpose-built stand that we cannot wait to show everyone!”

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022

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What else can you expect? The In Practice Theatre has an all-new agenda for this year, with new speakers and exciting new sessions covering a myriad of topics to help keep your business up-to-date and ahead of the competition. Big industry names will reveal their secrets to success and experts in key areas will impart their insights to ensure you stay on track with the latest regulations and business best practice. A sneak peek of the sessions include: Enhancing your profile with Julia Kendrick With intense competition in the aesthetic industry and the challenge of increasingly discerning consumers, how do you establish and enhance your profile? Award-winning business strategy and communications expert Julia Kendrick reveals how to utilise smart PR and marketing techniques in a multi-channel approach to engage, build and retain customers. Running educational events for patients with Miss Sherina Balaratnam Hosting regular educational events can be an integral part of achieving patient retention and acquisition. In this session, Miss Sherina Balaratnam will cover the key strategies behind hosting these events, how to maximise each opportunity to benefit your patients and deliver a high return on investment for your time.

CPD POINTS FOR EVERY SESSION YOU ATTEND! Register now for ACE 2022 Attend the sessions that suit your learning needs the most and contribute to your career and clinic development, whether that involves laser treatments, body-contouring methods, skincare approaches or business strategy. Further details on the agenda will be revealed soon with some sessions taking bookings with limited places available including clinical sessions from aesthetic giants TEOXANE, Allergan, Galderma and more. Register now for exclusive priority access to these sessions and the chance to secure your place early.

The after sale with Alan Adams The After Sale factors into most of the tasks that clinics can do to ensure repeat and profitable business. This includes things like offering VIP clubs for high-paying and loyal customers, gathering feedback and testimonials, securing core personal details like birthdays and anniversaries and developing customers into brand ambassadors. Business coach Alan Adams will advise on how to implement these strategies successfully.

SCAN HERE TO REGISTER FREE NOW 11 & 12 MARCH 2022 / LONDON

H EADL I N E SPON SOR

Exhibition opening times: Friday 11 March: 9:00 – 17:30 Saturday 12 March: 9:00 – 16:30

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Marketing Your Calendar Aesthetics tells you the top dates to incorporate into your marketing strategy in 2022! It’s the new year, and as we enter 2022, there are plenty of dates in our calendar that we need to look out for – and no, we don’t just mean your birthday or Christmas! There are so many days, weeks, and months throughout the year that can be specifically utilised for clinic and treatment marketing – National Bikini Day or International Kissing Day to name a few. According to PR consultant Julia Kendrick, using these can be key for connecting with your audience. She says, “Communications need to be timely to have maximum engagement, so by using key dates in your marketing strategy, you can create meaningful content and conversations on a topical, relevant ‘hook’ and link this back to your marketing messages. Key dates and environment-led ‘trends’ are cyclical and allow you to plan your content in advance, giving you key pillars in your communications plan that will naturally align with what people are searching for, or interested in, at any given time.” So, with that in mind, let’s take a look at some of the dates you can add into your marketing plan for 2022!

Skin awareness dates Skin health is a huge part of aesthetics, and throughout the year there are many dates in this realm for you to be aware of. For example, National Sunscreen Day on May 27, Melanoma Awareness Day on May 31, and World Psoriasis Day on October 29. According to digital specialist Alex Bugg, these days should be looked at less as a chance to push for sales, but instead as a way to educate your audience. She notes, “I’m sure all clinics and companies have an SPF that they want to sell, and while this might

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be a consideration when creating content for skin awareness days, this shouldn’t be shown as the focus. If you want your followers to trust you then you have to show them you have a duty of care to their wellbeing, and not just say ‘Happy Sunscreen Awareness Day... buy this product’.” Kendrick notes that she always recommends her clients have their social channels and communications as 75% educational, 25% commercial. She notes, “This builds engagement over time, people find the channel useful, interesting and will come back for more – whereas they will switch off or unfollow if they just feel ‘sold to’ all the time. Anchoring content around a big awareness day and topic means you can create lots of content and be judicious about seeding marketing messages with targeted calls to action. For skin awareness dates this could be something such as ‘did you know, we offer mole checks with our resident dermatologist’ or – ‘if you need help finding the right SPF skincare, book in for a free consultation’.” Bugg suggests that for Sunscreen Awareness Day, something like a swipe through outlining the main benefits of SPF, and the damaging effects that neglecting it can have, would be beneficial. “This way you’re not coming from a money-making angle, but showing them that you care about their wellbeing,” she says. The same can be done for dates that bring awareness to skin conditions, Bugg adds. “Things like psoriasis can have a real impact on people’s self-esteem, so doing a post that educates people on what it is and what can be done to help treat/manage the condition will be received a lot more positively than just a simple post noting what day it is and what you’re selling,” she says.

Wellness dates 2022 also sees several awareness days linked to psychology and wellness, for example International Mind-Body Wellness Day on January 3 and Stress Awareness Day on November 2.

