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Expand into a new category with Hydrafacial Keravive scalp health treatment that leads to fuller looking hair. Hydrafacial Keravive is a first of its kind 3-step treatment that includes an in-clinic component, as well as a 30-day take-home spray.
Practitioners highlight the common facial danger arteries to be aware of
Dr Ahmed El Houssieny advises on avoiding infection after filler injections
Announcing The Aesthetics Awards Finalists! The Finalists of The Aesthetics Awards 2023 have been announced!
Case Study: Addressing a Rhinoplasty Complication
Dr Bob Khanna treats a complex case of a patient following multiple rhinoplasty procedures 46
Exploring Chemical Peel Complications
Alex Henderson outlines the common complications of chemical peels 51
Evaluating Non-Surgical Rhinoplasty
Professor Alwyn D’Souza discusses his techniques for successful non-surgical rhinoplasty 56 The Gold Standard in Medical Skin Remodelling
Discover what makes SkinPen a multi-award-winning microneedling system 57 Abstracts
A round-up and summary of useful clinical papers IN PRACTICE 58 Reporting Complications in Aesthetic Practice
Dr Martyn King provides advice on reporting aesthetic complications 60
A History of Regulation
An overview of the development of regulation in aesthetics over the years 62
Identifying Body Dysmorphic Disorder
Jacqui Beasley provides an introduction to BDD, its prevalence in aesthetics and how to navigate it in-clinic 65 In The Life Of Linda Mather
Linda Mather details her typical working day and how she manages complications with ACE Group World 66
The Last Word: Mirrors vs Photos
Dr Manav Bawa debates the use of photos over mirrors when assessing patients in-clinic
Mr Jeff Downie is a consultant oral and maxillofacial surgeon who has a specialist interest in facial aesthetic and reconstructive surgery. He practises facial surgery in Glasgow and his NHS sub-speciality is facial deformity and post-traumatic facial reconstruction.
Mr Mark Devlin is a consultant cleft and maxillofacial surgeon. He is based at the Royal Hospital for Children in Glasgow. After owning a facial plastic surgery practice for a number of years, he now concentrates his non-NHS time to medicolegal work.
Dr Bob Khanna has been a cosmetic dental surgeon and facial aesthetic practitioner for more than 25 years. Dr Khanna is president of the non-profit organisation IAAFA, clinical director of The DrBK Clinics and the Dr Bob Khanna Training Institute.
Dr Ahmed El Houssieny is an anaesthetist and founder of Bank Medispa in Cheshire. He is an honorary lecturer at the University of Chester, an education provider on cosmetic procedures and an associate member of the British College of Aesthetic Medicine.
Alex Henderson is an independent nurse prescriber with 12 years’ industry experience. She has successfully opened two clinics in the Southwest of England and Harley Street. Henderson has experience in training practitioners on filler, toxin courses and threads courses.
Professor Alwyn D’Souza is a facial plastic and reconstructive surgeon providing both cosmetic surgery and aesthetic medicine services on Harley Street, London. He has held office as president of the BSFPS and is the president elect of EAFPS.
go go go
94% response rate 4 weeks post injection 1,** Demonstrated high patient satisfaction2 Proven consistent efﬁ cacy and tolerability with repeated injections for up to 12 months 1,2 Scan for Reconstitution Instructions Finalist 2023
*Letybo® is indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows in adults <75 years old seen at maximum frown (glabellar lines), when the severity of the facial lines has an important psychological impact. **Response rate was deﬁned as a ≥ 1-point reduction in FWS at maximum frown based on the investigators assessment. References: 1. Mueller DS, Prinz V, Adelglass J, Cox SE, Gold M, Kaufman-Janette J et al. Efﬁcacy and Safety of Letibotulinum Toxin A in the Treatment of Glabellar Lines: A Randomized, Double-blind, Multicenter, Placebo-controlled Phase 3 Study. Aesthet Surg J. 2022; 42(6): 677- 88. ; 2. Letybo® smPC, https://www.medicines.org.uk/emc/product/13707 2022
Welcome to our first issue of 2023! As you read this, I will undoubtedly be soaking up some much-needed sunshine in my home country of Australia (don’t worry, I have my SPF 50 ready). Even though I am away, I can feel the excitement that is gathering with the announcement of the 2023 Aesthetics Awards Finalists!
This year, the competition was tougher than ever, with almost 400 entries. As you know, unfortunately not everyone who enters can make it through as a Finalist, but I want to congratulate each and every one of you who put in the effort to apply – I know it’s no easy task. Of course, those who did make it through must be commended for their outstanding entries! The list of Finalists can be viewed on p.35 – don’t forget, category voting and nominations for the Outstanding Achievement Award are now open so be sure to have your say!
Now onto the journal… this month, we focus on safety, which I believe to be such an important topic in the field of aesthetic medicine.
Clinical Advisory Board
We know anecdotally that complication rates are rising, so it’s more important than ever to catch up on some of the latest articles promoting safe practice. We have articles on treating complications using devices (p.21), facial danger zones (p.28 – remember, it’s CPD approved), chemical peel adverse events (p.46) and non-surgical rhinoplasty (p.43 & p.51).
You will also notice some new features in the journal! I’m excited to be launching our new Expert Insights column, where we choose one high-profile industry figure to give us their secrets when it comes to successful practice. Our very first interviewee is Dr Lee Walker (p.14) – let us know who you want to hear from next! The other new feature is our ‘A History Of’ series, where we delve into the past of a particular treatment or topic and explore where we are now, as well as what the future holds. We hope this series will be valued by both those newer to the specialty and those who have been around for a while. This month, we focus on A History of Regulation – give it a read on p.60. If you’re interested in writing one of these articles this year, get in touch with the editorial team –firstname.lastname@example.org. Wishing you all a wonderful 2023!
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.
Mr Naveen Cavale has been a consultant plastic, reconstructive and aesthetic surgeon since 2009. He has his own private clinic and hospital, REAL, in London’s Battersea. Mr Cavale is the national secretary for the ISAPS, president of the Royal Society of Medicine, and vice-chair for the British Foundation for International Reconstructive Surgery.
Jackie Partridge is an aesthetic nurse prescriber with a BSc in Professional Practice (Dermatology). She has recently completed her Master’s in Aesthetic Medicine, for which she is also a course mentor. Partridge is a founding board member of the British Association of Cosmetic Nurses and has represented the association for Health Improvement Scotland.
Mr Adrian Richards is a plastic and cosmetic surgeon with 18 years’ experience. He is the clinical director of the aesthetic training provider Cosmetic Courses and surgeon at The Private Clinic. He is also a member of the British Association of Plastic and Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons.
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Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon. She is the lead oculoplastic surgeon at the Cadogan Clinic, specialising in blepharoplasty and advanced facial aesthetics. Miss Hawkes is a full member of the BOPSS and the ESOPRS and is an examiner and fellow of the Royal College of Ophthalmologists.
Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine.
Dr Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the founder of the Great British Academy of Medicine and Revivify London Clinic. Dr Samizadeh is a Visiting Teaching Fellow at University College London and King’s College London.
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What a wonderful conference full of fantastic speakers and informative presentations – I’d say the inaugural FACExpo was a great success!
The Aesthetics team @aestheticsjournaluk
As the team clocks out for Christmas, we’re wishing you all the best festive season – bring on 2023!
Dr Martyn King appointed as BAS chair
Aesthetic practitioner Dr Martyn King has been appointed chair of the British Association of Sclerotherapists (BAS) after serving as treasurer for the past five years.
Dr King is also vice-chair of the Joint Council for Cosmetic Practitioners (JCCP) and founder and medical director of the Aesthetic Complications Expert (ACE) Group World. Upon his appointment, Dr King said, “I am looking to raise the profile of sclerotherapy for practitioners, the relevant professional bodies and the general public. The BAS is the best platform for sclerotherapy education, information, guidance and mentoring, and we plan to unveil some exciting developments at the annual conference on May 23, 2023.”
Teoxane welcomes new additions to team
Dr Preema Vig
Always so good seeing Dr Shirin Lakhani and Alice Hart-Davis at the Cutera University Clinical Forum 2022!
Dr Raj Acquilla
Truly spectacular MEXS 2022 here in Vienna – the world’s finest aesthetic experts gathered in a sharing of brilliant minds.
International Society of Plastic Surgery
Kudos to all ISAPS plastic surgeons for their excellent lectures at the AECEP Meeting in Madrid, Spain.
Aesthetic manufacturer Teoxane has expanded its team in the UK with three new recruits. Rebecca Novak has become a permanent member of the product specialist team in the UK, now covering the North Celtic region. Rebecca Henry returns to the Teoxane sales team after a period of maternity leave. Finally, Jennifer McGuire has joined the team as a product specialist in Scotland. Hannah Nolan, national sales manager, said “We are delighted to welcome Henry back to Teoxane to reprise her role covering the North of England. We are excited to create a permanent position for Novak as a product specialist in the new North Celtic territory. We are also delighted to welcome McGuire to the Teoxane team.”
Exclusive programme with Dr Mauricio de Maio to take place
Plastic surgeon Dr Mauricio de Maio is hosting a two-day ‘Path to Expertise’ programme for medical professionals. The programme aims to help practitioners understand facial anatomy, expand injecting techniques and find inspiration around reimagining ageing across genders, ethnicities and age groups.
Dr Marco Nicoloso, medical director at Ouronyx Clinic, said “We are thrilled to have the opportunity to have Dr Mauricio de Maio here at Ouronyx for these two days only, giving experts the chance to hear him share his wealth of knowledge and his interesting approach to cosmetic injectables.”
The event will be taking place at Ouronyx Clinic on January 13-14.
The Aesthetics Awards Finalists are revealed
The list of Finalists for The Aesthetics Awards 2023 has been unveiled, highlighting the top achievements in the aesthetics specialty over the past year. More than 260 Finalists have been announced across the Awards’ 25 categories, marking the achievements of practitioners, clinics, companies, support services and more. Shannon Kilgariff, editor and content manager of the Aesthetics journal, commented, “The Aesthetics Awards is one of the highlights of the specialty’s calendar, and everyone in the Aesthetics team is so excited to celebrate with the biggest achievers in the industry. It is so important to recognise the accomplishments of the amazing individuals and teams in our industry so we can applaud best practice and top-quality products, and this year is no different. The full list of Finalists can be found on p.35 – congratulations and good luck!”
To vote for your winners in the applicable categories, create a free account at aestheticsawards.com now and cast your votes by January 31. Go to p.12 to get your tickets for The Aesthetics Awards ceremony on March 11 at Grosvenor House, London.
JCCP issues update on premises and best practice
The Joint Council for Cosmetic Practitioners (JCCP) has released further information clarifying regulation details, bringing into consideration the potential future licensing scheme.
The JCCP has updated its Premises Standards in preparation for the Parliament’s proposed licencing scheme for non-surgical cosmetic procedures which is set out in the Health and Care Act 2022. The standards have been formulated by the JCCP Clinical Advisory Group, in line with guidelines from the Chartered Institute for Environmental Health. They also consider the anticipated Department of Health and Social Care premises licence which is set to be introduced through the Act.
In addition, the organisation has updated its Good Practice Guide for Education and Training Courses. The guide covers how training providers should market their courses, how courses can be accredited, how CPD points can be awarded and how prospective participants should be assessed before being accepted onto courses. Updates have also been made to skin cleansing applications to promote patient safety and best practice. The changes were made following a recommendation within the Health and Social Care Committee’s report on the impact of body image on mental and physical health, published in 2022, that there should be a ‘minimum standard’ in non-surgical cosmetic training.
Professor David Sines, executive chair and registrar of the JCCP, said, “We are pleased to announce the publication of these updated documents. They have been produced following stakeholder engagement across the sector, and have been supported by the JCCP’s Education and Training Committee and Clinical Advisory Group. The JCCP will continue to work closely with key partner agencies in preparation for the awaited DHSC license for non-surgical practice in England.”
Just 17% of 2,000 women say they know how to prevent the signs and symptoms of menopause on the skin and body (Dr Yusra Clinics, 2022)
Of 4,000 respondents, only 31% agreed that society’s beauty standards are achievable (DREAM, 2022)
Of nearly 5,000 UK students, 62% said social media is their primary platform for keeping up with beauty trends and news (UNiDAYS, 2022)
The skin condition vitiligo affects between 0.5 and 1.5% of the global population, and up to 30% of cases arise due to genetic mutation (MedlinePlus, 2022)
Of 7,000 respondents, 72% agree that the price of an aesthetic treatment is an important factor in whether or not they invest (RARE: Group, 2022)
The natural and organic beauty market is expected to grow at a 7.51% annual rate between 2022 and 2026 (Statista, Mordor Intelligence, 2022)
Menopause in Aesthetics (MIA) www.menopauseaia.co.uk
ACE 2023 www.aestheticsconference.com
The Aesthetics Awards 2023 www.aestheticsawards.com
British Association of Sclerotherapists (BAS) Conference 2023 www.bassclerotherapy.com/events/ bas-2023-conference/
Advertising ASA issues ruling on Turkey dental service ads
The Advertising Standards Authority (ASA) has ruled that a dental service based in Turkey was not clear when advertising the services it provides.
A number of complaints were upheld against a dental facilitator based in Turkey. Firstly, the company was found to have falsely advertised itself as a provider of dentistry services, whereas it is actually a facilitator which directs patients to a number of independent dental clinics. The ASA stated that the company must ensure the differentiation between provider and facilitator is clear in any advertisements going forward.
Secondly, a complaint was upheld that the company was implying that it provided dental services in the UK, as its head office was advertised as being in Milton Keynes. The company does administrative work in the UK, but the ASA ruled that advertisements may lead consumers to believe that dentistry was performed there as well, so the solely Turkey-based procedures must be clarified in future.
Revision Skincare launches new serum
Supermodel physique back in fashion and causing concern
A trend for a super thin physique, known colloquially as ‘heroin chic’ due to connotations gained during the era of 1990s supermodels, is causing concern for women’s body image. Some mental health experts are warning the trend could lead to the glamourisation of disordered eating, and may undermine the recent body positivity movement. Actress and feminist activist Jameela Jamil has weighed in on social media: “Our bodies are not trends. I’m starting Not Hungry Chic. Happy Chic. Anything but this.”
Rapper Cardi B dissolves buttock fillers
American rapper Cardi B has confirmed that she has had biopolymer fillers in her buttocks dissolved at the age of 30. The rapper told Instagram followers she underwent surgery in the summer and removed 95% of her buttock fillers. She stated that her original reason for getting the body fillers was being teased for her thin physique, but has since warned her followers to be aware of health considerations before opting for a body enhancing treatment or Brazilian Butt Lift.
Skincare company Revision Skincare, distributed in the UK by AestheticSource, has announced the release of the D.E.J Daily Boosting Serum. According to the company, the new serum utilises Sunflower Sprout Extract Technology, which is clinically proven to address cellular ageing through using adenosine triphosphate, the antioxidant acetyl L-Carnitine and omega 3 fatty acids to reduce skin glycation.
Internal studies conducted by the company showed that 75% of users said their skin appeared plump, 75% said their complexion was vibrant and 83% said their skin looked hydrated after using the product.
Lorna Bowes, CEO of AestheticSource, said, “I am deeply passionate about skincare and ingredients. Our portfolio is a reflection of this enthusiasm and experience. ‘Sunflower sprout extract’ did not immediately grab my attention, but then I saw the scientific research. This new ingredient is exciting! This new product is exciting!”
New book published to reassure aesthetic patients
Aesthetic practitioner Dr Olha Vorodukhina and clinic manager Jean Bertram have released a book for prospective aesthetic patients – Beyond the Mirror According to publishers Matador, the book will provide patients with information about how aesthetic procedures could benefit them and dispel any myths surrounding the industry, all while promoting self-confidence for women of all ages and backgrounds. The authors state that the book can also be helpful reading for practitioners as it can assist them in better understanding their patients’ mindsets. Dr Vorodukhina said, “This book is a great guide that can help practitioners to better understand their patients’ emotional attributes and motivations behind treatments. It is also a great example of how important it is to build a friendly, trusted and professional relationship between the medical aesthetic team and your patients.”IN THE MEDIA What’s trending in the consumer press
New In Practice Zone to feature at ACE
With a rise in business support needs from across the aesthetics specialty, ACE 2023 is launching a new In Practice Zone featuring key business support companies and a theatre with two days of unmissable talks. Within the new Zone, the In Practice Theatre, sponsored by aesthetic service provider PLIM, will showcase the latest thoughts, insights and developments in the business world. Situated in the Gallery, talks include getting started in aesthetics, insurance advice, marketing and how to progress your clinic and career in the UK and beyond.