“If you know these kinds of dates in advance, you can add them into your marketing plan and make sure you develop some polished content” Alex Bugg

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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Kendrick comments that these broader awareness days can allow clinics and practitioners to point to additional products or services they may offer outside of the specific aesthetics space, which can form part of a holistic approach. She says, “Of course, stress and skin are intrinsically linked, but there are patients who might not know that. Many clinics have integrated hormone or sleep experts into their offering to amplify the treatments at this broader level, so building understanding about why these products and services are interlinked is a great way to increase understanding, and thereby, demand.” She emphasises that practitioners shouldn’t underestimate the importance of showing personality and humanity when creating content, noting, “Users tend to engage well with real people doing real things. So you could, for example, consider sharing some of the things you or the team do for their own mental wellbeing – be that a yoga class, a de-stressing zone in the clinic after a busy day, or a favourite herbal tea!” October 10 is World Mental Health Day, and Bugg notes that this can be a great way to educate your patients on the psychological conditions that are more commonly seen in the aesthetic industry. She comments, “Body Dysmorphic Disorder is a growing issue, and is something that is becoming increasingly more common for practitioners to suspect/ identify in their patients. Mental health awareness days can be a great way to not only teach your patients about the condition, but also inform them how to maybe help a friend or a relative who may be experiencing these kinds of emotions. Again, this all links back to the duty of care you have as a healthcare professional, and it’s important that people know you would turn down treatment if you believed the patient didn’t need it.”

Personal dates Throughout the year there are many dates that can help you reach out to your female audience, including International Women’s Day on March 8, Mother’s Day on May 8, and Menopause Awareness Day on October 18. A key date for female patient education is breast cancer awareness month in October, says Bugg. “Being candid and open with your female patients is so important here,” she comments. “You could do a post telling them how to check their breasts correctly and when to see a doctor, or you could post something in the morning stating that the

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team has just done their monthly check-up. It serves as a gentle reminder and also gives your messaging a more personal edge which can help them connect to you.” Bugg also notes that focusing on male centric days as well as female is a good way to connect with a new patient base but advises switching up your style of communication. She says “In my experience, men and women respond to different things and as a lot of clinics have a main patient demographic of women it’s something people can often get wrong. Women want to know how something will make them feel, whereas men like to see the practicalities behind it. So, this is what needs to be clear in your messaging.” Bugg notes that hair loss awareness month, which takes place in August, is a great time to communicate with your male followers. She comments, “Hair loss treatments are really emerging in the industry, – it’s an issue that a lot of men struggle with and feel shame around. Rather than pushing a certain product or treatment, the key is providing facts about what they might be experiencing, why it could be happening, the options that are available to them, how they work, and what the outcomes of these will be. Again, this could be done as a swipe through or even as a reel/video.”

Diversity dates There are many days in the calendar that serve to celebrate diversity, such as pride month throughout June and Transgender Awareness Day on November 20. While these dates are important, Bugg emphasises that you should be showing allyship and support all year round. She says, “For these awareness days, I feel quite strongly about not signaling without actually following through all year. Being accepted, included and feeling safe to visit a clinic as LGBTQ+ or BIPOC all year round is vital and not something that should be used as a marketing tactic or money-making scheme. It’s fine to post something on those days, and of course awareness is always important, but as a practitioner you need to make sure that this support is being backed up by what you’re putting in place for the other 364 days of the year.” To deliver more inclusive marketing, Bugg suggests always using marketing that includes people of different colours, genders, sexualities, and cultures. “If you never use gay or trans models, show their results, or discuss their journeys, none of these minorities are

going to be able to trust you to treat them correctly,” she says, “In addition they won’t be able to know if your clinic is open and accepting of them, and people won’t get treated in a place that they don’t feel safe. It’s always important that your marketing is full of diversity so that there’s something for everyone to relate to.”

Plan ahead! Bugg advises that in order to utilise all the aforementioned dates, you need to ensure that you plan your marketing strategy in advance. She notes, “Whether you just plan for the first quarter, half, or for the whole year, the key is planning ahead! If you know these kinds of dates in advance, you can add them into your marketing plan and make sure you develop some polished content. It’s no use just realising on the day that something’s happening and shoving something up! Making use of these dates is a great way to connect to new or existing patients and show them that they can trust you, so make sure you do it correctly!” Kendrick notes that because there are so many awareness days that you could include in your marketing calendar, clinics should be selective and tailor the ones that you want to focus on to your current clinic demographic. She concludes, “If you don’t have any particularly relevant clinic link to these awareness days, for example a treatment or specialist practitioner that you’d be driving towards as part of your call to actions, you could consider including a charitable or corporate social responsibility element to the content. Perhaps you and the team will be raising money or donating a percentage of profits during breast cancer awareness month, or someone in the team is running the marathon for melanoma awareness. Rounding out your communications with value-driven and human-centric content is a critical element to balance educational and commercial posts.”

Find your dates While these are some great days to incorporate into your marketing, this is just a taster! There are so many others out there that could be applicable to you and your practice. Head to www.awarenessdays.com to discover more!

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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the scope of services on offer or perhaps diversifying into other areas.

2. Systems and processes

Building Resilience in Your Clinic Business coach Alan S Adams shares his top five strategies for building and maintaining resilience in your clinic Growth is the treasure every clinic owner rushes towards, and many focus on turnover as a metric of success. But – as we’ve seen over the past two years – unless you have resilience built into your business model, surviving (let alone thriving) will be incredibly tough. In 2020, Hamilton Fraser Cosmetic Insurance conducted a review to assess the impact of the pandemic on businesses – with 80.51% of practitioners reporting the closure of clinics, a reduction in revenue (67.28%), and a reduction in enquiries (63.31%).1 In this article, I will share my five strategies for how practitioners can build, and maintain, a resilient business that is able to flex and adapt to whatever challenges are thrown its way.

1. Plan When creating a business plan, it is vital that you consider how to manage and treat your business’s growth, but it is even more important that your plan can guide you on what to do if a challenge presents. For example, even if you have a rough idea of where you’re going with your business, you still need to define what your dream destination is and outline the steps along the way. Otherwise, you are essentially getting in your car and heading off on a road trip without checking a map, working out how long the journey will take, or ensuring there are plenty of places to stop for petrol en route. Within any business plan, practitioners need to cover all areas from a 360-degree viewpoint. Questions that should be covered in a business plan include: • • • •

What’s your plan for growth and how will you track it? What are your weaknesses? What risks could your business face? How can you mitigate these or take appropriate action if they do happen?

The overall strategy should be created at owner/management level but should include input from the team around their processes and long-term vision of the clinic. When you’re ready to create your plan, it should be simple and stored easily online for accessibility and referral at any time. Any strategy needs to consider your growth and how you can support yourself when events don’t go to plan. It could be that you must deal with staffing issues and need to recruit quicker than expected, that you need a robust HR framework in place, or it could be management issues around services or procedures – such as identifying a need to widen

An aspect of having a resilient business is ensuring that each member of the team is in the correct role and that, as a business owner, you have the time and freedom to focus on the critical areas so that you can reap the rewards of having a business that works for you. It should be able to function without the owner being actively involved — particularly in the day-to-day operations. For a clinic owner, the idea that their business can run without them can be overwhelming, but it’s important to the success of their clinic. For it to work smoothly without you, it’s vital that you write down everything (even the smallest of tasks) and create a process for each one. It’s great practice for your team to do the same – therefore, in the event of staff absences, several members of the team are trained and able to step in, ensuring business continuity. This can be done through training across the clinic where everyone learns about each other’s roles and responsibilities, presented in various ways such as video demonstrations, recordings, or ‘how-to’ guides. It’s a common problem for a business owner to be embroiled in the day-to-day operations and working in their business, that they don’t have time to work on their business. This leads to them becoming frustrated that they aren’t achieving the rate of growth they desire. Creating a business which works for you, and provides you with the lifestyle you want, is achievable by having the right systems in place. Knowing your worth is vital, so consider how you’re spending your time. For example, you can implement automation systems like website bots to answer common patient questions and get patients booked into your clinic or you can use scheduling software for social media posts, email marketing and newsletters. You can also integrate a sophisticated customer relationship management (CRM) system to keep patient contact details up-to-date, track patient interaction and manage accounts easily. If you are unsure on CRM systems, then consider talking to someone in the field who can advise on the best tools based on your requirements and needs.

3. External support and outsourcing You’ll never know it all, and there’s no use in pretending that you do. It’s important to know what you don’t know, which is where external business support and outsourcing comes in.

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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It’s a good idea to build a team of trusted advisors around you to support you when you need it. Outsourcing and calling on expertise is a fantastic way to streamline costs and free up time to focus on what you love and what makes you profitable and should be considered in terms of return on investment. Firstly, you need to recognise where you feel you need some additional support in your clinic, and this can help you determine the right person/company for the job. For example, reception, marketing and PR, call answering services and accountancy are all areas which can be easily outsourced. Or if you need assistance on revenue growth planning, then perhaps a business coach can guide you on the small changes that will make a difference to the growth of your business whilst supporting you in creating a resilient business plan. Before you engage with any professional or company, do your research and ask questions that will give insight into their suitability for your needs, as not everyone will be ideal for your business. Perhaps ask your colleagues who they use and can recommend, attend events to meet more relevant people in the industry or watch business talks at conferences and take away contacts from those. After conducting your research, it’s your job as a business owner to spot the good from the bad. There are plenty of people who claim to be great at what they do, but they need to be able to meet your clinic’s needs and prove to you that they are enhancing your business and making it more resilient. Ask appropriate questions such as: tell me about some of your successful clients and how you helped them, what guarantees can you give me that your services will improve my business, or what if you don’t deliver on your promises to improve my business, which should help you on your way to choosing the relevant professional or company for the job.