As well as the theatre, the Zone will host all the latest companies, product and support services just outside the theatre doors. Companies specialising in finance, clinic software, digital marketing and more will be on hand to help guide you on your business developments and offer solutions to your business problems. Businesses featuring in the In Practice Zone include AesthetiDocs, Aesthetic Nurse Software, e-clinic, Enhance Insurance, Hamilton Fraser, InDesk, Inspire to Outstand, MeTime, PLIM and Web Marketing Clinic.
Courtney LeBorgne, event director of Aesthetics, said, “The brand-new In Practice Zone is the perfect opportunity to unite the theatre and companies under one umbrella. Attendees will be able to listen to insightful talks and gain invaluable business knowledge while talking to and meeting companies right outside the door!”
At ACE 2023, the In Practice Zone will also host the In Practice Networking drinks, bringing businesses and delegates together to build connections and give advice.
The free drinks will be taking place in the In Practice Zone at 4:30pm on March 10. ACE will be taking place at the Business Design Centre, London, on March 10-11. Turn to p.18 to start the free registration process, sponsored by Church Pharmacy.
Harpar Grace offers business health check to boost profits
Aesthetic distributor Harpar Grace International (HGI) has announced the launch of a new initiative to help aesthetic businesses boost their profits. According to the company, the HGI Business Health Check will provide practitioners and clinics with free individualised consultations with HGI business growth specialists, aiming to boost revenue through strategies such as diversification and sustainability awareness. The consultation could cover an audit of current offerings, an introduction to the benefits of providing skincare, an overview of the benefits of HGI digital services and recommendations of free training opportunities to increase knowledge, explains the company. Head of engagement in the UK, Ireland and Caribbean, Sadie van Sanden Cooke, commented, “HGI is committed to providing ongoing support to its partners. We have developed the HGI Business Health Check to launch at the beginning of the year when we know a lot of practitioners and clinics will be reviewing and putting into place new procedures and protocols to optimise opportunities for the year ahead.”
BACN REGIONAL MEETINGS
As last year drew to a close, so did our final round of regional meetings. A huge thank you to everyone who came along – we had some of our best attended meetings to date!
Regional meetings will make a return this month, taking a new format for the new year. We will be offering one meeting a month, attending a new region each time. This staggered approach will allow us to focus on providing the highest quality content for our members. Regional leaders will be running informal, localised get-togethers alongside regional events, for members to come together more regularly to network and build a sense of local community.
The BACN Autumn 2022 newsletter was published on Friday November 18. All members received an email enclosing the newsletter with important updates from BACN chair Sharon Bennett and CEO Paul Burgess, including a statement on remote prescribing, regulation updates and exciting events coming up in 2023.
BACN MAP-IQ ASSESSOR TRAINING PROGRAMME
The BACN is proud to announce the launch of the BACN MAP-IQ Assessor Training Programme – a L3 Assessor Training Programme in Aesthetics. Since the first mention of the programme at the BACN Annual Conference back in September, the association has received more than 40 expressions of interest. MAP-IQ will officially be running the programme, with the BACN subsidising members’ costs from its Education and Training Fund. This is the first L3 Assessor Programme specific for medical aesthetic nurses, designed by BACN nurses. The training programme was officially launched by MAP-IQ on November 21, with BACN members among the first intake of students the course has accepted.
This column is written and supported by the BACN
A round-up of the latest news and events from the British Association of Cosmetic Nurses
Join Your Peers in Celebrating Aesthetics
Don’t miss out on the biggest event in the aesthetics calendar and make sure you’re a part of The Aesthetics Awards 2023. Host to the industry’s top KOLs, rising stars and leading brands, it’s the perfect place to expand your network and celebrate with the rest of the aesthetic specialty. The event will take place on March 11 after the second day of ACE, at the dazzling Grosvenor House, London. Tickets are selling quickly, so make sure to grab yours now and avoid missing out on an incredible evening of glitz and glamour.
Learning Dr Patrick Treacy releases complications book
Aesthetic practitioner Dr Patrick Treacy is launching a book on his experiences – Aesthetic Complications and Other Interesting Cases
According to publisher Austin Macauley, the book contains cases encountered by Dr Treacy since he established a hyaluronidase protocol in 2005. The book, which is due to be released this month, provides details of how to treat various complications, and minimising the risk of adverse events. Dr Treacy said, “This is my second book on aesthetic complications, and it includes 100 interesting cases, from using toxin to treat different indications, to sharing the secrets behind my PLUS and HELPIR techniques.”
mesoestetic launches new retinol product
Congratulations to our Finalists!
The Aesthetics Awards Finalists are revealed on p.35, so make sure to take a look and see if you, your friends or your colleagues have been shortlisted. We received an incredible number of entries this year and the standard was extremely high, so we want to say a massive congratulations to everyone who made it as a Finalist – we can’t wait to celebrate with you all very soon!
Get your tickets now
Whether you’ve been shortlisted or not, the Aesthetics Awards is an event not to be missed. It is the ideal occasion to catch up with colleagues old and new, recognise the hard work that everyone has put in over the last year and network with the future leaders of the aesthetics industry. Single tickets are available, or you can get a table of 10 and bring your whole team along! By purchasing a ticket, you will receive:
• A delicious three course meal
• Professional photographs at the Press Board
• Live music and entertainment
• A ceremony presented by celebrity host Cherry Healey
• Champagne drinks reception and ½ bottle of wine per person
Voting for the Awards is now OPEN! Visit our website to find out which categories are eligible for voting and make your opinion count. To purchase your ticket, scan the QR code below. Please hurry, limited tickets are available and sell out quickly.
Scan the QR code to book your Early Bird tickets now!
Pharmaceutical company mesoestetic has released a new antiageing cream, skinretin 0.3%.
mesoestetic says that the product uses a post-biotic complex, centella asiatica and ectoine to target signs of ageing including spots, lack of luminosity, wrinkles and expression lines, as well as loss of skin density and elasticity. Adam Birtwistle, managing director at mesoestetic, commented, “skinretin 0.3% represents another innovation using retinol. Backed by clinical and invitro studies, we have combined 0.3% pure retinol and 0.7% bakuchiol in the formula. Enhancing the efficacy of retinol, bakuchiol is a natural active ingredient of plant origin that has become established as an alternative to retinol as it has similar benefits and is ideal for sensitive skin. We are really excited to have this evolution available for our customers now.” Imagery
QuantifiCare expands 3D photography offering
3D aesthetic imaging company QuantifiCare has released the newest addition to its aesthetic photography range – the LifeViz Mini Pro. According to the company, the LifeViz Mini Pro allows practitioners to capture 3D images of their patients in-clinic via a hand-held device, specifically designed for aiding practitioners in delivering facial treatments. Jean-Philippe Thirion, founder and CEO of QuantifiCare, explained, “The LifeViz Pro series is one of the only wireless 3D photography systems on the market powered by artificial intelligence. It helps you ease your staff workflow thanks to automatic wireless image transfer, optimise the time needed for analysis and provide more in-depth explanations during consultations.”Skincare
Nominations open for outstanding achievement award
The Aesthetics Awards is accepting nominations for the Outstanding Achievement in Medical Aesthetics Award to mark an incredible contribution to the specialty. This Award, which previously recognised a lifetime achievement over a long, established career, now aims to recognise one specific achievement made by an individual within the specialty in the past 12 months. This achievement, and individual, will have helped to progress the industry, and had a positive impact on those working within the field. Individuals can nominate themselves or others for the accolade. To submit a nomination, email firstname.lastname@example.org by February 6 with the following information:
1. The name of the individual
2. Details of the achievement made
3. 100-word explanation of why this person and achievement deserves to win.
Shannon Kilgariff, editor of Aesthetics, said, “This Award aims to shine a spotlight on an individual who has made remarkable progress in furthering the field in 2022, showcasing their commitment and significant contribution to the profession. This is an opportunity to celebrate someone who has gone above and beyond to enhance our industry. I look forward to reading the nominations!”
SkinCeuticals to unveil new mist
Skincare brand SkinCeuticals will be launching a new mist in its Phyto range. According to the company, the Phyto Corrective Essence Mist is formulated with a high concentration of botanical extracts and moisturising agents to hydrate and soothe red, inflamed and irritated skin. Ingredients include a botanical blend of cucumber, thyme, olive, rosemary, grapefruit and mulberry. The mist can be used in-clinic post-laser and for continued use at home as part of patients’ aftercare programme, SkinCeuticals explains. The mist will launch on January 9.Lauren Gibson, Hydrafacial country manager, UK&I
It’s been an exciting 12 months for Hydrafacial, talk us through what’s new…
It’s been a fantastic year for brand expansion and innovation. In Spring 2022, Hydrafacial opened the doors to Europe, the Middle East and Africa’s first flagship location here in London, welcoming thousands of new customers. We have also expanded into more than 1,200+ verified Hydrafacial partner clinics across the UK and Ireland. Most importantly, we continue to innovate in the skin health space. From booster collaborations with Murad, to new protocols with Dermalogica and six new HydraBody protocols, we are delighted to be offering more customisable treatments to suit our clients’ skincare needs.
Tell us more about the newly released HydraBody protocols…
Following demand from our loyal Hydrafacial partners, we have just launched the much-anticipated HydraBody protocols to the aesthetic market. HydraBody has six new protocols designed to treat beyond the jawline, including the neck and décolleté, back, booty, legs, arms and hands. As a brand, we have always aligned ourselves with a 360° approach to health and wellbeing, and the new body protocols help Hydrafacial fans benefit from head-to-toe skin health and confidence.
Why should clinics invest in Hydrafacial?
New mentorship programme unveiled
Nurse prescriber Julie Scott has launched a new mentorship programme to help grow the careers of aesthetic practitioners. The Facial Aesthetics Mentorship (FAM) programme aims to help practitioners improve their clinical practice, business growth and patient care. With 12 mentorship places available each year, the programme will include a mix of one-to-one mentoring directly with Scott and her team, in-clinic shadowing and an e-learning library. The programme will take on two cohorts a year, one in February and one in August. Applications are currently open for the February cohort with the closing date on January 15.
Hydrafacial is an ‘and’ treatment. It can be used standalone to treat common skin concerns, but is also deployed by surgeons, doctors and aestheticians to amplifying the efficacy of other in-clinic treatments. As a brand, we have always aligned ourselves with a 360 approach to health and wellbeing, and this collaborative approach is great for both clinics and patients.
What’s next for Hydrafacial in 2023?
Continuing to innovate with technology and science, we look forward to launching the new Syndeo Hydrafacial machine in early 2023. Look out for more booster collaborations with more well-known skincare brands such as Omorovicza, and JLo Beauty too!
This advertorial was written and supplied by Hydrafacial
Dr Lee Walker’s Expert Insights
Dr Lee Walker is an aesthetic practitioner and former cosmetic dental surgeon, as well as chair of the Complications in Medical Aesthetics Collaborative (CMAC).
Dr Walker is also a key opinion leader for aesthetic manufacturer Teoxane. Here, Aesthetics shares his recommendations and top tips for success in the specialty…
What techniques and products work best for treating lip asymmetry?
Find the cause of asymmetry first – it may be muscular or dental-related. Treat the asymmetric side with a dynamic filler which will work with the high muscle activity.
What are the top three things practitioners get wrong when it comes to injectable safety?
Lack of knowledge and respect for 3D anatomy or injecting too much volume, too fast. Inappropriate patient selection can also play a part.
Do you aspirate? If not, why not? No, I don’t. Aspiration, in my mind, is unreliable –there is no high-quality evidence to suggest it’s safe.
Do you have any advice if a practitioner experiences a vascular adverse event?
Take ownership of the complication, stay calm and follow protocols. Use lots of hyaluronidase with lidocaine, and refer on if you are struggling.
What are your top three safety tips for fillers?
1. Use a filler that is reversible
2. Choose a brand with FDA approval to ensure the highest levels of clinical data
3. Use small amounts and inject slowly
What is the best way to seek advice and further knowledge about complications?
Join a complications association like CMAC – a non-profit group of global professionals who publish papers dedicated to various complications. We also have a telephone number for emergencies and will guide you through the process of complication management.
How can you get your confidence back after causing/managing a complication?
Find a mentor and create a local support network.
How can you become an expert and trainer in aesthetic complications?
Progression to this level involves lots of reading, attending conferences, learning and reflecting on your mistakes.
What’s the next treatment you’re looking to bring into your clinic and why?
The new long-lasting toxin called Daxxify which has just received FDA approval, because I think it will diversify what I will be able to offer my patients when it becomes available in the UK.
New scientific abstracts received at MEXS in Vienna
On November 19, pharmaceutical company Merz Aesthetics held its annual Innovation Forum at the Merz Aesthetics Expert Summit (MEXS) in Vienna, Austria, reviewing newly submitted scientific extracts from across the aesthetics specialty. The finalists were invited to MEXS in Vienna to present their abstracts, and the winners was declared as Dr Indira Rivas of Nicaragua for her abstract entitled ‘MONOS Neck-lift: Modified Non-surgical Neck Lift’, and assistant Professor Dr Pansakorn Tanratana of Thailand for his study on ‘The Effect of Different Hyaluronic Acid Preparations on Human Skin Fibroblast’. Terri Phillips, chief medical affairs officer at Merz Aesthetics, said “For us, providing a stage for emerging industry professionals to present cutting-edge research to medical aesthetics experts from around the world is an important part of our dedication to driving innovation and, in turn, delivering trusted results to patients.”
GetHarley celebrates three years of skincare success
On November 22, skincare platform GetHarley invited 100 aesthetic practitioners, friends and press to The Ned Hotel in Bank, London to network and celebrate another successful year of GetHarley. Founder and CEO of GetHarley Charmaine Chow thanked those who have supported the GetHarley platform since its inception three years ago. She said, “My sincere hope is that by powering clinics and ensuring as many of your patients as possible are happy and loyal, perusing the skincare you recommend any time anywhere. We help you do more with less time, achieve more and earn more while you focus on doing the things you love with the people you love.”
Thermage marks 20 years with networking party
On December 9, aesthetic device company Thermage, distributed in the UK by Solta Medical, celebrated its 20 year anniversary with an evening of education and networking at the Mandarin Oriental Hotel in Knightsbridge, London. According to the company, the Thermage User Event celebrated 20 years of delivering radiofrequency treatments to UK patients. Duncan Dow, business director for Solta Medical in Europe, the Middle East and Africa, said, “We really are delighted to be celebrating the 20th anniversary of Thermage. The biggest privilege is to be part of the evolution within the medical aesthetics industry, and we’re certain that the next 20 years will see continued innovation that sits alongside a steadfast reputation.”
Dr Tapan Patel hosts Cutera University Clinical Forum 2022
On November 27, Cutera held the annual Cutera University Clinical Forum (CUCF) 2022 at the De Vere Beaumont Estate in Windsor, with Dr Tapan Patel hosting 185 delegates. This year’s event focused on sharing the latest clinical developments and promoting best practice in the specialty, according to Cutera. The spotlight was on treatments achieved through using devices, namely skin resurfacing, skin rejuvenation and body contouring. Speakers at the event included aesthetic practitioners Dr Tapan Patel, Dr David Eccleston, Mr Rishi Mandavia, Dr Tatiana Lapa, Dr Anna Hemming, Dr Manav Bawa, Dr Yusra Al-Mukhtar, Dr Amit Sra, Dr Nestor Demosthenous, dentist Dr Nima Mahmoodi, nurse practitioner Sarah Gaughan and facial plastic surgeon Mr Kambiz Golchin. Following the event, Dr Patel said, “Cutera, you’ve smashed it again. What a great idea to bring together practitioners for a device-led agenda. We’re so used to having these for the injectable side. People are really appreciating it – the interaction, the advice and the camaraderie.”
After the day of education, a charity gala dinner and ball was held in aid of Great Ormond Street Children’s Hospital, and £12,500 was raised – greatly surpassing the initial £5,000 target.
FACExpo conference held for aesthetic beginners
A one-day educational programme for healthcare professionals starting out in aesthetics was held on November 27 at the Royal Society of Medicine, London. FACExpo began with a welcome from founder and oral and maxillofacial surgery registrar Mr James Olding, who was followed by aesthetic practitioners Dr Zainab Al-Mukhtar discussing dentistry and aesthetics, Miss Caroline Mills outlining surgical aesthetics and Mr Olding introducing non-surgical aesthetics. After a networking break, Mr Olding outlined the various training pathways available in aesthetic medicine, with Mr Tom Walker discussing post-graduate curriculums and Mr Felix Karst introducing Level 7 Diplomas. Headline sponsor Allergan Spark then introduced its resources to delegates, which was followed by a lunch break. In the afternoon sessions, independent nurse prescriber Julie Scott gave a talk on facial assessment, aesthetic practitioner Dr Eithne Brenner discussed filler complications and Mr Olding and Dr Arthur Gasperazzo looked at facial harmonisation treatments. The talks then continued with aesthetic practitioner Mr Jordan Faulkner speaking on starting up in aesthetics. This was followed by Dr Jane Leonard who looked at the use of social media in the industry, Miss Sieuming Ng who outlined common trends in aesthetics and Mr Steven Brandsma who discussed how to balance your career between NHS work and aesthetics.
To round off the day, chair of the Joint Council for Cosmetic Practitioners Professor David Sines discussed law, regulation and ethics in aesthetics. Mr Olding commented, “FACExpo was an event without precedent or blueprint, and the level of engagement we received from all levels of healthcare professionals was incredible. We had more than 200 medics, dentists and nurses attend, consisting of a mix of undergrads and postgrads. Most of all, the educational programme was both broad and detailed enough to provide value to delegates, whatever their level of experience.”
News in Brief
Medik8 launches new overnight mask Skincare company Medik8 has introduced a new two-step overnight mask to its portfolio. The H.E.O Mask contains humectants to keep the skin hydrated and help maintain its structure, emollients to minimise transepidermal water loss and maintain hydration in the upper skin layers and occlusives to reinforce the skin’s protective barrier and prevent moisture from escaping, explains Medik8. The mask is ideal for patients with dry, dehydrated skin, as well as for those looking for a boost of moisture.
Ambassador for melanoma charity unveiled Aesthetic practitioner Dr Sophie Shotter has been appointed as skin ambassador for the Melanoma Fund Charity. In her new role, Dr Shotter will support the charity’s mission to increase awareness around the cause and effects of sun exposure, as well as the psychology of sun protection. Dr Shotter commented, “There is a lot of misinformation and misconceptions around sun protection that impact both skin cancer and sun damage, so it’s important to me that the risks and prevention measures are accurately communicated.”
New range of marking-up pens released Aesthetic company Aesthetic Excellence has unveiled a range of marking-up skin pens. According to the company, the pens, which come in white, black, red and blue, are designed to be highly-pigmented, precise and smudge-proof, as well as non-irritant. Jemma Gewargis, founder of Aesthetic Excellence, said, “Marking-up prior to aesthetic treatments is a key component of improving safe and reproducible outcomes for patients, as well as enhancing learning during treatment demonstrations in a training setting. The four available colours possess an ultra-precise tip to allow accurate demarcation of treatment zones, and pin-point accuracy for marking-up.”
Aesthetic Response unveils rebrand Clinic support company Aesthetic Response has unveiled a new rebrand to reflect its evolution as a clinic partner, including a redesigned logo and new-look website. Jo Fisher, client services director, commented, “We wanted to have a complete refresh because we are unrecognisable to where we started in terms of how we have embraced all of this change that the industry has seen, particularly around increased treatment portfolios, specialities such as women’s wellness clinics and communication and the types of channels patients are engaging with.”
IMCAS World Congress
The International Master Course On Aging Science World Congress returns in 2023
Following its sweeping success in June, the IMCAS World Congress will return to Paris again for its 24th edition in January of 2023. The event will take place at the Palais de Congrès, with a carefully curated scientific programme, engaging new medical material within the 15 key themes of aesthetic treatment (ie. ultrasonography, fillers, toxins, body shaping, lasers and EBD,
clinical dermatology, cosmeceuticals, face, breast and body surgery, PRP and lipofilling, threads, hair restoration, genital treatments, practice management, male treatments and future tech).
The new additions for this year’s programme feature a variety of formats with the latest technical updates in modern medicine. The signature IMCAS Surgery course includes live, simultaneous anatomical dissections and demonstrated surgery – both by the performing surgeon – to fully explain procedural theory through implemented technique.
Likewise, the Live Anatomy on Cadaver Workshop will feature simultaneous procedure and dissection formats as well, including ultrasonography visuals to further explore methods to manage and avoid complications in injection treatments.
Professionals can also expect extended modules in clinical dermatology, specialised injection technique, hair restoration, female genital treatments, cosmeceuticals, ethics and practice management, as well as revolutionary regenerative tech.
To complement the educational content, the exhibition hall completes the IMCAS learning experience by showcasing a wide variety of aesthetic industries and their latest products and devices in 2023.
With a mission to provide transparent, accredited and evidence-based education, this learning event is one of the largest international congresses for dermatology and plastic surgery. Be sure to join them this January 26-28 to take part in the future and advancement of aesthetic science and education.
Visit www.imcas.com for more information!
Changing Regulation in Scotland
Aesthetics investigates the HIS announcement requiring non-prescribing medical practitioners in Scotland to have a prescriber present for filler injections
Last month, the regulator for Scottish independent healthcare services, Healthcare Improvement Scotland (HIS), announced that non-prescribing medical practitioners can no longer perform dermal filler injections without a prescriber present on-site, although when this will come into effect remains unclear.1 For many practitioners in Scotland, particularly non-prescribing nurses, this announcement came as a shock, and has left them uncertain about their future within the specialty. In a document emailed to aesthetic practitioners in early December, HIS laid out the updated healthcare rules, including the new requirement contained within Regulation 12 of the ‘Requirements as to Independent Healthcare Services’.2 It stated in the report that the presence of the prescriber is intended as a safety precaution for the scenario in which hyaluronidase is required to dissolve dermal filler, and originally enforced their required presence with immediate effect. Following a number of complaints from non-prescribing injectors, HIS has since stated that it is looking into a solution, and all medical practitioners can continue treating patients for the time being, to allow them to make arrangements to implement prescribing into their clinic. No set timescale for this has yet been outlined. In a statement from an HIS spokesperson, it was explained that this development can be attributed to “An increase in applications for registration from newly-qualified healthcare professionals where experience is very limited, and a recent increase in service providers offering training to healthcare and non-healthcare professionals in non-surgical aesthetic treatments and procedures.”
However, many Scottish practitioners feel this regulation change was handled insensitively due to the apparent lack of warning. In this report, Aesthetics spoke to an HIS spokesperson and a number of nurses in Scotland to gauge the reaction to the news and consider how Scottish aesthetic regulation may progress going forward.
Medical aesthetics is widely regarded as an industry lacking in the adequate regulation to sufficiently preserve patient safety.3 Under current Scottish law, all medical aesthetic practitioners must be registered with HIS in order to practise, but non-medics performing injectable treatments have no such obligation.4 Whilst the recent regulation changes have not altered this fact, they are designed to protect patients by ensuring a safeguard is in place in the case of complications. According to an HIS spokesperson, the organisation’s priority is ensuring patients of private healthcare services in Scotland receive the best quality treatment in safe and regulated environments. They explain, “For these reasons, registered clinics are required to demonstrate that they take the safety of their patients seriously, that they operate to the highest standards and are committed to continually improving the service they provide.”
Nurse prescriber and honorary board member of the British Association of Cosmetic Nurses (BACN) Frances Turner Traill agrees,
saying that best medical practice must be evident whenever dermal fillers are being administered.
“Although the specialty is geared toward an aesthetic outcome,” she says, “the procedures involved are still medical and should therefore only be carried out by healthcare practitioners. It may look like beauty, but the second you break skin to reach muscles, arteries, veins, fat, bone and nerves it’s no longer beauty, it’s medicine. Complications are rare but they do happen, and they can become a burden on the NHS.”4
However, nurse prescriber and founder of the online HIS Support Group Jill Smith has rejects the idea that implementing the changes without sufficient warning or planning will improve patient safety. “I support patient safety and a potential move towards having clinical oversight whereby there is a prescriber onsite during injections,” she says, adding, “however, there should be a significant transitional period to allow us to look at strategies to support those applying for prescribing courses or university places so they can practise independently. I think this would take a couple of years, so if the changes are introduced without sufficient time for provisions to be put in place, there may be a number of practitioners unable to perform treatments which is very concerning.”
An uncertain future
Through her HIS Support network, Smith has seen an influx in nurses concerned about the impact this announcement will have on their businesses. “Nobody expected or knew that this was coming. A lot of people were really distressed,” she adds.
Linda Strachan, aesthetic nurse prescriber and regional lead of the BACN for Scotland, is disappointed with how HIS has handled this announcement due to the distress caused, but acknowledges the value of being a prescriber, saying, “The BACN wants nurses to work towards the highest level of competency, and part of this would be for everyone to become a prescriber in their area of expertise, but this has to be done at the right time so they have sufficient experience to do so.”
Change moving forward
The future of medical aesthetic regulation in Scotland, and indeed across the UK, is uncertain, with as yet undetermined changes projected to be on the horizon. Until further details regarding these regulatory changes are finalised, Smith advises practitioners to reach out to local networks for reassurance, and join associations like the BACN to receive updates and support.
Turner Traill believes HIS is on the right track to a safer specialty. She concludes, “I think there were a few shockwaves after this announcement amongst colleagues who aren’t prescribers, but the path to independent nurse prescribing is now a well-trodden one, and regulatory changes such as this have been discussed by HIS for some time. I hope HIS brings more medical personnel under its jurisdiction to tighten other loopholes.”5
Visit www.aestheticsjournal.com for ongoing updates on this story.
1. Healthcare Improvement Scotland. ‘Clarification of the interpretation of Regulation 12 of The Healthcare Improvement Scotland (Requirements as to Independent Health Care Services) Regulations 2011’ Information for Services (UK: HIC, 2022)
2. ‘Regulation 12’ The Healthcare Improvement Scotland (Requirements as to Independent Health Care Services) Regulations 2011 (UK: Government Legislation, 2011) <https://www.legislation.gov.uk/ sdsi/2011/9780111011966/regulation/12>
3. Holden E, ‘News Special: Controlling Dermal Filler Regulation’ Aesthetics journal (UK: Aesthetics, 2022) <https://aestheticsjournal.com/feature/controlling-dermal-filler-regulation>
4. Healthcare Improvement Scotland. Registration: new independent healthcare services (UK: HIC, 2020) <https://www.healthcareimprovementscotland.org/default.aspx?page=12693>
5. Turner Traill F. ‘The Last Word: Scottish Regulation’ Aesthetics journal (UK: Aesthetics, 2022) <https:// aestheticsjournal.com/feature/the-last-word-scottish-regulation>
Grow Your Business at ACE
Discover the latest business insights, tips and advice at ACE 2023
Establishing yourself and standing out from the crowd can be tough, especially in an ever-growing industry like aesthetics. Whilst clinical expertise and knowledge is vital for a thriving career and clinic in aesthetic medicine, business intelligence and skill is essential for overall success. At ACE 2023, we have all the tools to help set your clinic apart and stand out from the competition. Taking place on March 10&11 at the Business Design Centre, London, our new In Practice Zone will provide you with all the latest support and solutions on everything needed to run a successful clinic, from social media, patient relations and marketing, to finance and regulation. There is something for everyone to learn and discover!
Unmissable talks from key industry experts
The In Practice Theatre, sponsored and supported by PLIM, is the hub of the In Practice Zone, showcasing the latest developments in the clinical business world. This year, the agenda is separated into different themes to help you discover what will benefit you and your business most. Here’s a taster of just some of the content you can expect:
Getting started in aesthetics
• How to Develop and Maintain a 5 Star Practice with Miss Sherina Balaratnam
• Using Social Media to Grow Your Practice with Dr Nisha Menon
• Developing the Ideal Patient Journey with Dr Manav Bawa
• TAX and VAT with Jonathan Bardolph
• Incentivising Your Clinic Team To Grow Your Profits with Vanessa Bird
Marketing and PR
• Dealing with Negative Social Media Reviews, Complaints and Trolls with Mr Naveen Cavale
• Videos for Marketing with Alex Bugg
• Building Creative Content with Chloé Gronow
Women in business
• Balancing Work and Family Life with Miss Priya Chadha
• Knowing Your Worth with Julie Scott
The rest of our In Practice agenda will be revealed soon, so make sure to keep your eyes peeled and start planning your day!
Discover the companies advancing aesthetic businesses
As well as providing you with first-class educational content around all your favourite business topics, you can also discover free advice at the In Practice Zone. Situated right outside the In Practice Theatre, you can find all the companies, products and support services which can help make your life easier in clinic. Ranging from specialists in finance, CQC, clinic software, digital marketing and more, the companies in this Zone are not to be missed and are on hand with solutions to drive the success of your clinic. At ACE 2023, you can visit:
• Aesthetic Nurse Software
• Enhance Insurance
• Hamilton Fraser
• Inspire to Outstand
Network with your industry
• Web Marketing Clinic
This year we will also be hosting the brand new In Practice Networking drinks, ensuring you have the chance to connect with like-minded colleagues and businesses over a glass of bubbly. To attend the free drinks, make sure you head over to the In Practice Zone at 16:30 on March 10!
It doesn’t stop there…
As well as the above business content, ACE 2023 will also provide you with clinical agendas that will help refine your treatment skills and expand your clinic offering. We will be hosting masterclasses, symposiums and innovation sessions with top industry speakers and brands, taking you through the latest clinical education as well as showcasing live demonstrations.
TEOXANE will once again return as the Headline Sponsor of ACE, with a stand-out line-up of expert KOLs providing injectable demonstrations for delegates to watch and discover new techniques. Attend ACE 2023 with your whole team to ensure you all gain the latest education and CPD points towards your professional development.
Celebrate your new skills!
After two days of soaking up all the latest business knowledge, it’s time to head to the biggest aesthetics ceremony of the year – The Aesthetics Awards! Taking place after the second day of ACE on Saturday 11 March, you can come together with friends, colleagues, businesses and industry leaders to celebrate the last 12 months of success in the aesthetic specialty.
You can buy single tickets or tables of 10, so it’s the perfect way to bring your whole team together. Last year, tickets for the ceremony sold out a month before the event, so make sure to purchase your tickets as soon as possible!
Finalists have now been announced – head to p.35 to find out if you or someone you know has been shortlisted! Voting for certain categories is now OPEN, so head to our website now and make your opinion count!
Treating Complications with Devices
Three practitioners outline how they manage aesthetic complications using different devices
Big or small, there are always risks when conducting aesthetic procedures, and even the most skilled or trained practitioners can cause a complication.
However, in recent years, there has been a rise in the incidence of complications, perhaps in line with more aesthetic
treatments being performed than ever before.1 Alongside this rise, there has also been a greater development of technology within the aesthetic sector.
Not only has this been positive in terms of performing aesthetic treatments and giving patients great results, but now these devices
are also used on the other side of the procedure – specifically when it comes to the management of complications.
In light of this, Aesthetics spoke to three aesthetic practitioners about what devices they use to manage complications, providing their tips for best practice.
Using laser for bruising
The complication Bruising is a common side effect that can be expected after performing injectable treatments, and most of the time it is nothing to worry about. However, I’ve found that while it is something to be expected, in recent years the tolerance for it has reduced. Nowadays, patients don’t want any downtime or evidence highlighting that they have had a treatment. There are of course things that we can ask them to do prior to treatment that can help minimise the risk of bruising, such as avoiding anti-inflammatories, anticoagulants and alcohol intake amongst many, but it is never guaranteed. It’s worth noting that practitioners should be mindful of the difference between a bruise and a vascular occlusion, and to assess and treat appropriately as well as inform the patient when it is something to be concerned about.
We already treat a lot of indications using laser where we target blood, for example varicose veins, spider veins and even rosacea. Treating bruising essentially works in the exact same way. The right kind of laser or intense-pulsed light device can help to completely get rid of, or help speed up the process of resolving the visibility of a bruise. In my clinic I use the BBL Hero device which uses broadband light, an advancement of intense pulsed light, which has different filters for different skin types. It can be used in most cases across skin types. However, there is also the possibility of also using a 1064 nm laser in my practice, which may be more useful for darker skin types. The light or laser targets the components of blood, leading to its breakdown. Typically, the patient should see an improvement in the bruising by the next day.
The size of the bruise doesn’t really matter – you can treat anything from a small spot to something the size of a 10p coin. The main thing is catching it early and treating it quickly. This is because once the haemoglobin has already started to break down, there’s nothing that the device can do. So, you really need to be treating the bruise within one to two days after it has been presented.