4. Email communication Have systems in place (such as CRM noted above) that allows you to easily access details of all existing and prospective patients so you can regularly engage and communicate with them effectively. I suggest you create a strong email marketing campaign, which ensures your clinic remains on your patients’ mind and helps improve patient loyalty which ultimately leads to a more resilient business. Be wary of being too sales focused in your email marketing, providing educational advice and support messages, rather

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than ‘selling’. You can provide advice and guidance around everything aesthetics-related, share skincare tips and tricks, and update on what’s going on in your clinic, future plans, and exciting developments such as new treatments and offers. Keeping in touch via email through your clinic’s CRM system once a week is acceptable. You don’t want to just email people the same thing for the sake of it as they will likely unsubscribe to your updates. It’s a good idea to work out the right level of email frequency through testing and measuring. If you’re getting a lot of unsubscribes, try tweaking the number of times per month you send emails, the time you send them or even the day of the week. Other factors like the subject line and content can also have a huge impact in your open rate and subscriber count. Another way to increase subscribers is A/B testing email campaigns, in which you send one variation of your email to a subset of subscribers and a different variation to another subset of subscribers.2 This allows you to see clearly what gets more engagement from your patients and which ultimately works. However, bear in mind that if you’re providing advice and guidance along with updates about your clinic, and still getting a lot of unsubscribes, chances are they are not your ideal patient anyway.

5. Measurement It’s important to measure all aspects of your business’s growth so that you can check that you’re heading in the right direction or whether you need to tweak what you’re doing in a particular area, which contributes to a resilient business. I work with businesses to help them make a 10% improvement in each area – from returning customers and average spend per visit, to lead generation and lead conversion. It’s an achievable percentage that doesn’t feel too overwhelming or stressful, and over time, it can skyrocket turnover (in many cases I’ve seen, more than double it). Some of the key factors you should be monitoring, and measuring are: • How many new patient leads you gain? • How many new enquiries convert into patients? • How often your patients spend money? • How much your patients pay for your services? • What are your patient satisfaction rates? Are they happy with services you offer or could there by improvements? The above can be measured if you put

time in and have an effective CRM system, which can track how many website clickthroughs an email received and how many got in touch because of seeing the campaign. Asking new leads how they found you, or why they’re getting in touch, can provide you with valuable insight. A bi-annual patient survey is also a good idea to keep track of your progress and make any relevant changes necessary. I use a traffic light system to give practitioners an indication of where improvements can be made, what they are great at, and where there are weaknesses. Green – you’re doing great, keep it up. Amber – needs some work. Red – this is a challenge to your growth. Clinic owners can create their own individual systems to give a good idea of how they’re performing. For example, a scoring system which is linked to the traffic lights will give you an indication of where you are.

Overcome the hurdles There are many aspects in life – and business – that we can’t predict. Having a solid business plan in place isn’t a guarantee that your clinic will sail through, but it does put you in a stronger position to deal with the ups and downs. Returning to the road-trip analogy, you will hit traffic and roadworks on the journey but having an effective business plan means you’ve factored it into your day and will still arrive on time. You already know of alternative routes you can take if option A is blocked. Alan S. Adams is an awardwinning business coach, professional speaker, and bestselling author. His third book, The Beautiful Business: Secrets to Sculpting Your Ultimate Clinic, focuses on the medical, cosmetic, and aesthetic clinic sector. He was a finalist in The Association of Professional Coaches, Trainers and Consultants’ Coach of the Year Awards and has been recognised by Enterprise Nation in 2020 and 2021 as a Top 50 Advisor in the UK (Sales Category). REFERENCES 1. Hamilton Fraser Cosmetic Insurance, ‘What is the Impact of COVID-19 on the industry?’, 2020 <https://hamiltonfraser.co.uk/ knowledge/covid-19-aesthetics-industry/> 2. Mailjet Blog, ‘The Definitive Guide to A/B Tests in Your Email Marketing’, 2019, <https://www.mailjet.com/blog/news/ab-testing-beginnersguide-for-email-marketing/>

Alan Adams will be speaking at ACE. Register for free on p.61

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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England (HEE) guidelines. Finding one that is regulated by The Office of Qualifications and Examinations Regulation (Ofqual) is also strongly recommended. Each Ofqual Level 7 course will be different and can take six to 36 months to complete, but typically it will include safe use of needles and cannulas, business advice, in-depth knowledge of skin and facial ageing, anatomy, complication management, and the psychological driving forces and issues for patients considering cosmetic treatments.

Starting Out Safely Nurse prescriber Natalie Haswell provides an introduction to safety considerations when starting out in aesthetics Delving into the aesthetics field can be daunting, but you’ve got to start somewhere. Everyone starts their journey differently, and everyone’s journey is unique. It depends on many factors including your current job, family status, finances and how you will manage extra work, training, study, responsibility, and pressure. It’s a juggling act! There is no ‘right way’ but hopefully this article will help you cover what I believe to be the most important aspects to ensure you are safe and, most importantly, so are your patients. Take your time, do it right and do it safely. It does not matter if it takes two or 10 years to have 50 regular returning patients or if it doesn’t go to plan the first time – that’s how we learn and make patient care standards and business even better.