Because of this time frame, I always offer complimentary laser or BBL treatment for bruising after injection (should they require it) during the initial consultation and procedure. Usually, the patient will then call me the next day if they are concerned. It’s also important for practitioners to add into their consent forms that bruising is an expected side effect, so that patient expectations can be managed.
When it comes to treating bruising, the main thing that I advise my patients to do for management is to ice it and follow all other post-treatment care such as reducing intake of alcohol.
“The size of the bruise doesn’t really matter – you can treat anything from a small spot to something the size of a 10p coin”
Mr Benji Dhillon
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Ultrasound for filler misplacement
While most side effects from dermal filler injections are mild and nothing to worry about, there can be some more serious adverse events. One of the most serious complications that can arise following dermal filler injection is caused by injecting into a vessel, which can cause vascular occlusion, skin necrosis and in rare but serious cases, blindness.2
While even the most skilled injectors can cause complications, there are ways that they can be minimised. Ultrasound is one of the newest methods for preventing vessel obstruction and is fast becoming common practice in an aesthetic clinics. Scanning your patients prior to injecting means that you can see their anatomy, identify where the large blood vessels are, and therefore plan where your injection points are going to be. This visualisation allows you to identify where to place your needle and cannulas so that your filler does not get placed into a vessel.
After treatment, ultrasound also allows you to see whether there is normal or abnormal blood flow through the vessel and identify if you have injected safely. If a complication has occurred, ultrasound is useful for two reasons:
1) You can see where the filler has been placed, so you know exactly where you need to inject the hyaluronidase. Without ultrasound and being able to visualise what is under the skin, you cannot be as accurate as to where you are targeting.
2) You can see whether blood flow has resumed or not following hyaluronidase injection. This is useful so as not to overtreat, as you can see exactly when the hyaluronidase has started working. Without ultrasound, practitioners typically keep injecting and wait for the skin to go pink to know it has been rectified.
When it comes to using ultrasound, you need to be trained appropriately so that you are aware of how to interpret the image properly. There’s no point scanning but not being able to fully understand what you are seeing! I recommend going to a training course that can teach you this in advance before using it on a patient and practicing a lot so you can train your eye. Practitioners also shouldn’t have a false sense of security simply by having the ultrasound machine and should implement all other precautions for preventing complications.
You should also make sure that you buy an ultrasound device that works for you – there are a lot of different products on the market, with some of the popular brands being Clarius, VScan, Butterfly IQ, Lumify, and Sonoinject. Some of these are quite big, so if you have small hands it wouldn’t be easy to use. Some also heat up quite fast, so you may need a fan added to them to cool it down, but that can make it quite bulky. I advise that when you go to a training course, trial them all out and see what feels the most comfortable in your hands! Of course, the big conference and exhibitions such as ACE and CCR also have ultrasound companies exhibiting, so this is a good opportunity to speak to the companies first-hand.
Prior to treatment, you always need to make it clear to the patient what adverse events to watch out for – while some vascular occlusions, for example, can occur straight away, if you aren’t using ultrasound some may not be obvious until after the patient has left the clinic. So, advise them what might indicate an issue and ensure they are provided with an emergency number to contact should they suspect a problem.
Ultrasound is also great to help progress your skills. If you inject without ultrasound, you can reflect on where you have injected by scanning afterwards to see where your product has ended up. It really can allow you to become more accurate and precise when injecting.
Radiofrequency microneedling for surgical scarring
Scars will form any time a cut or incision is made in the skin, and the role of a scar is to close a wound in the skin as quickly as possible. Many of our patients will experience the formation of scar tissue on the body after plastic surgery, which may contract and tighten for six to 12 months following the initial procedure. During this time, the scar may become dry and irritated, and can also negatively affect the patient’s self-confidence due to its appearance.
Scars tend to heal as a fine line and they may be barely visible. However, when a scar doesn’t heal in as fine a line, it can fall into one of the following categories:4
1. Flat and widened scars – common in areas of constant motion
2. Raised and widened/keloid scar – these grow and spread resulting in unsightly firm nodules
3. Raised and widened/hypertrophic scar – appear similar to keloid but do not spread beyond the borders of its original shape
“Without ultrasound and being able to visualise what is under the skin, you cannot be as accurate as to where you are targeting”
Mr Dalvi Humzah
It is common for younger and more healthier patients to have formed more scar tissue than older patients, as their bodies may have a bigger scar response to tissue.5
Over the last five to seven years, the aesthetic industry has seen an advancement in technology and device development, which in turn has seen the introduction of new procedures and systems that combine more than one modality for optimal results. Microneedling has long been used to successfully treat scarring, which involves creating micro-punctures in the skin, helping to break down old scar tissue and stimulate fresh new collagen and elastin. While this has produced good results, I have found that these can be further boosted when supported with radiofrequency (RF) energy.
In my clinic I use the Secret RF machine, a device that combines the two modalities to work on most types of scarring. It uses microneedles to deliver radiofrequency energy into varying levels of the skin, including the deeper layers, where the treatment is most beneficial. The amount of energy released can be customised and delivered at targeted depths, ranging from 0.5mm-3.5mm. For surgical scarring, you would vary the depth and customise the number of treatments.
In general, patients can see results for surgical scarring after a minimum of three treatments due to the unique nature and depth. However, this will vary between individuals and will depend on components such as the age of the patient, the quality of their skin and their lifestyle (for example whether they are a smoker, what their diet consists of, what their health levels are, etc).
It’s important to note that not everyone is suitable for a RF microneedling treatment, so a thorough consultation should be held where patients can disclose their full medical history and lifestyle factors.
Contraindications for this treatment include:7
• Pregnancy, cardiac pacemakers or implantable medical devices, as well as patients who are undergoing treatments for skin cancer or have a history of cancer
• Lactation period
• Active viral, fungal or bacterial skin infections
• Unregulated diseases (diabetes, Hashimoto’s, etc.)
• Anticoagulants intake
• Isotretinoin intake as this leads to a tendency to develop keloids
• Purulent, pinkish acne and all active forms of acne
• Active skin lesions in the course of lichen planus, atopic dermatitis or seborrheic dermatitis
• Open wounds in the treatment area
• Recent trauma
• Ablative aesthetic treatments including peels and CO2 laser
If a patient is not suitable for RF microneedling, I would refer them for CO2 laser treatment to help with their surgical scarring instead.
In conjunction with RF microneedling, I also advise that my patients adhere to a cosmeceutical topical home care routine, as well as appropriate skin preparation before treatment. This helps to minimise any inflammation, hyperpigmentation in the skin and speed/support healing. I recommend using the iS Clinical Super Serum and iS Clinical Brightening Complex.
1. Amelia Hill, Botched Cosmetic Procedures on the Rise, 2022, <https://www.theguardian.com/ lifeandstyle/2022/mar/01/botched-cosmetic-procedures-on-the-rise-says-campaign-group>
2. Haneke E, Managing Complications of Fillers, 2015, < https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4728901/>
3. Millicent Odunze, Overview of 3 types of surgery scard, 2022, <https://www.verywellhealth.com/ plastic-surgery-bad-scars-2710210#:~:text=A%20scar%20that%20does%20not%20heal%20as%20 a,may%20remain%20flat%2C%20but%20become%20widened%20with%20time.>
4. Whitney Palmer, Being Older Helps Skin Heal with Less Scarring, 2018, <https://www. dermatologytimes.com/view/being-older-helps-skin-heal-less-scarring>
5. Cutera, data on file
“In general, patients can see results for surgical scarring after a minimum of three treatments due to the unique nature and depth”
Dr Preema Vig
The New Skin Hero
The newest member of the Phyto family, Phyto Corrective Essence Mist, is the first mist by SkinCeuticals and a future icon. It is formulated with a high concentration of botanical extracts and moisturising agents to hydrate and soothe red, inflamed and irritated skin. This ‘no-touch’ essence offers an immediate reduction in visible redness and improvement in smoothness and plumpness. It is perfect for in-clinic use post-laser and for continued use at home as part of your patient aftercare programme, and has been clinically proven to improve hydration by up to 69%.1
The Phyto Corrective Essence Mist is enriched with the same phyto botanical blend –combining cucumber, thyme, olive, rosemary, grapefruit and mulberry – at the heart of SkinCeuticals’ hero product and #2 bestseller globally, Phyto Corrective Serum.
In a self-assessment study of 52 subjects:
• 88% agreed skin feels soothed
• 80% agreed skin feels hydrated and moisturised
• 90% agreed skin feels refreshed
Additional benefits of this NEW skin hero…
• Improves skin texture
• Hydrates and soothes all skin types, even sensitive
• Helps repair skin barrier function
• Helps lock in moisture
• Soothes skin
• Enhances the skin’s natural radiance, texture and clarity
• Can be used over makeup
SkinCeuticals brand background
Born from decades of research, SkinCeuticals’ high potency formulas are proven to be absorbed optimally into the skin. Our mission is to improve skin health. Dedicated to this purpose, we make one simple promise – to provide advanced skincare backed by science.
Made in the US, we provide complete skincare solutions recommended by dermatologists, plastic surgeons, medispas and other skincare professionals worldwide to both correct the appearance of the signs of ageing and help prevent future damage.
Speak to your SkinCeuticals representative for more information about NEW Phyto Corrective Essence Mist and the full Phyto range.
If you do not have a dedicated contact please email Contact@SkinCeuticals.co.uk
Dr Munir Somji, aesthetic practitioner and founder of DrMedispa UK Clinics, said, “Redness is inevitable when treating my patients inclinic with our various energy delivery devices, especially those which rely on heat treatment for the desired effect. Leaving the clinic with a red face is not ideal, so anything that counteracts that is a godsend and this mist works a treat. There’s no need to touch the face on application which is great so we’re not transferring any bacteria to the newly treated area. The mist is a further extension of the Phyto range which we rate highly at my clinics, as do our patients for its unparalleled soothing and calming effect.”
This advertorial was written and supplied by SkinCeuticals
Introducing the latest addition to the SkinCeuticals Phyto Range… Phyto Corrective Essence Mist
“We rate the Phyto range highly at my clinics, as do our patients, for its unparalleled soothing and calming effect”
Identifying Facial Danger Points
Mr Jeff Downie and Mr Mark Devlin outline the common facial danger arteries to be aware of when administering dermal filler treatments
Using reliable surface landmarks for localising important facial neurovascular structures, as well as their corresponding depth to the skin, plays a crucial role in minimising injury risk and rate of complications. This is particularly important when injecting neuromodulating agents and soft tissue fillers. Most of these structures follow a reliable trajectory that can be identified by either a vertical or a curved line.
Surface landmarks are key in planning and completing injectable treatments effectively and safely. In this article, we describe a simple method of identifying these key anatomical points.
This vertical line, drawn through the medial canthus of the eye, crosses the location of two important landmarks of the upper and middle face.
1. The supratrochlear neurovascular bundle
2. The point where the facial artery gives away its terminal branch –the angular artery
Supratrochlear neurovascular bundle
The supratrochlear neurovascular bundle exits the superomedial orbit through a supratrochlear notch or foramen, at approximately 2cm (1.7-2.2cm) from the midline of the face. The skin landmarks described in the literature are the glabellar frown lines.1,2 They demarcate the corrugator and procerus muscles and have been reported to lie within 6mm of the neurovascular bundle.1
The supratrochlear artery (STrA), along with the dorsal nasal artery, are the two terminal branches of the ophthalmic artery, which in turn is the first intracranial branch of the internal carotid artery.2 At its origin in the face, STrA is relatively constant, lying at 3mm around the medial canthal line.3 It pierces the orbital septum and travels superiorly between the orbicularis oculi and corrugator muscles. At this level, the artery is found 1-2mm deep within the muscle layer and makes an ‘S’-shaped bend.4 In the lower forehead, the neurovascular structures are located within a deeper plane: either exiting a bony foramen/notch, under or within the muscle layer.1,3 At this level, the intramuscular or supraperiosteal injections should be done with caution to avoid the rich network of vessels and anastomoses between the STrA, ipsilateral angular and supraorbital arteries.1,3
The STrA pierces the frontalis muscle at 15-25mm above the supraorbital rim and gradually becomes more superficial, ascending in a subcutaneous plane.4 At the junction of the inferior and the middle third of the forehead, STrA gives away medial and lateral vertical branches.4 These tend to run towards the midline from the level of the middle third of the forehead superiorly.4 Within the upper and middle forehead, dermal fillers are advised to be injected deep underneath
the frontalis muscle, aiming towards a supra-periosteal placement of the product as at this level, one is likely to be underneath the vessels.5 Over its course, the STrA provides small branches to the overlying skin, muscles and periosteum. The supratrochlear nerve and veins are consistently seen to accompany the STrA in the forehead.1
The angular artery
As the line continues inferiorly it passes just lateral to the nasal base. This locates the position of the facial artery as it becomes the angular artery. This terminal branch of the facial artery lies relatively superficial at this point.
This vertical line passes through the medial limbus of the iris defining the anatomical locations of three important landmarks:
• Supraorbital neurovascular bundle (SO NVB)
• Infraorbital neurovascular bundle (IO NVB)
• Mental neurovascular bundle (M NVB)
Supraorbital neurovascular bundle
The SO NVB arises in the medial third aspect of the supraorbital rim on the vertical line crossing the medial limbus, at approximately 17-22mm lateral to the midline.4 It enters the face through either a foramen or, more frequently, a notch.
The supraorbital artery (SOA) is a terminal branch of the ophthalmic artery, which in turn is a branch of the internal carotid artery. As it exists, the orbit is usually surrounded by a ligament which is constant in cases where it passes directly over the rim, and absent when passing through a foramen.6 SOA runs from medial to lateral over the supraorbital rim and divides into a superficial and a deep branch.4 The superficial branch divides into two vessels: a vertical and a brow branch which have a similar trajectory to STrA. After a short course through the muscular layer, they enter the subcutaneous plane of the forehead.4 The deep branch gives way to three smaller vessels: medial, oblique and lateral rim, which run deep, in a sub muscular plane.4,6
In the lower forehead, most branches of the SOA and STrA are located deep to the frontalis muscle, while in the upper forehead they tend to run superficial to it.6 The artery pierces the frontalis muscle 15-40mm above the orbital rim before surfacing in the subcutaneous tissue between 40 and 60mm.7 As the vessels become more superficial, the filler should be placed at the level of the periosteum to decrease the risk of vascular occlusion.