The importance of training Arguably, the most important aspect of patient safety is training. Let’s say you have completed a foundation day course – this is a great place to start. Hopefully you liked it and have decided aesthetics is the specialty you want to pursue, and you’re willing to put in the time, money, and of course the extensive training it takes to become a top aesthetic

practitioner with patient safety at the forefront. So, how do you gain competence in order to feel confident and safe to practice as a sole clinician or get enough experience to get a job in a clinic? The answer… book more training. This is a specialty, and although there is no law on minimum training requirements to practice aesthetic medicine, a one or two-day course is not enough to become a leading practitioner in the field. Look for training that will give you continued learning and mentorship so you can develop steadily and safely. Learn your anatomy and know the products you are going to use inside out! How do they work? How are they administered and why? What dermal layer are your products injected into and again why? Think, correct training, product, tool, dose, technique and aftercare. If you decide you are committed to a career in aesthetics, I suggest checking the training providers on the Joint Council of Cosmetic Practitioners’ (JCCP) website.1 A Level 7 Diploma in Injectables for Aesthetic Medicine is a great route to take. Some Level 7 courses are JCCP-approved, and others are not, but I would recommend looking for one that is as they own the original Health and Education

You can also look to complete a Master’s in aesthetic medicine which is similar to a Level 7 and can be a good choice for furthering your academic career, although it can be a bit less practical and more academic. The University of Manchester, for example, offers a part-time MSc in aesthetics, incorporating online learning, group work, and written assignments, two five-day residential sessions and a final dissertation over 36 months.2 Although it’s not formal training, attending conferences like the Aesthetics Conference and Exhibition (ACE) and CCR is a great way to keep track of industry updates, further your learning, network and attend talks and demonstrations from some of the best practitioners out there. Turn to p.60 to find out more about ACE.

Complications management An essential way to ensure you are a safe practitioner is to complete a complications management course. For example, you should look to complete a course on how to manage injectable complications like botulinum toxin and the undesired effects of fillers, granulomas, nodules and post-inflammatory swelling. I highly recommended this not just for patient safety but for insurance purposes too. You can never do enough of these, and I encourage practitioners to attend and complete one course annually alongside your basic life support (BLS), intermediate life support (ILS) or advanced life support (ALS) resuscitation training. As well as training mentioned above, join an emergency complications group for 24/7, 365 days a year support and expertise such as the two main complications groups: the Aesthetic Complications Expert Group (ACE) World and the Complications in Medical Aesthetics Collaborative (CMAC).3,4 They both offer clinical guidelines for aesthetic practice, as well as share research, support, templates, webinars and much more. Joining these groups is invaluable to have

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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place for a safe practice. At a minimum, I believe you should have the following:

Look for training that will give you continued learning and mentorship so you can develop steadily and safely such experts at the end of the phone when you need them and is excellent value for money when you consider how they can support you. Another way to ensure you are practising safely and to reduce the likelihood of complications is to make sure you only use well-established, well-researched quality products – this is essential. Do not purchase products from unmonitored or unauthorised parties as they may be counterfeit and may not contain the ingredients they state, putting your patients and you at risk from undesired complications and potentially irrevocably damaging your brand. I recommend using reputable product distributors and regulated pharmacies or go direct from the manufacturers. As well as taking all the necessary steps to avoid a complication, it is also essential to know what to do when one does occur. Ensure you have the recommended emergency drugs kit prior to any treatment, that all drugs are in date, stored correctly and you have enough as per the ACE Group World emergency drug kit list and policy.5 Vials of adrenaline are recommended instead of adrenaline branded pens due to the Medicines and Healthcare Products Regulatory Agency (MHRA) report that one failed to auto inject in the last few years.6 Make sure you have a medical fridge for emergency drugs and botulinum toxin storage and monitor the temperature daily. In a 2021 US study, out of 370 participating dermatologists, 106 (28.6%) reported at least one vascular occlusion, so it is essential to have hyaluronidase on site in case of a vascular occlusion.7 ACE Group World recommends to store your hyaluronidase at a temperature between 2-8°C to maintain the quality of the product.8 CMAC recommends using 1,500 units of hyaluronidase in the case of a vascular occlusion, and once opened the remaining

contents needs to be disposed of, so bear that in mind when thinking about amounts to store in clinic.9

• Health and safety for you, any employees and your working environment, slips, trips and falls • Fire safety ensuring there is an evacuation plan and fire extinguisher if required for your premise size • Infection control prevention and management plans • Data protection and GDPR • Complaints process and recording • Risk assessments • MHRA medicines and prescribing • Information Governance Policy • Equality, diversity and disability/human rights

Waste disposal You should also consider the importance of sharps disposal and clinical waste. There are many companies out there that can assist with this, and you need to find which is right for you and your business. The best place to search for this is online, as not all companies cover the whole of the UK. PHS who supply the NHS have been known to be very good. Some local councils also request you have a sharps license so check this with your local council too. JCCP, ACE Group World and CMAC provide clinical policies and procedures for safe practice within aesthetics as well as Save Face, who will also attend your clinic and complete an assessment with you.10 When you have a waste disposal service arranged, they will ask you to display your certificate within your clinic setting so the collectors can review it and also the public.11