The supraorbital nerve (SON) is a branch ophthalmic nerve (V1) which is the first and smallest division of the trigeminal nerve (CNV).8 It runs
along the orbital roof and divides near the orbital rim into superficial and deep branches that closely follow the course of the arteries.6 The largest branch of the SON accompanies the superficial vertical branch of the SOA, often travelling lateral to it.6 The superficial branches pass medially, entering the galea-frontalis layer and supply the skin of the forehead up to the anterior margin of the scalp, while the deep branches tend to run laterally between the galea aponeurotica and pericranium, providing sensation to the frontoparietal scalp.9,10 Some of its branches innervate part of the upper eyelid. In practice, the nasoglabellar region is a particularly dangerous area. All autologous fat grafting and filler injections into the glabella region, inner canthus and nasal dorsum come with a risk of skin necrosis.11 Studies suggest that whilst nose injections come with a higher chance of vascular compromise, the glabellar augmentation seems to be linked with an increased risk of vision loss due to retinal artery compromise.7,11,12 This can be easily explained by the anatomy located in the upper third of the face where a rich vessel network between SOA, STrA and angular artery is located.
gingival mucosa of the upper lip.14 After a short supraperiosteal course, it bifurcates into three branches: superior vestibular, nasal and zygomatic-malar branch, just under levator labii superioris.15 The nasal branch runs in an upward direction and seems to remain deep, just above the periosteum, and anastomoses with the angular, dorsal nasal or STrA. The zygomatic-malar branch tends to run horizontally, becoming more superficial as it runs towards the zygomatic arch, coursing through the malar fat pad and ending in the skin of the cheek.15 The vertical branch has the most constant path, passing through the orbicularis oculi and running downwards ending in the upper vestibular mucosa.14
The infraorbital nerve (ION) is the largest sensory branch of the maxillary nerve (V2), which is the second division of the trigeminal nerve (CNV). It supplies the skin overlying the medial cheek, lower eyelid, ala nasi, lateral part of the nose and the upper lip.8,16
Supratrochlear neurovascular bundle
Supraorbital neurovascular bundle
In practice, the mid-cheek region can be separated into two areas by using the same vertical line that crosses through the medial limbus. Medial injections to the line in a supraperiosteal layer are to be avoided to reduce the intravascular injection risk. Retrograde propagation of product through the IO nasal branch may occlude terminal branches of the internal carotid artery, inducing ocular or cerebral compromise. It is thus advised to remove the cannula at least 2mm from the periosteum and deliver the product in small boluses, pushing the product from lateral to medial.8,15 Laterally to the medial pupillary line, injections should be performed on the periosteum to avoid the shallow vessel network of the zygomatic-malar artery which could result in skin necrosis.17
Infraorbital neurovascular bundle
Mental neurovascular bundle
Mental neurovascular bundle
The M NVB arises from the mental foramen, which is frequently located on the same line as the supraorbital and infraorbital NVBs.18 There is a great variety described in the literature regarding the specific location of the foramen: at the level of the first or second premolar, between them, or even more medially, at the level of the canines.7,19 The mental artery, terminal branch of the inferior alveolar artery, in turn is a branch of the maxillary artery, supplying the lower lip and chin.18
Moreover, the ophthalmic and facial veins drain into the orbits and can allow passage of large emboli, while the presence of choke anastomoses between the posterior and anterior ciliary vessels could also react with spasms after injection of filler product.11 Commonly reported complications are ophthalmoplegia, ptosis and temporary or permanent vision loss.11
Infraorbital neurovascular bundle
The IO NVB exits the face through an infraorbital foramen, at about 6.3-10.9mm below the orbital rim.7 Clinically, this anatomical landmark is located at one-third distance between the medial and lateral canthus in the same vertical plane, crossing the medial border of the pupil (the medial limbus) and at approximately a finger-breadth below the infraorbital rim.7,13 Usually easily palpable, the foramen should be located prior to any procedure.7,13
The infraorbital artery (IOA) is a terminal branch of the maxillary artery, which in turn is a branch of the external carotid artery. IOA reaches the mid-facial region via the infraorbital foramen and supplies the skin of the malar and upper lip region, as well as the vestibular and
Additionally, the ascending mental artery (AMA) and terminal branch of the submental artery are the main arterial supply to the top of the chin.20 After crossing the mandibular margin from the submental area, it travels upwards towards the lower lip.20 Most of the time, AMA travels superficially within the dense subcutaneous tissue and would end at the level of transverse labiomental fold.20 AMA would sometimes give away a terminal branch that travels through the mylohyoid muscle, into the floor of the mouth and anastomoses with the sublingual artery.20 This close relationship could potentially result in floor of the mouth or lingual infarction following chin augmentation.20 It has been suggested that there is frequently one dominant AMA that enters the chin at approximately 6mm from the midline, within the muscular plane and at a depth of 5mm from the skin.20
The mandibular nerve (V3), the third and largest division of the trigeminal nerve (CNV), contains both sensory and motor fibres. After leaving the skull it passes though the infratemporal fossa and bifurcates into an anterior and posterior branch. The posterior division enters the mandibular foramen as the inferior alveolar nerve, passing through the mandibular canal and exiting the face via the mandibular
foramen as the mental nerve, providing innervation to the skin of the chin and lower lip. It is important to highlight that although most of the sensory innervation of the face is provided by the CNV, a small area around the mandibular angle and the auricular lobe is innervated by the auricular nerve. Moreover, both the mental nerve and the marginal mandibular branch of the facial nerve provide sensory innervation to the lower face, and the role of the direct connections between the trigeminal and facial nerves that are implicated in sensory recovery following facial trauma should be acknowledged.18
Considering the anatomical relationships described above, a deep supraperiosteal injection in the midline zone is the preferred technique as it is associated with a lower risk of vessel injury. An alternative entry point is at the level of the transverse labiomental crease, where the cannula would preferably be inserted downward, parallel to the course of the artery as it is safer to inject transversely in relation to the vasculature.7,12
First curve – the facial artery curve
We can follow the trajectory of the facial artery by drawing a medial concave line from its origin at the mandible to its termination at the medial canthus. The facial artery arises from the external carotid artery, where it passes through the submandibular gland, to cross the mandible just in front of the masseter muscle, where it can be palpated as it crosses the mandible midway between the angle and mental tubercle.6,10 Note that the artery is deep to the platysma. As the platysma lies subcutaneously, the needle should not pierce the fascia when injecting the jaw, so avoid the facial artery here.4
From the jaw, the artery then curves medially to a finger breadth’s distance lateral from the commissure of the lips, where it gives off the superior and inferior labial arteries.14 Here, the artery lies deep to, or within the muscle layer. To avoid both the facial artery and its anastomoses with the labial arteries, keeping injections superficial and subcutaneous is recommended.7
As it branches from the facial artery, the inferior labial artery briefly passes deep to the depressor anguli oris at the commissure, running submucosally along the lower lip in relation to the orbicularis oris.4
The superior labial artery similarly tends to run submucosally, giving off both superficial and deep branches along its course. To avoid intra-arterial injections and complications such as tissue necrosis, injections for the lips should not be performed outside of the vermillion border and should not exceed a depth of 2-3mm.6,11
As the facial artery ascends the face from the corner of the mouth, its course can be approximated using the nasolabial fold. Although the artery initially lies deep to or just above muscle, as it ascends to the level of the alar base and branches to give the lateral nasal artery, it quickly becomes superficial, putting it at risk of injury when injecting subcutaneously.7 Injections in this area should be performed intradermally or pre-periosteally to avoid complications such as tissue necrosis or vision loss, with extra care taken as the artery ascends.7,11 After it gives off the lateral nasal artery, the facial artery continues to ascend the side of the nose as the angular artery. The angular artery is superficial to the superficial muscular aponeurotic system (SMAS) and can be palpated at the junction between the nasal bone and the maxilla.10 Injections should be performed deep in order to avoid the vessels here, and, as the angular artery forms anastomoses with the ophthalmic artery, caution is required in order to avoid vision loss which can occur as a result of retrograde embolism.7 The angular artery terminates at the medial canthus by forming an anastomosis with the dorsal nasal branches of the ophthalmic artery.7,21
Second curve – superficial temporal artery curve
The course of the superficial temporal artery (STA) can be followed by drawing a lateral convex curve from the temples to the forehead. From its origin within the parotid gland, it emerges medial to the auricle and crosses over the zygomatic process of the temporal bone, bifurcating as it enters the temporal fossa to give its frontal and parietal branches around 5cm above the process.17 The artery can be palpated at the temple as it passes in front of the ear.8 At the zygomatic process, the frontal branch of the STA travels within the superficial temporal fascia, deep to the subcutaneous level, and can be found 2cm above the arch, running closely to the temporal or frontal branch of the facial nerve.22 Injections should be performed deep in the periosteal plane or superficially in the subcutis, but not within the fascia.4
As the artery travels more medially and approaches the brow, its course also becomes more superficial, and just superior to the arch of the brow, the artery travels subcutaneously.6,7 There is a danger zone as the artery approaches the lateral border of the occipitofrontalis, which may be tentatively located as the area covered by the pad of the thumb when the tip of the thumb is placed on a vertical line through the lateral epicanthus and its radial border placed on the peak of the brow.23 The artery continues to travel across the forehead superficial to the occipitofrontalis muscle, remaining subcutaneous.23 Injections into the forehead must be placed superficially, no deeper than the mid-dermis. This is because small branches of the STA extend into the deep dermis, and occlusion can result in tissue necrosis or vision loss.5 As highlighted by the intersection between the STA curve and the second vertical line, the frontal branch of the STA forms an anastomosis with the supraorbital artery. Intra-arterial injections of the STA and its branches can lead to blindness from embolisms travelling to the ophthalmic artery, so care must be taken to avoid complications when injecting along the route of the STA.4
The facial nerve ‘tree’
The course of the facial nerve and its five branches can be mapped out by drawing the facial nerve tree. After the facial nerve emerges from the stylomastoid foramen, the facial nerve surfaces to the face through the parotid gland. From here, the nerve then splits to give five branches, which are, from superior to inferior: the temporal or frontal, zygomatic, buccal, marginal mandibular and cervical branches.24
The temporal branch innervates the muscles of the forehead, and its function can be tested by asking the patient to frown or raise an eyebrow. From the parotid gland, it travels over the middle third of the zygomatic arch, into the temporal fossa, within or just below the SMAS.7,18,25 As the nerve branch courses upwards and approaches the lateral border of the frontalis, its level becomes more superficial, and therefore when injecting near the temporal branch of the facial nerve, it is important to stay above the SMAS and not pierce fascia to avoid accidentally impinging upon the nerve. As mentioned with the STA curve, this lateral border can be tentatively located using the thumb. The temporal branch runs close to the frontal branch of the STA, with the nerve branches always lying anteriorly and inferiorly to the frontal branch of the STA.7,25 Locating the STA can be a useful method of locating the temporal branch of the facial nerve, which is further demonstrated by the meeting of the temporal branch of the nerve tree with the STA curve.23
The zygomatic branch innervates the lower muscles of the orbit and can be tested by asking the patient to tightly shut their eyes. Like the temporal branch, the zygomatic branch runs below the SMAS, and therefore injections should be superficial.25 To locate the zygomatic branch, a reference point of 2.5cm in front of the intertragic notch on a straight line from the notch to the lateral canthus can be used.26 The zygomatic branch bifurcates to give upper and lower branches, with the upper travelling above the orbit to innervate orbicularis oculi and the lower travelling below the orbit to the nose and mouth.25
The buccal branch innervates the muscles of expression around the nose and mouth, and can be tested by asking the patient to puff out their cheeks and smile showing teeth.8,27 The buccal nerves travel in the sub-SMAS fat layer, crossing the masseter to pierce into the masseteric ligaments at its anterior border, then continuing to travel below the orbit to encircle the mouth.8 Injections in the buccal area should be superficial to avoid injuring the nerves.28 It is important to note that the buccal branch shows a great degree of variation, in terms of the number of ‘sub-branches’ it may have, and care must be taken when injecting in this area to avoid injury.29
The marginal mandibular branch innervates the muscles of the chin, and its function can be tested by asking the patient to downturn their lower lip. It courses near the inferior border of the mandible, always travelling superior to the border while it is anterior to the facial artery, and while it is posterior to the artery, travelling superior to the border in most patients.30 About a finger’s breadth below the mandible, the marginal mandibular branch curves medially at the angle.30 As the marginal mandibular branch leaves the parotid, it lies deep to the fascia, and is tightly bound as it travels superficial to the facial artery.25,30 When the nerve reaches the depressors of the lower lip, the marginal mandibular nerve courses deep to the muscle layer.25 Generally, due to the deep course of the nerve, as long as the needle does not pierce deep fascia, injury to the nerve can be avoided.
The cervical branch innervates the muscles below the chin, including the platysma. After exiting the parotid, the cervical branch travels deep to the SMAS, between the platysma (which lies within the SMAS) and deeper fascia.8,25 The cervical branch travels superficially to the marginal mandibular branch where they travel together, and because of this and its superficial course, the cervical branch is at risk of injury when injections pierce fascia.25 The branching point of the cervical nerve can be identified as being 1cm below the halfway point of a line drawn from the mentum to the mastoid process, from where the cervical branch proceeds to travel downwards to innervate the neck.31
Know your danger zones
Despite the variation in anatomy found within the head and neck region, there are consistent surface landmarks that the clinician can rely upon. The diagrammatic description we present is a simple aid to these points and how they relate to the key neurovascular structures in the face. This should be a useful, easy to remember aide for the aesthetic clinician.
Mr Jeff Downie is a consultant oral and maxillofacial surgeon who has a specialist interest in facial aesthetic and reconstructive surgery. He practises facial surgery in Glasgow and his NHS sub-speciality is facial deformity and post-traumatic facial reconstruction. In addition, he treats skin cancers, salivary gland disease and is trained in all aspects of hard and soft tissue oral-facial surgery.
Qual: FRCSEd(OMFS), FDSRCSEd, FDSRCSEng, FDSRCPS
Mr Mark Devlin is a consultant cleft and maxillofacial surgeon. He is based at the Royal Hospital for Children on the Queen Elizabeth University Hospital campus in Glasgow. For many years he maintained a facial aesthetic surgical practice but now concentrates his non-NHS time to medicolegal work. Aside from his clinical work, he is involved in medical education and training for undergraduate and postgraduate.
Qual: FRCSEd(OMFS), FRCSEd(CSiG), FRCS(Glas), FDSRCPS, FFSTEd, PGDipClinEd(RCPSG), MBChB, BDS, MEWI
Grace Yeodu Lee is a medical student at the University of Glasgow Madalina Elena Radu is a clinical fellow in the Department of Plastic Surgery, Canniesburn Unit at the Glasgow Royal Infirmary Qual: MB ChB
Philip Ferguson Jones is a registered medical illustrator Qual: MMAA, MIMI
Test your knowledge!
Complete the multiple-choice questions and go online to receive your CPD certificate!
1. Which main branch of the trigeminal nerve supplies sensation to the upper lip? a. Mandibular b. Maxillary c. Zygomatic d. Buccal
2. The facial artery enters the face at which point? a. Just in front of the masseter muscle in a superficial position b. Just in front of the masseter muscle in a deep position on the bone c. At the angle of the mandible d. At the mandibular ligament
3. The facial nerve is primarily responsible for: a. Motor supply to the muscles of facial expression b. Sensory supply to the face c. Motor supply to the muscles of mastication d. Sensory supply to the muscles of mastication
4. A line dropped vertically running through the medial canthus crosses: a. The infraorbital neurovascular bundle b. The mental nerve c. The supratrochlear neurovascular bundle d. The oral commissure
5. Which statement is true about the mandibular nerve (V3)?
a. It is the third and largest division of the trigeminal nerve (CNV), contains both sensory and motor fibres b. It is the sensory supply to the maxilla c. It is the motor supply to mentalis d. It supplies fibres to the sub-mandibular gland
Answers: B, B, A, C, A
Preventing HA Filler Infections
Hyaluronic acid (HA) dermal filler procedures are a mainstay of most aesthetic practices, helping to rejuvenate and contour our patients’ faces with effective and long-lasting results. As with all medical procedures, however, complications can occur. For HA dermal fillers, these can include:1
• Migration – whereby the filler moves from the intended treatment area
• Vascular occlusion – which can lead to tissue necrosis and vision loss
Each requires a different prevention and management strategy, which practitioners should be well-versed in before offering treatment. Within this article, I will focus on how to prevent infections associated with HA dermal filler treatment.
Types of infection
As we know, any aesthetic procedure that breaks the skin’s surfaces comes with a risk of infection. Following HA dermal filler injection, we see both early- and late-onset infections. Typically, early-onset infections present with redness, pain and/or swelling within two weeks. They are usually due to common pathogens present on the skin such as Staphylococcus aureus or Streptococcus pyogenes.2
Late-onset infections, on the other hand, can present anywhere from two weeks to years after injection. Research suggests they’re most frequent around four months post-treatment.2 They may involve an atypical organism such as Mycobacteria or Escherichia coli 2 Often described as delayed-onset nodules (DONs), these late infections typically present as hard lumps that can come with redness or swelling, but not always. They may be solitary or multiple, and generally appear around the site of injection.3
Practitioners should never rush into treatment and must always carry out a thorough consultation with the patient to ensure they are suitable. When taking a medical history, you should establish whether they have any contraindications to the HA dermal filler treatment. These can include active infections near the injection site such as acne, herpetic lesions, psoriasis or eczema, as these can carry pathogens. You should also avoid treating patients with systemic infection such as the flu, as viral infections may inhibit the immune system.4,5
Careful assessment of immunosuppressed patients, or those with auto-immune disease, should be undertaken. While some chronic conditions may not present much risk, others could flare up and exacerbate the chances of infection.4,5 Other considerations include dental issues such as poor oral hygiene, infection or planned dental procedures, as infection of the mouth is often associated with low levels of infection in the blood.4,5 The Complications in Medical Aesthetics Collaborative (CMAC) notes that research says although the mechanism of transportation is not fully understood, it is highly likely that the rupture of blood vessels can lead to localised infection.4
Diabetes, obesity, poor nutrition status and being over the age of 65 have also been found to increase the risk of infection.4,5 While not infection related, general assessment is of course also essential.6
It may sound obvious, but you must ensure the product you are using is in date and is licensed for treatment. You must also be confident that it has been sourced from a trusted supplier and has been appropriately stored and transported. Anything not maintained appropriately could risk contamination.6,7
Maintaining cleanliness is of course essential for every aesthetic treatment. Standard medical infection control procedures should be in place and include:8
• Bare below the elbow
• No jewellery apart from a plain metal band and/or religious bangle
• Short and clean fingernails
• Cuts and abrasions covered
• Appropriate hand hygiene followed
Dr Ahmed El Houssieny shares advice on avoiding infection following dermal filler injections
Despite following all described preventative measures, infections can still happen; something I know from personal experience.