Insurance and policies Covering yourself and your business should anything go wrong is vital, so insurance is an absolute must. Contact some insurance companies and get quotes for aesthetic insurance and compare, ensuring it covers what you need. A few reputable insurance companies include Enhance Insurance, Cosmetic Insure, Hamilton Fraser, PolicyBee, and there are more available. I choose Hamilton Fraser as they came highly recommended by a colleague and they had the best plan to meet my needs.12 Make sure the provider covers you for onward referrals if required medically, clinical complications, each procedure you intend to carry out and the products you intend to use. You should also ensure you are clear as to how they receive a complaint. As well as insurance, next comes policies and procedures that you should have in

Don’t be put off! It may seem like there is a tidal wave of legislation and jumping through hoops to start out safely in aesthetics, but as medical professionals, you all already understand the need for stringent procedures when dealing with human health. Don’t be put off by the overload of information at the beginning, complete training, network at events to gain mentors and helpful allies, and do as much research as you can. Patient safety is paramount in any aesthetic practice, and it’s key in ensuring the longevity of your business. Natalie Haswell is an aesthetic nurse prescriber with a Level 7 in skin injectables. She is the founder and CEO of Haswell Aesthetics Ltd. and a senior medical trainer at Harley Academy. Qual: RGN, INP REFERENCES 1. JCCP, 10 Point Plan for Safer Regulation in the Aesthetic Sector, 2021, <https://www.jccp.org.uk/ckfinder/userfiles/files/10%20 point%20plan.pdf> 2. https://www.manchester.ac.uk/study/masters/courses/ list/09805/msc-skin-ageing-and-aesthetic-medicine/ 3. Aesthetic Complications Group World - <https://acegroup. online> 4. Complications in Medical Aesthetics Collaborative - <https:// www.cmac.world/members-area/> 5. Aesthetic Complications Group World, Practice Standards, 2020, <https://uk.acegroup.online/policies/practice-standards/> 6. Medicines and Healthcare Products Regulatory Agency, ‘Adrenaline Auto-Injectors: Recent Action Taken to Support Safety, 2019, https://www.gov.uk/drug-safety-update/adrenalineauto-injectors-recent-action-taken-to-support-safety 7. Alam, M. et al., ‘Rates of Vascular Occlusion Associated with Using Needles vs Cannulas for Filler Injection, JAMA Dermatol, 157(2), 174 – 180, 2021 8. Aesthetic Complications Group World, ‘The Use of Hyaluronidase in Aesthetic Practice’, https://www.bacn.org.uk/ content/large/documents/members_documents/complications_ guidance/acegrouphyaluronidasev2.4.pdf 9. Murray G, Convery C, et al., ‘Guideline for the Management of Hyaluronic Acid Filler-Induced Vascular Occlusion’, J Clin Aesthet Dermatol, 14(5): 61-69, 2021 10. Save Face, <www.saveface.co.uk> 11. PHS Group, ‘Sharps Box and Bin Disposal’, <https://www.phs. co.uk/our-services/healthcare-hygiene/sharps-disposal/> 12. Hamilton Fraser, <https://hamiltonfraser.co.uk/cosmeticinsurance-quote/>

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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and so my need for space has also grown! As a result, we are opening a second clinic in London.” Taking a different medical pathway, Mr Mandavia attended King’s College London Medical School, but decided instead of becoming a space doctor, he wanted to pursue a career as an ENT, head and neck facial plastic surgeon. He says, “I was really pleased to secure the only National Institute for Health Research (NIHR) Academic Clinical Fellowship for ENT, head and neck surgery in London. It was a one-of-a-kind fellowship which enabled me to develop research skills alongside my surgical training.” Following this, Mr Mandavia was awarded a scholarship with the National Institute for Health and Care Excellence (NICE) and simultaneously completed a Master’s degree in Health Policy at Imperial College London. He recalls “At NICE, I had the opportunity to help develop national ENT head and neck surgery guidance

“Becoming a leader and organising a team is a pivotal part of running a successful aesthetic clinic” Dr Tatiana Lapa and Mr Rishi Mandavia discuss their differing paths into aesthetics, being a husband-and-wife duo, and their biggest achievements so far With a joint interest in becoming space doctors and gaining a Bachelor of Science in Aerospace Physiology during their medical school training, Dr Tatiana Lapa and Mr Rishi Mandavia’s relationship blossomed, while their careers in to aesthetic medicine took different paths. As a husband-and-wife duo, Dr Lapa and Mr Mandavia reflect that it was a simple decision to set up a clinic and work together. Talking about how they met, Mr Mandavia reflects, “We were both studying Aerospace Physiology and Tatiana was doing a research project where she studied the effects of hypoxia (lack of oxygen) on brain function. I, of course, volunteered to be her subject and that’s how we met! Was it oxygen deprivation or was it love at first sight – we’ll never know!” Dr Lapa first became interested in aesthetics when she qualified as a junior doctor at St George’s University of London in 2011. She reflects, “I started working for another clinic in London, which was a great introduction into the world of aesthetics. I attended lots of training courses, workshops and achieved a first-class Master’s degree in Aesthetic Medicine at Queen Mary University of London. I completed my GP training and wanted more autonomy in my aesthetic practice and so decided to open my own clinic.” In 2014, Dr Lapa established the Dr Tatiana Aesthetic Dermatology clinic in Harley Street London, which she ran alongside Mr Mandavia. She comments “I developed a passion for skin health and found myself being drawn to the exciting innovations that were on the market. Soon I realised that I was running out of space in my little one room and expanded to have a multi-room clinic.” She laughs, “My love for machines and technology has grown

“We work very much as a team. I bring my research, management and surgical skills, whilst Tatiana brings her passion for creativity and innovation” Mr Rishi Mandavia

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My favourite treatment to perform is… RM: I would say combined radiofrequency and CO2 lasers. TL: I guess I would need to say something different, so fillers!

Any industry pet hates… RM: Aesthetics isn’t as collaborative as other medical specialties. If I have a patient with a complex ENT problem, I can work across specialties and seek help from a colleague, but aesthetics isn’t built like that yet. TL: People who aren’t even the smallest bit medically qualified can perform injectable procedures. It’s all about the safety of the patient.

Best piece of career advice… RM: Put your patients first and care about them, you will get good results and your success will follow. TL: Don’t wing it! If you don’t know something, look it up and research it!

and my Master’s degree gave me insights into health policy development”. Recently, alongside his NHS clinical practice, and his work at the Dr Tatiana clinic, Mr Mandavia completed a PhD Fellowship in Therapeutic Implementation at University College London. He recognised that whilst there is a huge drive for development of novel medical treatments and technologies, there is also significant delay in patient access to these innovations. His PhD focuses on how to lessen this gap within healthcare systems. Mr Mandavia naturally became involved in aesthetics when Dr Lapa started the clinic. “As Tatiana started to become involved in aesthetics, I did too. I was genuinely amazed by the remarkable results of non-surgical procedures and was particularly interested in the complimentary nature of aesthetics to facial plastic surgery,” he explains. As well as working in surgery, research and aesthetics, Mr Mandavia is an expert advisor for the World Health Organization, a consultant to the Lancet Commission, associate surgical specialty lead to the Royal College of Surgeons and a committee member of the European Academy of Facial Plastic Surgery. Working together with Dr Lapa in their clinic has led to a successful business, Mr Mandavia states, “We work very much as a team. I bring my research, management and surgical skills, whilst Tatiana brings her passion for creativity and innovation. Why would you work with someone else when you can work with your husband/wife – someone you can trust, learn from and who understands your goals?” As their aesthetic careers developed, both Dr Lapa and Mr Mandavia have become

plan, but running a clinic meant I had to rapidly pick up these skills and work outside my comfort zone.” With aesthetics gaining popularity as a career path, Dr Lapa discusses what helped their clinic to grow. She notes, “If you have a patient whom you’ve cared for, achieved brilliant results and delivered an excellent experience, they are likely to return and refer their friends and family. This will slowly but surely lead to an organic and sustainable growth of your clinic and help you gain a positive reputation.” Going the extra mile for your patients and delivering great patient care is integral for a successful practitioner. Mr Mandavia adds, “I think what separates a good doctor from an outstanding one, is

“I think the day I decided to venture into aesthetics was a life-changing day! I’m so glad I did it and it’s a career that I love so much and has become a huge part of our lives” Dr Tatiana Lapa

key opinion leaders (KOLs) for various companies. Dr Lapa notes, “We have had some fantastic opportunities in aesthetics. Working with companies such as VIVACY, InMode, Cutera and Syneron Candela has been so rewarding. I’ve always enjoyed working with Stylage dermal fillers and using innovative devices like the Excel V+, Morpheus8, Profound and CO2RE. Recently we’ve had the opportunity to launch the SecretPRO in the UK, a unique platform combining radiofrequency microneedling and fractional CO2 laser.” Mr Mandavia reflects that being a clinic owner has also meant learning about business management and leadership. “Becoming a leader and organising a team is a pivotal part of running a successful aesthetic clinic. Doctors are not typically trained in or exposed to business or financial management. I didn’t even know how to make sense of a financial spreadsheet, let alone develop a business

someone who always puts their patients interests at the centre of any management plan and genuinely strives to achieve the best outcomes for their patient.” Reminiscing about their careers thus far, Mr Mandavia recalls that his proudest moment was marrying Dr Lapa. He notes, “We have wonderful careers, I have a great wife and an amazing son, and another baby on the way! I’m so proud of Tatiana and how she handles having a clinic, whilst being pregnant and having a baby at home. She is amazing!” Dr Tatiana adds, “I think the day I decided to venture into aesthetics was a lifechanging day! I’m so glad I did it and it’s a career that I love so much and has become a huge part of our lives. It’s enabled me and Rishi to work together, and I wouldn’t have got this far without him. Another big achievement would be the amount of joy I get from my family – my son and second baby on the way – this is unparalleled by anything else.”