A few years ago, I consulted with a 38-year-old female patient who had undergone previous HA dermal filler treatment with no problems. She presented to me with concerns about her general ageing face and sagging jawline, for which I recommended HA injection in the cheeks, around the chin and along the angle of the jawline. After a detailed consultation, the treatment went ahead with no problems. All aftercare recommendations were given – including avoiding makeup and touching the face –and the patient left the clinic happy. She called back six days later, however, highlighting that one side of her jaw felt more swollen. I advised the patient to return to clinic for an in-person review, which she declined, opting instead to send a photograph. There was no redness and she did not note any pain. I explained that swelling can happen and advised her to take an antihistamine to see if that helped.
Three days later the patient’s swelling had not improved, and she was not happy. This time, the patient agreed to come in for review and again did not report any pain or redness. I outlined that we could either dissolve the filler or watch and wait. She agreed to the latter and two days later, she started experiencing pain and tenderness. By this point, the patient was also struggling to open her mouth and chew. She was not systemically unwell.
From this, I immediately suspected infection and prescribed flucloxacillin 500mg daily for seven days. I also recommended dissolving the filler, to which the patient agreed. Upon doing so, a little puss came out of the wound, but after this there was no further sequelae. Two days later, the infection had completely resolved with no lasting impact and the patient was satisfied. The patient later admitted that she had applied makeup in the evening following treatment, which I believe may have caused the infection. While this case had a positive outcome, it made me aware of the lack of clarity in infection management guidance. I spoke with a local maxillofacial surgeon, as well as the complications expert for the product I used and other peers. All gave conflicting advice on what antibiotics to use and if/when to dissolve the HA. There were also recommendations to take a culture to confirm the type of infection, but at that time I did not have a culture kit or know how to process this with a lab.
Since then, I have invested in a culture kit and established a relationship with a local lab. Additionally, I have an agreed referral pathway in place if anything was to go beyond my expertise. To aid management further, I strongly believe the UK needs clearer consensus guidelines that are easily accessible for all.
• PPE worn
• Clean-on uniform or scrubs worn daily
• Decontamination between patients
• Waste disposed of immediately after use in appropriate bins
Patients’ skin should be thoroughly cleansed prior to treatment. The Aesthetics Complications Expert (ACE) Group World advises disinfection with 2% chlorhexidine gluconate in 70% alcohol.6 Hair should be kept away from the treatment area with a headband for patients and practitioners, while a patient’s makeup should be completely removed before the procedure.5 A ‘no-touch’ technique is also recommended. One consensus study advises that this should consist of reducing activity in the area where procedure will be performed, checking sterile packs for evidence of
damage or moisture penetration, ensuring all fluids and materials to be used are in date, ensuring contaminated equipment is not placed in a clean treatment field, not re-using single-use items, using sterile gloves and ensuring appropriate hand decontamination prior to procedure.5 If any contamination occurs during injection, it is advised that the procedure is stopped, gloves are changed and hand decontamination is undertaken. The cannula/needle should be replaced if asepsis has been breached and the contamination must be addressed.5
Both verbal and written aftercare guidance is recommended and, to prevent the risk of infection, it is essential that patients avoid makeup and touching their face for 24 hours following treatment. High-water
content cosmetics have a greater risk of microbiological contamination compared with oil-based products, while makeup brushes and sponges can present a high risk of cross contamination.5 Some people have a tendency to touch their face excessively. Anecdotally we are aware that this increases when something has changed; meaning it can be even more likely to happen after an aesthetic procedure! One study noted that 10 students touched their faces 16 times an hour on average.9 Given the amount of bacteria present on every-day objects we touch, such as our phones, kitchen service and toilet seats, it is imperative that we make patients aware that they will risk contaminating their faces through unnecessary touching.
Prevention is always better than cure, but if you do find yourself managing a patient with an infection then you must know how to do so safely and effectively. While the detail of management is outside the scope of this article, I would recommend looking into the research available, as well as joining organisations such as ACE Group World and CMAC which offer recommendations to members. As mentioned earlier, guidance does vary across the board, so I would encourage practitioners to read as much as possible to make informed decisions relevant to individual cases. In the future, I believe it would be hugely beneficial to have consensus guidelines on infection management freely available to everyone. We will then hopefully see a reduction in infection rates, an increase in safety and, ultimately, happier patients.
Dr Ahmed El Houssieny is an anaesthetist and founder of Bank Medispa in Cheshire. He is an honorary lecturer at the University of Chester and an education provider on cosmetic procedures.
Dr El Houssieny is an associate member of the British College of Aesthetic Medicine, as well as being a faculty member of Allergan and Lynton.
Announcing The 2023 Finalists!
Known as ‘The Oscars of Aesthetics’, The Aesthetics Awards aims to endorse excellence, celebrate achievements of the specialty over the past year and help drive the industry forwards through recognising best practice. Established in 2011, The Aesthetics Awards is regarded as the longest-serving and most prestigious awards ceremony in the UK aesthetics specialty, bringing together the very best in medical aesthetics.
With hundreds of high-quality entries this year, the Aesthetics team is delighted to present the shortlist for The Aesthetics Awards 2023! With such a large number of exceptional applications, unfortunately not all can be shortlisted, so we want to extend a huge congratulations to everyone who is doing fantastic work in the industry and put in the time and effort to submit their entries. Of course, the biggest congratulations must go to all of the 2023 Finalists! We look forward to welcoming you, as well as the rest of the aesthetics community, at the ceremony in March 11, following the second day of ACE 2023.
Vote for your Winners!
Voting will comprise 20% of the final score in the applicable categories and you can submit your vote by creating a free account and logging into aestheticsawards.com by January 31. You can view the appropriate categories to vote for on The Aesthetics Awards website.
Note that voting is monitored through IP addresses, and individuals
can only vote once per category. Multiple votes under the same name will be discounted from the final score and multiple votes from within the same organisation will be monitored.
Meet the judging panel
We are proud to have an esteemed judging panel with a range of skillsets consisting of more than 80 aesthetic professionals. Every category is assigned at least five judges, who are chosen specifically for their knowledge and expertise in each area. Judges sign a declaration and are carefully selected to ensure there are no conflicts of interest, making the judging process as fair and balanced as possible. To view our honoured judges, go to the Aesthetics Awards website!
Feedback on entries
We at Aesthetics know how much hard work, time and dedication it takes to write an Aesthetics Awards entry. That’s why feedback is available upon request for those who did not make the shortlist. We encourage all entrants to submit again next year and use this constructive feedback to develop your future Aesthetics Awards entries.
Please contact email@example.com if you would like to receive feedback on your entry. Requests for feedback close on January 31
THE SKINCEUTICALS AWARD FOR ENERGY DEVICE OF THE YEAR –VOTE NOW!
Alma Hybrid (Alma Lasers)
BYONIK® Pulse Triggered Laser (Pure Swiss Aesthetics Ltd)
CRISTAL Pro® (Deleo)
Emerald™ Laser (Erchonia Lasers Ltd)
GentleMax Pro Plus (Candela)
LaseMD ULTRA™ (Lutronic UK)
Potenza (Cynosure UK)
Secret PRO (Cutera)
SkinPen® Precision (Crown Aesthetics)
Sofwave™ (Sofwave Medical Ltd)
Stellar M22™ (Lumenis Be UK Ltd)
Thermage FLX (Solta Medical)
XCellarisPRO Twist (mi.to.pharm UK Ltd)
THE SILKANN CANNULA AWARD FOR INJECTABLE PRODUCT OF THE YEAR – VOTE NOW!
Profhilo® Body (HA-Derma Ltd)
Restylane Lyft (Galderma)
Revanesse Contour™ (Prollenium Medical Technologies®)
Teosyal RHA (Teoxane UK Ltd)
Cohen (Bottled Science Ltd)
Miskelly (BF Mulholland and Med-fx)
Regional Clinic Finalists
THE HAMILTON FRASER AWARD FOR BEST CLINIC SOUTH ENGLAND
• Atelier Clinic • Azthetics • Cosmex Clinic • Elite Aesthetics Ltd • Escape Aesthetics • Facial Aesthetics Ltd • Health & Aesthetics • Koha Skin Clinics • L1P Aesthetics • Perfect Skin Solutions • Radiance Aesthetic Clinic • Revitalise Skincare Clinic • Romsey Medical Practice • Vie Aesthetics
THE GETHARLEY AWARD FOR BEST CLINIC NORTH ENGLAND
• Aesthetically You • Bank MediSpa • Dr Sobia Medispa • Dr Yusra Clinic • Freyja Medical • KP Aesthetics • Laser Clincs UK, Manchester • MySkyn Clinic Ltd • Paragon Aesthetics • Skyn Doctor • The Wynyard Clinic • VL Aesthetics • Yorkshire Skin Centre
BEST CLINIC LONDON
• 111 Harley St. • Adonia Medical Clinic • Cadogan Clinic • Cosmetic Surgery Partners • Harley Street Injectables • Laser Clinics UK, Brent Cross • London Aesthetic Medicine • London Professional Aesthetics • PICO London • Skinfluencer • Simply Clinics • Thames Skin Clinic • The MediShed by Dr Dil
BEST CLINIC MIDLANDS AND WALES
Air Aesthetics & Wellness Clinic
Dr CP Aesthetics
Dr Sharon’s Facial Aesthetics
Kat & Co
Laser Clinics UK, Birmingham Grand Central
THE JOHN BANNON PHARMACY AWARD FOR BEST CLINIC IRELAND & NORTHERN IRELAND
Belfast Skin Clinic
Dr Bonny Clinic
Eden Medical Clinic
Elite Aesthetic Clinic Ltd
ORA Skin Clinic
The Laser and Skin Clinic
THE FILLMED AWARD FOR BEST CLINIC
Dermal Clinic Ltd
FTT Skin Clinics
Laser Clinics UK, Glasgow
Platinum Medi Cosmetic Clinic
Other Clinic Finalists
THE HYDRAFACIAL AWARD FOR BEST NEW CLINIC, UK & IRELAND
• Beechwood House Healthcare
Dr A Aesthetics Clinic • Dr Kane Aesthetics Co.
House of Saab
Natali Kelly Clinic
The Courtyard Aesthetic Clinic
The Clinic Holland Park •
The Clinic by Dr Maryam Zamani • Thérapie Clinic, Clapham Junction
THE CROMA PHARMA AWARD FOR BEST CLINIC TEAM OF THE YEAR
Cosmetic Surgery Partners
Dr Sobia Medispa
Elite Aesthetic Clinic
Health & Aesthetics
Laser Clinics UK, Richmond
Look Lovely London
Natali Kelly Clinic
Radiance Aesthetic Clinic
The Clinic Holland Park
Younique Aesthetics Clinic
Clinic Support, Company or Organisation Finalists
BEST CLINIC SUPPORT
PARTNER/PRODUCT OF THE YEAR – VOTE NOW!
• Aesthetic Nurse Software • DermaFocus • InDesk
• Sophie Attwood Communications Ltd • T Chauhan Consultancy Ltd • The Clinic Builders
BEST SURGICAL RESULT
• Mr Duncan Atherton
• Mr Daniel Ezra
• Mr Sotirios Foutsizoglou • Miss Elizabeth Hawkes • Dr Furqan Raja • Mr Jonathan Roos • Miss Sujatha Tadiparthi • Mr Tunc Tiryaki • Dr Maryam Zamani
THE HEALTHXCHANGE AWARD FOR BEST NON-SURGICAL RESULT
• Dr Yusra Al-Mukhtar • Dr Zainab Al-Mukhtar • Dr Nina Bal • Dr Manav Bawa • Dr Rehanna Beckhurst • Dr Harriett Cant • Sarah Donaldson • Dr Anna Hemming • Dr Andrew Kane • Dr Varna Kugan • Lynn Lowery • Dr Ana Mansouri • Dr Megan McCann • Dr Tanja Phillips • Dr Emily Stanworth • Dr Rekha Tailor • Dr Jasmin Taher • Dr Joshua Van der Aa
PROFESSIONAL INITIATIVE OF THE YEAR –VOTE NOW!
• Aesthetics United Charity Conference • Black Skin Directory • Human Health by The Clinic™
IBSA Derma Me as a Masterpiece Campaign
Integrated Practitioners of Aesthetic Wellness
In the Consulting Room by S-Thetics Clinic
Individual Practitioner Finalists
THE ALUMIERMD AWARD FOR RISING STAR OF THE YEAR
Dr Raquel Amado
Dr Chloe Aucott
Dr Amrita Bhogal
Dr Dorota Chudek
Dr Jemma Gewargis
Dr Hannah Higgins
Dr Andrew Kane
Mr James Olding
Dr Goziem Onuchukwu
Dr Arreni Somasegaran
Dr Rachel Tunney
Dr Natasha Verma
THE AESTHETICSOURCE AWARD FOR NURSE PRACTITIONER OF THE YEAR
THE DERMALOGICA PRO AWARD FOR MEDICAL AESTHETIC PRACTITIONER OF THE YEAR
Dr Yusra Al-Mukhtar •
Dr Rehanna Beckhurst •
Dr Ahmed El Houssieny • Dr Ifeoma Ejikeme • Dr Mayoni Gooneratne • Dr Uliana Gout •
Dr Anna Hemming • Dr Shirin Lakhani
Dr Steven Land
Dr Brian McCleary
Dr Aileen McPhillips
Dr Dev Patel
Dr Emma Ravichandran
Dr Eleanor Reid
Dr Souphi Samizadeh
Dr Sophie Shotter
Dr Sobia Syed
Dr Preema Vig
CONSULTANT SURGEON OF THE YEAR
Mr Jeff Downie •
Mr Sotirios Foutsizoglou •
Mr Lorenzo Garagnani •
Miss Elizabeth Hawkes • Miss Rachna Murthy • Miss Sujatha Tadiparthi • Dr Maryam Zamani
CELEBRATE WITH THE COMMUNITY!
Nominations open to recognise outstanding achievements in medical aesthetics
There are countless individuals working tirelessly within aesthetic medicine who are striving to progress the profession forward, each and every day. The Aesthetics Award for Outstanding Achievement, which previously recognised a lifetime achievement over a long, established career, now aims to shine a spotlight and recognise one specific achievement made by an individual within the specialty. This achievement and individual will have had a positive impact on the industry, and those working within the field. As part of the criteria for this Award, the individual must have an example of an outstanding achievement from 2022, which showcases their commitment and significant contribution to the profession and industry in the UK. To be considered for this Award, individuals may nominate themselves, or another person who might be worthy.
To send a nomination, email firstname.lastname@example.org by February 6 with the following information:
1. The name of the individual
2. The name of the achievement (confirm the achievement occurred in the past 12 months/2022)
3. 100-word explanation of why this person and this achievement deserves to win
There will be no shortlist for this accolade, and the Winner for The Aesthetics Award for Outstanding Achievement 2023 will be selected by the Aesthetics team. Best of luck to all nominees!
Secure your Aesthetics Awards tickets!
Last year, tickets to attend The Aesthetics Awards sold out weeks before the ceremony, so to avoid any disappointment, make sure to grab yours now!
With the Awards taking place at a brand-new venue – the luxurious Grosvenor House – the ceremony is expected to be the biggest one yet! After spending two educational days at ACE, you can celebrate the achievements of the aesthetics specialty with fellow colleagues and professionals on the evening of the second day.
• Individual ticket – £340
• Table of 10 – £3,400
Those who are paying Full Members of the Aesthetics community are eligible to receive the Early Bird ticket rate all year round. If you are unsure if you are a paying Full Member, please contact the team at email@example.com who will be able to check your Membership and send across a discount code, if applicable.
We can’t wait to see you there on March 11 and good luck to all our Finalists!
Case Study: Addressing a Rhinoplasty Complication
When presented with a complex complication, aesthetic practitioners must reflect on their own capabilities and knowledge before agreeing to take on the case. They must consider whether they have sufficient experience, anatomical knowledge and resources to maintain the patient’s safety as well as deliver an acceptable aesthetic result. This is particularly important when a complication has occurred in an area of the face with complex and potentially altered neuro-vascularity, such as the nose.
The case study presented in this article fits this criteria, and despite over two decades of global teaching and referrals for the management of complications, I feel it is important to stress that complacency is to be avoided. Indeed, if one is unsure about how to proceed with a case due to its complexity, there is no shame in referring the patient to a more experienced colleague.