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


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The Last Word Dr Parneet Sehmi argues why brands and cosmetic clinics need to more carefully consider the language they use in advertising In December, the Advertising Standards Authority (ASA) banned an advert by an aesthetic manufacturer citing misleading and exaggerated earning claims for clinics it was selling its products to.1 A quick flick around the advertising watchdog’s website shows that this incident is far from isolated in the aesthetic and cosmetic industry – hyperbolic claims in advertising are rife.2,3,4 Although this recent example impacted clinics, the public are frequently the ones to be targeted with inflated marketing claims around beauty and cosmetic services. Brands have often faced criticism for feeding into unattainable ideals of attractiveness, promoting products and treatments in a way that suggests they can achieve the idea of ‘perfection’. At first glance, it may look like the industry revolves around image and videos rather than words when it comes to marketing, but I find the type of language used is often the main component in the creation of misleading advertising. As regulated medical professionals, I believe we have a responsibility to ensure we are ethically advertising our services and being transparent with the public about what our products and treatments can achieve. However, in my view, many businesses are falling short. So, what is the problem and what should aesthetic practitioners be doing to improve the advertising landscape in our sector?

one treatment’, ‘get the lift nobody else can get with our superior techniques’, and ‘we can make your face beautiful’, to name a few. In aesthetic marketing, there are often misleading adjectives used that imply consumers will be more physically attractive – especially to the opposite sex. Hyperbole is a facet of advertising in every medium, and we are still seeing ads that promise to bestow upon the user super strength, blinding-white teeth, pain-free results, and an uncanny ability to attract men/women. This gives our patients unrealistic, and false, expectations of what they can expect following a treatment. Therefore, using this exaggerated kind of advertising shows that the cosmetic products that perpetuate the idea of a ‘perfect’ body use women’s low self-esteem against them. With so many brands, clinics and companies using hyperbolic language that could be considered false advertising, it seems many are unaware of (or choosing to ignore) the rules that the ASA has in place. As such, it is imperative that all practitioners ensure they are well educated on the Committees of Advertising Practice (CAP) code6 which is enforced by the ASA, and regularly keep updated so as not to mislead patients. It’s also worth noting that this will help protect your own reputation and career. I also believe we have a responsibility to report any company who are misleading patients in this way to the ASA.

The problem

Ethical marketing

One of the strengths of the advertising industry lies in its ability to transform mundane objects into highly desirable products. Often, this is done well, for example, saying the product is ‘perfect for adding light volume, boosting hydration and enhancing your smile’. However, some companies in our sector are exaggerating the efficacy of their products or treatments. Statements such as ‘you’re just one click away from changing your skin forever’ have been picked up by the ASA2 because as we know, they aren’t realistic – improving skin takes time and a dedicated treatment plan using many modalities. A quick look on social media provides more examples: ‘turn back the clock 20 years with

Instead of selling a dream through words your patients want to hear, I believe the aesthetics industry should advertise reliable information that leads to better and more informed decision-making about cosmetic products and treatments. In its marketing code, the CAP and ASA states that marketing communications must not mislead consumers by exaggerating the capability or performance of a product.6 Thus, if practitioners are making an advertising claim which goes beyond a simple cosmetic effect for the product, they should use sufficient evidence to support it. For example, practitioners should reference moisturising products having the potential ability to

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plump the top layers of skin with moisture, thereby reducing the appearance of wrinkles, rather than completely removing wrinkles altogether. It is important for practitioners to focus on the cosmetic effect of the product on consumers in general, suppressed by data-led science. At my clinic, we ensure to use honest and objective statements when referencing the efficacy of aesthetic treatments. For example, in our social media we will explicitly state something like: ‘treatment is subject to a medical consultation. As hyaluronic acid dermal fillers are not a permanent treatment, the effects will wear off over time, so it’s recommended that the procedure is repeated every five to six months for effective results’. This creates trust between me and my patients, and also means they don’t come to the clinic with unrealistic expectations. Trust is extremely important for all practitioners across the aesthetics specialty because we are dealing with public health. When patients believe that they are receiving the best, most reliable treatment from an honest, professional and trustworthy practitioner, they are likely to come back again and recommend it to their family and friends.

Consider your marketing language Advertising and marketing language is a powerful tool which can really impact people’s decision making – for the good or the bad. The language of cosmetic brands has a particularly emotive importance for consumers, and small and subtle differences can make a tangible difference. A new language — one that is thoughtful and trustworthy — should be our aim to ensure transparent messages are delivered to the public. Dr Parneet Sehmi qualified from Guys Kings and St Thomas’ Dental Institute and is the principal dentist at Hermes London Dental Clinic. He specialises in cosmetic dentistry and facial aesthetics including dermal fillers and antiwrinkle skin treatments. Qual: MJDF, FDS, RCS

VIEW THE REFERENCES ONLINE! AESTHETICSJOURNAL.COM

Reproduced from Aesthetics | Volume 9/Issue 2 - January 2022


L AST C HAN C E TO BO O K !

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