Medical history and concerns
A 45-year-old woman was referred to my clinic with nasal complications following a history of a number of surgical rhinoplasty procedures which had left her with an unsatisfactory aesthetic result and impaired breathing, which was worse in the right nostril. The patient first had a septo-rhinoplasty 20 years ago to address both aesthetic and functional concerns, followed by three surgical revisions, including a cartilaginous graft from her rib. As Figures 1-3 show, these procedures left her with an unsatisfactory, asymmetrical result.
The patient had been advised against further surgical intervention, so sought a non-surgical option, with the understanding that it would be solely to address the aesthetic concerns. To manage the patient’s expectations, I had to explain the complexity of her situation without confusing or alienating her, ensuring she knew that I had her best interests and safety in mind. This is paramount when approaching any treatment, whether complicated or straightforward. It’s our responsibility to explain all the potential risks of the procedure being proposed, so that our patients are fully informed before obtaining their consent to proceed. The risks of a vascular occlusion leading to possible tissue necrosis, or embolism leading to visual impairment and even blindness, are all well documented and therefore need to be discussed with each patient.1
Challenges of the case
There were a number of challenging anatomical and aesthetic factors I needed to navigate and address in this case. These were present in the upper nasal region (radix/sellion), mid nose (dorsum) and lower nasal region (nasal tip). In the upper nasal region, Figures 1-3 (p.45) show a step deformity on the left-hand side of the radix. In the mid nose, there was an 8mm axial deviation in the dorsum from the superior to inferior aspect. In addition, there was a discernible breach or dehiscence in the rhinion, which was devoid of any bone or cartilage, and was largely composed of fibrous scar tissue. The overall width of the dorsum was also unsightly. In the lower nasal region, the lower lateral cartilages of the nasal tip had collapsed, resulting in a ptotic and rounded tip.
In a case such as this, comprehensive knowledge and understanding of the internal and external anatomy of and blood supply to the nose is of paramount importance (Figures 4-6), although it should be noted that the neuro-vasculature may have been compromised and altered due to the previous surgical interventions.2 In addition to this, natural and quite normal anatomical variations often exist. Hence, in order to be able to map all of the essential and intricate anatomy within a fraction of a millimetre, I would strongly recommend the use of a good ultrasound unit, as I did in this case.
There are several key arteries which practitioners need to be aware of when injecting the nose (Figures 4-5). The external blood supply of the nose is derived from key branches from the ophthalmic
Medial internal nasal branch of the anterior ethmoidal artery
Lateral branch of posterior ethmoidal artery
Lateral internal nasal branch of anterior ethmoidal artery
External nasal branch of anterior ethmoidal artery
Branch of anterior ethmoidal artery
Septal branch of superior labial artery
Septal branch of posterior ethmoidal artery
Posterior septal branch of sphenopalatine artery
Descending palatine artery
Lesser palatine artery
Greater palatine artery
Dr Bob Khanna treats a complex case of a patient presenting with a poor aesthetic and functional outcome following multiple rhinoplasty procedures
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.firstname.lastname@example.org Tel: +44 (0) 300 3035674
infraorbital and facial arteries. There are also additional branches in the form of the external nasal artery, which is derived from the anterior ethmoidal artery, which provides blood supply to the dorsum and is sometimes violated during non-surgical treatment of the nose due to being often overlooked.3
The intricate internal blood supply of the nose should also be considered. It is mainly derived from the third part of the maxillary artery, in the form of the anterior and posterior ethmoidal arteries, the sphenopalatine artery, greater palatine artery and several branches from the superior labial artery (derived from the facial artery). Practitioners must also consider the vascular plexus known as Little’s area or Kiesselbach’s area, found in the anterior nasal mucosa.3 The combination of an in depth knowledge of the anatomy and verification with ultrasound allowed me to plan precise entry points and depth of delivery of the dermal filler, in any given section of the nose. Prior to injection, I also aspirated to help ensure I wasn’t injecting into a significant vessel. Aspiration can deliver false negatives or positives on occasion, but I find it is useful as a guide when selecting my entry points.4 I feel that every precaution taken in cases of this complexity is another step to preserve the safety of the patient.
Product selection and technique
Due to the patient’s soft tissue scarring from a history of acne and surgery and the thinness of her skin, I had to be very selective about the most appropriate materials to use to achieve a smooth and aesthetically satisfactory result. In this case, I used my own layering technique by selecting two different dermal fillers with varying viscosities: Pluryal Biovolume, which has a higher viscosity, and Pluryal Bioclassic for the less viscous option. I injected Biovolume deep to the nasal superficial musculoaponeurotic system (SMAS) to reinforce the foundations of the nasal structure, and Bioclassic was used superficial to the nasal SMAS to fine tune and create a smoother aesthetic result, without damaging the patient’s delicate skin. I selected these bio-stimulating fillers, to create longer-lasting results through tissue
regeneration alongside re-sculpting the nose. Using Matricyl 3Dtechnology, the Pluryal bio fillers facilitate a slow release of free HA and stimulation of mainly CD44 receptors to increase levels of hyaluronic acid and fibronectin, which is essential in neo-collagenesis.5-7
In my view, when encountering a case that has issues like those aforementioned, it is safer to use a cannula, as using needles carries a greater risk of breaching the internal wall of the nose in cases where it has already been compromised.8 I used two different Dermasculpt cannulas: a 22 gauge 70mm for the Biovolume, and a 25 gauge 40mm for the Bioclassic. In this case, I chose to inject the nose via two entry points – one in the nasal tip and one in the mid-dorsum – because access to the nasal tissue was restricted by the contour defects from the patient’s previous procedures. In total, I used just over 1ml of dermal filler to complete this procedure in one session. The patient was extremely happy with the results and felt I had surpassed her expectations (Figures 1-3). Aftercare in a case like this is crucial to help preserve the results achieved. I warned my patient not to wear glasses of any kind for two weeks following treatment, not to blow her nose with force and to sleep on her back for a fortnight to reduce the risk of the nose receiving any trauma whatsoever. I also told her to avoid either very hot or very cold showers/baths as the extreme temperatures can affect blood flow and therefore affect the healing process. I discouraged her from using any highly active skincare on her nose for two weeks, instead recommending a moderatestrength glycolic acid on the nose both morning and night, with SPF 50 in the mornings and a gentle moisturiser before bed. All products were from my skincare line, DrBK Skin. I made sure the patient was aware that rare delayed complications could arise after treatment, so informed her to report back to me if she noticed any irregular skin discolouration, swelling or changes in skin texture.9
Taking on complex cases
When presented with complex cases like the one described in this article, practitioners must take a step back and assess their own capabilities before deciding whether to proceed with treatment themselves or refer on to a more experienced colleague. So as to safeguard patient safety, an advanced knowledge of anatomy is perhaps the most important factor in order to assist in planning and allow you to fully interpret ultrasound imaging. Having a sound technique with carefully selected products is essential to create a good result and prevent further damage.
Dr Bob Khanna is globally renowned in facial aesthetics and has been practising as a cosmetic dental surgeon and aesthetic practitioner for more than 25 years. As well as being a visiting professor at the University of Seville and the Medical University of Vienna, Dr Khanna is president of the non-profit organisation the International Academy of Advanced Facial Aesthetics. He is the clinical director of The DrBK Clinics in Reading and Harley Street, and clinical director the internationally renowned Dr Bob Khanna Training Institute.
Qual: BDSFigures 1-3: Before and 3 weeks after non-surgical rhinoplasty treatment by Dr Bob Khanna
Exploring Chemical Peel Complications
Chemical peels are one of the most common non-invasive cosmetic treatments performed in clinics around the world.1
The treatment’s popularity and longevity are down to how effective it is at treating a range of dermatological conditions, such as pigmentation disorders, acne and photoageing. The results a patient can expect are typically linked to the depth of wounding. However, while the side effects associated with superficial peels are generally moderate, medium and deep peels are linked to a higher likelihood of severe complications. Complications can range from the minor, such as uneven pigmentation and darkening of the skin, to extreme irritation and permanent scarring.2
Background of peel complications
When conducting a peel procedure, chemical agents of differing strengths are applied to the treatment area to exfoliate the skin, leading to a period of skin regrowth and rejuvenation. Darker skin types are commonly known to experience side effects from peels. A study of 132 patients with darker skin received 473 chemical peels to determine how prevalent side effects were. 18 patients experienced side effects of crusting, dark spots and reddening. The study showed that patients with darker skin tones were more likely to experience side effects and complications.3
Superficial chemical peels
The lightest superficial peels are a common treatment for skin dryness, uneven pigmentation and fine lines. They typically use a combination of alpha and beta hydroxy acids, which are milder than the chemicals used for deeper peels. The patient may feel some mild stinging while the treatment is applied, and the expected skin response is some sensitivity, erythema (which usually disappears in three to five days) and skin flaking. The moderate complications patients may experience include increased skin
sensitivity, pigmentation, prolonged erythema, activation of the herpes virus and allergic and irritant contact dermatitis.4
Medium chemical peels
Medium-strength chemical peels are a viable treatment option for uneven skin colour, deeper wrinkles and acne scars. The chemicals, typically trichloroacetic acid (TCA) (35% and above), Jessner’s solution (containing salicylic and lactic acid and resorcinol) and glycolic acid, remove skin cells from both the epidermis and the dermis. TCA peels are less commonly used on patients with darker skin types due to the risk of scarring and post-peel dyschromia.5
The expected skin response to a medium peel is skin shedding and peeling, increased sensitivity and erythema, which will typically disappear after 15-30 days.4 Moderate complications are similar to a superficial peels, however, severe reactions are also possible such as epidermolysis, prolonged erythema, hypo- and post-inflammatory hyperpigmentation and permanent scarring.4
Deep chemical peels
Stronger chemical peels are recommended for severe blotches, coarse wrinkles, precancerous growths and excessive sun damage. The peels contain phenol acid to penetrate into the lower dermal layer of the skin. This treatment can be uncomfortable, and the practitioner may give a sedative or local anaesthetic to manage the pain. There is usually a pre-treatment, typically with retinoic gel or acid cream, which prepares the patient for the peel by thinning the surface layer of the skin so the peel can penetrate deeply.4
The expected skin response is redness, peeling and crustiness, as well as swelling and discomfort that can last several weeks post-treatment. The skin can also remain red for up to three months. Deep peels have more severe complications, including hypo- and post-inflammatory hyperpigmentation, prolonged erythema
(lasting more than 60-90 days) and permanent scarring.4
Deep peels carry a heightened risk for patients with a history of heart disease in the family, as the phenol in deep peels can damage the heart muscle and cause irregular heartbeats.6 Given these risks, deep peels should only be performed by experienced medical aesthetic professionals.
The similarity between the expected skin responses and some complications, such as peeling and erythema of medium and deep peels, means practitioners should be able to tell the difference between the expected and abnormal responses confidently. Given the severity of some of the complications associated with medium and deep peels, it’s worth monitoring the patient closely and treating any side effects immediately. Early identification and treatment are crucial to preventing scar formation, and lead to the best outcome for the patient. Whilst you must warn the patient of all complications that can occur during your consultation, you should reassure them that the risks with chemical peels are relatively small.
If a patient experiences a complication, a key part of any treatment is communication. It’s important to know your limits as a clinician regarding those treatments. If you believe the best outcome for the patient could be provided through a treatment you don’t perform, you should refer them to a practitioner who does.
Repairing skin health, whether it’s maintaining the results of a successful treatment or treating a peel complication, takes time. The patient and practitioner must be committed to the process and the patient should understand that the first treatment may not be successful, and if it’s not, there are other options to explore. Typical treatment options for common peel complications include steroids, laser, creams, and anti-viral agents.
This complication is characterised by a redness of the skin that extends beyond the expected period for each peel type. If erythema persists beyond three to five days following a superficial peel, 15-30 days following a medium peel and 60-90 days for a deep peel, it is a predictor of skin thickening and scarring.2 Treatment options
Independent nurse prescriber Alex Henderson outlines the common complications of chemical peels and provides appropriate treatment options
for persistent erythema include systemic, topical or intralesional steroids if the skin is thickening and pulsed dye laser (PDL) treatment to counter the vascular factors. I recommend steroid use for no more than seven days, as continuing to use steroid cream on the face after this can increase the risk of perioral dermatitis, requiring antibiotic treatment.12 A series of one to five PDL treatments (depending on the severity of erythema) usually leads to an improvement in redness and blood vessels.
A common side effect of superficial and medium peels is transient hyper or hypopigmentation, which is likely to occur in patients with darker skin. Hyperpigmentation can occur any time after a peel and is likely to affect higher-risk groups, including those with Fitzpatrick types III-VI skin. This is because darker skin creates more melanin, and the damage caused by a peel can trigger an increase in melanin production. Hyperpigmentation is commonly a side effect of TCA peels.11 One study suggests the mechanism underlying TCA-induced hyperpigmentation relates to the skin stress response system, with TCA peels directly inducing pro-opiomelanocortin and melanocortin-1 receptor production, which darkens the skin.7 Treatment options for hyperpigmentation which I use include 0.05% retinoic acid cream in combination with 4% hydroquinone applied daily for three weeks (longer if necessary), or hydrocortisone cream if worried about erythema resulting from retinoic acid. Patients should use the cream sparingly around the eyes and not use for longer than two weeks at a time as it can thin out the skin.7 Other options include intense pulsed light therapy and fractional and non-fractional laser.
Herpes simplex infection
Herpes viral infections is a less common complication but can be activated by all depths of chemical peel if the patient suffers from this. This type of infection is often caused by a fungal overgrowth and is characterised by the skin remaining red for longer than expected.11 Although this is a rare complication, patients who are susceptible to cold sores and herpes simplex infections may experience a recurrence of the infection on the face and around the mouth, characterised by the sudden appearance of grouped erosions.8
Patients with a history of recurrent herpes labialis or primary orofacial herpes simplex infection are recommended to receive
A 54-year-old patient attended a consultation for pigmentation and signs of ageing. She had spent time researching peels, so favoured this over laser treatments. She was skin type III, tanned well and had signs of post-inflammatory hyperpigmentation. I analysed her skin and found deep pigment damage as well as fine lines and static wrinkles.
I started with a low-grade, superficial TCA peel before building up to a medium-depth peel. Her consultation consisted of home prescription care with the daily use of tretinoin and hydroquinone to suppress melanin production. I prescribed this for one month prior to any peeling or in-house therapies. Her treatment was non-eventful, and I checked that she had stopped her skincare five days before the peel. She confirmed this was the case. Later that day, the patient reported increased discomfort and excessive redness on both sides of her face. By day three, her skin had darkened, and her cheeks had turned dark brown, with evidence of burning. She was prescribed a recovery cream combined with hydrocortisone and SPF 50 to reduce the risks of post-inflammatory hyperpigmentation. By day seven, she had completed her peel process and was left with redness at the site of burning. By day 30, she was almost fully recovered. She was left with mild erythema on a small 1cmx3cm site on her lower cheek. The patient still has a small patch of slightly pink skin where the burn was. She has consented to further treatment of microneedling to improve the site. Upon review and patient questioning, she later stated that she had been using a home retinol that she had applied prior to the peel, which was the likely cause of the burning. On reflection, it’s possible that double-checking and rephrasing my questions may have enabled me to get this information from the patient and helped protect them from the potentially long-term effects of scarring.
prophylactic antivirals before and after undergoing medium and deep peels.9
Treatment options for a herpes simplex infection include a seven-to 10-day course of anti-viral agents taken in pill form, such as valacyclovir, acyclovir and famciclovir. Early detection and treatment can prevent scarring.8
Patchy or persistent erythema can be an early indication of scarring, which is frequently seen around the perioral and mandibular regions.10 The risk of scarring from medium and deep peels is rare, although it’s likely to be with the use of TCA rather than phenol peels due to the caustic nature of TCA.10 There are also several predisposing factors that increase the risk of scarring, including a history of smoking, hypertrophic scars and recent skin resurfacing procedures such as dermabrasion.10
Treatment options for scarring I use include a scar massage, which patients can do by putting the flat part of their fingers on the scar and moving the skin and tissue and holding it for a few seconds, helping to break down collagen forming under the skin.10 Taking topical or oral steroids can also help reduce the redness, itching and burning sensations these scars can produce, soften the scar tissue and reduce the size of the scar. PDL therapy can also be effective, with one study showing that three PDL treatments can improve postdermatological surgery scars significantly.10
Treat complications quickly
Peels can reduce discolouration, smooth the appearance of fine lines and wrinkles and improve the colour, clarity and texture of the skin. As with all treatments, there can be complications, so practitioners must know how to prevent, diagnose, manage and treat them. Being able to differentiate between an expected skin response and the signs of a complication is key, as early treatment can be crucial to the overall outcome.
Alex Henderson is an independent nurse prescriber with 12 years’ industry experience. She has successfully opened two clinics in the Southwest of England and has recently opened her third on Harley Street. Henderson has experience in training practitioners on foundation filler and toxin courses as well as foundation and advanced PDO threads on behalf of 4T Medical.
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Evaluating NonSurgical Rhinoplasty
Professor Alwyn D’Souza discusses his techniques for performing non-surgical rhinoplasties using dermal fillers and the anatomical knowledge required
The term rhinoplasty refers to a procedure that changes the shape, size or proportion of the nose.1 The goal of the procedure is to alter the appearance of the nose (cosmetic rhinoplasty), to improve breathing (functional rhinoplasty) or both.1 These procedures often involve modifying the nasal septum, in which case the procedure is referred to as a septo-rhinoplasty.1 Examples of commonly altered features of the nose include removing the hump, reshaping the tip and changing the length and/or width.
The aim of this article is to provide practical pointers for safe practice of non-surgical rhinoplasty (NSR) using dermal fillers to practitioners who may not have received formal training in naso-plastic surgery.
Types of rhinoplasty
Rhinoplasty can be broadly divided into surgical and non-surgical types. Surgical rhinoplasty is usually performed under general anaesthesia.1 Two approaches (closed or open) are used to expose the nasal skeleton.1 In closed rhinoplasty, cuts are made inside the nostrils, whereas open rhinoplasty entails making the cuts on the midline partition of the nose (the columella), which are joined to the cuts inside the nose.1 Both approaches also allow exposure of the nasal septum to straighten it, achieving an improvement in breathing. The surgeon may use various materials during surgical rhinoplasties,
such as cartilage, bone, implants and various types of lining as required.1
To achieve an optimal result, surgeons adopt two main approaches. Most commonly, the nose is deconstructed and reconstructed to a variable degree, commonly termed structural rhinoplasty. On the other hand, I focus on preservation rhinoplasty techniques. In this method, cartilage, bone and the skin envelope is preserved as much as possible, thus maintaining pre-existing anatomy. In my clinical experience, this leads to a quicker recovery, while achieving the required natural aesthetic outcome.2 This is my primary reason for using this technique. Advanced technologies such as ultrasonic piezoelectric devices are used for this purpose, hence the commonly used term ultrasonic rhinoplasty. These devices allow for accurate sculpting and cutting of nasal bones (nasal bone osteotomy), which is an important part of rhinoplasty surgery.
NSR uses non-invasive methods such as threads, botulinum toxin or dermal fillers to change the shape and appearance of the nose. With fillers, the procedures are often referred to as ‘filler’ or ‘liquid’ rhinoplasty.3 Filler rhinoplasty has gained popularity over the last decade with increasing use of fillers by aesthetic practitioners to reshape the nose. Though a variety of fillers may be used, I recommend using hyaluronic acid (HA) fillers as they can be dissolved using hyaluronidase. In addition, botulinum toxins may also be used (rhino-myomodulation) to modulate muscle action on the nose, thus reducing some unwanted effects such as excessive drooping of the tip or widening of the nasal base when smiling.3 The combination of fillers and toxins often provides a superior result.3,4 Non-surgical methods have gained popularity among patients due to their limited downtime, low costs and reported safety and efficacy in achieving the desired results.4
Patient selection for filler rhinoplasty
Filler rhinoplasty is suitable for patients with certain cosmetic deficits such as a low radix, small hump, shallow nasal bridge, low/ droopy tip or any minor asymmetries or irregularities.5 This method is also appealing to patients who are not medically fit to undergo surgical rhinoplasty, or those who want to avoid the risks, costs and downtime associated with surgery.5 Patients with a large dorsal hump, severely crooked nose, significant tip issues or substantial contour irregularities and breathing issues should be offered surgical rhinoplasty instead.5
Other contraindications for filler rhinoplasty include patients with pre-existing vision problems, a history of autoimmune diseases, bleeding disorders, allergies to filler components, previous NSR using silicone or unknown injection material, previous filler-related complications and patients with suspected or known body dysmorphic disorder (BDD) which has not been appropriately addressed.5
Nasal base (~0.2ml)
Figure 3: Common sites of injection with approximate volumes: please note that the volume should be titrated to individual patient needs.
will return to pre-injection aesthetics within a few hours. I call this the ‘saline test’. After ensuring the patient is happy with the saline test result, the patient is asked to return a week later to inject the filler. I use both hands when injecting – one for injecting and the other for stabilising and moulding to achieve the desired result. Personally, I believe it is also good practice to compress the dorsal nasal and superior portion of the angular arteries while injecting. I start injections from the radix and work down to the base as required. Side walls are addressed last. This ensures a standard pattern of injection with adequate attention to all areas of the nose. Skin colour is monitored closely, and the patient is asked to report any visual symptoms or discomfort immediately. This ensures any vascular compromise is noted and remedial action may be instituted, thus minimising/avoiding serious complications such as skin necrosis and blindness. Typically, vascular compromise starts with blanching of nasal skin in and around the area of injection, and over a period of three to five minutes, blueish discolouration is noted. They may also complain of altered vision if ophthalmic circulation is affected.8 Adequate attention should be paid to overall facial aesthetics to ensure facial harmony.
To achieve safe and effective results, the radix needle should be used in a perpendicular fashion, injecting on bone, while watching for glabellar blanching (as a sign to stop the injection).9 Tenting the skin upwards to mitigate vascular occlusion, placing a finger above the radix to prevent superior filler migration and immediate massaging and moulding to ensure a smooth contour are additional techniques to optimise practice.5
For tip augmentation, injection should be in the deep plane on the cartilage at a carefully selected location that corresponds to the desired tip defining point, avoiding blanching or injecting directly between the domes to prevent splaying and widening of the tip.5 For nasal base injections, neuromodulation can be used one week prior to the procedure and fillers should be placed in the deep plane with care taken to avoid the columellar blood vessels. Extra caution is required when performing this procedure in patients who had previous rhinoplasties because the vascular pattern changes considerably post-surgery, making them more prone to complications.5
The patient is monitored for at least 15 minutes after injection and given clear instructions to report back should there be any unwanted effects such as visual symptoms, changes in skin colour (redness/blueish tinge in particular), increasing pain or discomfort.
Patients should be counselled regarding the potential complications associated with filler rhinoplasty.5 These include early complications like asymmetry and surface irregularities, hypersensitivity reaction with pain, swelling, itching, infections with abscess formation, cellulitis or Tyndall effect (blue hue underneath the skin due to fillers being injected too superficially).5 The severe complication of vascular occlusion, which can cause tissue ischaemia and even blindness or stroke secondary to retrograde embolism of the fillers, are fortunately rare, but patients should be aware that they can occur.5 Delayed onset complications include scarring, foreign body granuloma and build-up of biofilms with infection and cartilage necrosis.5
It is important to identify risk factors and undertaking a thorough assessment before performing the procedure to ensure it is safe for patients to undergo filler rhinoplasty. Patients may require antibiotics if there are signs of infection, or corticosteroids for hypersensitivity reaction or granuloma formation. Immediate expert help should be sought in cases of impending skin necrosis and blindness.5 Close follow-up is essential to monitor for any possible complications after a NSR. Patients should also receive clear instructions on symptoms and signs to look for and be advised to avoid excessive nose manipulation in the first 24-48 hours.
Anatomy is key
Filler rhinoplasty has gradually evolved over the years with excellent aesthetic outcomes when performed well. Careful patient selection, adequate counselling, meticulous technique and follow-up are essential pillars that should be followed by every filler rhinoplasty practitioner, and we owe this to our patients. It is my view that filler rhinoplasty should be performed by those who have a thorough understanding of surgical rhinoplasty. This is likely to ensure that any complications are minimised, and if they arise, are dealt with immediately and effectively.
Professor Alwyn D’Souza is a London based, board certified facial plastic surgeon with experience in both surgical and non-surgical facial aesthetics. He is the current president of the EAFPS, past president of BSFPS and is also the editor-in-chief of Facial Plastic Surgery Journal. He is an invited speaker at national and international facial aesthetic meetings.
Qual: MBBS, FRCS Eng, FRCS (ORL-HNS), PGCertMedEd
1. Saban Y, ‘Rhinoplasty: Lessons from “errors”: From anatomy and experience to the concept of sequential primary rhinoplasty’, HNO, (2018).
2. Saban Y, Salvador S, ‘Guidelines for Dorsum Preservation in Primary Rhinoplasty’, Facial Plast Surg, 2021.
3. De Maio M, ‘Myomodulation with injectable fillers: An innovative approach to addressing facial muscle movement’, Aesthetic Plast Surg, (2018).
4. Jasin ME, ‘Non-surgical rhinoplasty using dermal fillers’, Facial Plast Surg Clin North Am, (2013).
5. Raggio BS, Asaria J, ‘Filler rhinoplasty’, Statpearls, Treasure Island (2022).
6. Humzah MD, Ataullah S, et al., ‘The treatment of hyaluronic acid aesthetic interventional induced visual loss (AIIVL): A consensus on practical guidance’, J Cosmet Dermatol, 2019.
7. Redaelli A, Braccini F, ‘Medical rhinoplasty’, Basic principles and clinical practice, OEO publishers, (2010).
8. King M, Walker L, et al., ‘Management of a Vascular Occlusion Associated with Cosmetic Injections’, J Clin Aesthet Dermatol, 2020.
9. Loh KTD, Phoon YS, et al., ‘Successfully managing impending skin necrosis following hyaluronic acid filler injection, using high-dose pulsed hyaluronidase’, Plast Reconstr Surg Glob Open, (2018).
Technique Filler Rhinoplasty
An in-depth knowledge of the anatomy/landmarks is essential when performing a safe and effective filler rhinoplasty.5 This includes familiarity with the layers of the nose encountered during injection (Figure 1).5 From superficial to deep the layers are: the skin (epidermis and dermis), superficial fat, superficial musculoaponeurotic system (SMAS), deep fat, perichondrium over the cartilage and periosteum over the bone, nasal cartilage and nasal bones.6
Superficial fatty layer
Fibromuscular layer Deep fatty layer Perichondrium or periosteum
Cartilage or bone Sites for injection
Although rare, as blindness and skin necrosis are potential major complications, detailed knowledge of nasal vasculature is essential (Figure 2). To date, there is no documented evidence of an intervention resulting in complete vision rescue after central retinal artery occlusion with HA.6 Encountered during this procedure are the blood vessels which are branches of the ophthalmic artery (from internal carotid system) and the facial artery (from external carotid system).5 The ophthalmic artery gives rise to the dorsal nasal artery and external nasal artery, which supply the upper part of the nose.5 On the other hand, the facial artery gives rise to the superior labial and angular artery to supply the lower part of the nose.5 These communicate with each other in a variable fashion and are superficially located, leaving the deep plane relatively avascular.5
The NSR practice began with surgeons using fillers to correct minor irregularities in the nose following surgery.6 Practitioners gradually used the technique for other types of defects such as deep radix (mentioned later), and extended the use for the nasal tip and base. A landmark book published in 2010 outlined the procedure in detail, with other publications cited.7
All patients should have standard photographs taken as part of the consultation process, and nasal function should be assessed. It’s my preference to apply topical anaesthetic to the entire nose and surrounding areas 30 minutes prior, even though most fillers have lidocaine incorporated in them. This lidocaine does take a few minutes to work, and using the topical application ameliorates immediate pain while lidocaine takes effect. In my opinion, regional nerve blocks (infraorbital, supratrochlear and external nasal) are also effective as this achieves almost complete
anaesthesia of the nose. It is also useful to mark the key nasal landmarks and any contour irregularities or areas of concern at the beginning of the procedure.5 Clinicians performing this procedure should always follow a safe injection practice when placing fillers into the nose.5 This includes injecting into the avascular deep plane (sub-SMAS) directly above the perichondrium or periosteum, in order to avoid blood vessels.5 It is also crucial to stay in the midline where possible, and aspirating helps to assess for intravascular placement of the needle prior to injection.5 Inject slowly with small aliquots of filler to make incremental enhancements, minimising the number of injection sites (Figure 3).5
Individual injectors may adopt their own techniques for injecting. The following is my recommendation to ensure the patient is fully aware of what to expect and the outcome. I see the patient at least one week before the procedure. Standard photos are taken. Normal saline is injected using 1ml lock syringe with a 30 gauge needle to the areas to be corrected, immediately followed by standard photos again. Patient is also asked to appraise the results of this. I give a copy of photos to the patient. Patient is informed that saline will resorb, and the nose
Dorsal nasal artery
External nasal artery
Superior labial artery
Although rare, as blindness and skin necrosis are potential major complications, detailed knowledge of nasal vasculature is essential
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The SkinPen microneedling treatment is a safe and effective treatment for men and women for the face and body, that can be done all year round. There are no limiting factors to having this treatment, such as laser therapy or sun exposure, making it a flexible option for patients.
At Crown Aesthetics, we have found that medical microneedling is growing in popularity each year within the aesthetic speciality, with more plastic surgeons, aesthetic practitioners and dermatologists turning their attention to skin remodelling to support their patients. SkinPen Precision is one of the world’s most trusted microneedling technologies on the market and has revolutionised skin remodelling treatments for all. Powered by state-ofthe-art technology, the SkinPen device sets the gold standard for safety and efficacy. It is an award-winning device that provides patients with a non-surgical procedure for complete skin rejuvenation, delivering natural-looking results with little to no downtime.
Patients can expect improvements between four to six weeks, allowing time for the body’s natural production of collagen and elastin. Patients may notice improvements as early as seven days post-procedure, with improved skin tone and texture. Proper skincare and maintenance are required to sustain desired results.1-4
Aesthetic practitioner’s perspective
What is SkinPen Precision?
SkinPen Precision utilises collagen induction therapy to deliver medical aesthetic treatments through controlled micro-injuries to the skin. SkinPen creates up to three million micro channels in a 30-minute treatment, eliciting the body’s natural wound-healing cascade.1-4 This process begins with injury/inflammation, progresses to tissue proliferation, and ultimately results in tissue remodelling, including new collagen and elastin. SkinPen offers a natural and nonsurgical collagen boosting treatment, suitable for all skin tones and types all year round. It is a minimally-invasive procedure performed by qualified healthcare professionals in the clinic with little to no downtime. With a patented, single-use advanced cartridge unit that is FDA-cleared and CE-marked, housing only sterile medical-grade needles, this offers the best protection for crosscontamination and provides the highest safety and quality microneedling procedures.
With unrivalled technology that medical professionals and patients can trust. SkinPen Precision has passed more than 90 validated tests to set the standard in microneedling. SkinPen’s patented disposable microneedle cartridge has an in-built reciprocating mechanism for precise calibration when treating the skin.
The mechanism of action
The treatment involves creating controlled microinjuries in the skin, eliciting the body’s natural wound healing cascade.
Dr Ana Mansouri, medical director of Dr Ana The Skin Clinic in Birmingham, commented, “SkinPen has been my go-to treatment for some years, having sought out an FDA-cleared safe and effective device capable of optimising my clinical outcomes. It remains the most popular option amongst my patients for collagen induction, thanks to its minimal discomfort and downtime while providing impressive results. I am particularly interested in the newly approved indications, including surgical scars and stretch marks.”
She continued, “Crown Aesthetics remains at the forefront of the aesthetic industry, given their device’s safety and efficacy profiles.”
1. Bellus Medical, ‘A Single-Center Trial to Evaluate the Efficacy and Tolerability of SkinPen® on Male and Female Subjects’ Acne Scars on the Face’ (2022).
2. Wamsley C, et al., ‘A Single-Center Trial to Evaluate the Efficacy and Tolerability of Four Microneedling Treatments on Fine Lines and Wrinkles of Facial and Neck Skin in Subjects With Fitzpatrick Skin Types I-IV: An Objective Assessment Using Noninvasive Devices and 0.33-mm Microbiopsies’ (2021).
3. Chopra V, ‘Microneedling of Immature Scars Is Safe and Improves Scar Esthetics’ Aesthetic Abstracts (2019).
4. Alqam M, et al., ‘Efficacy and tolerability of a microneedling device for treating wrinkles on the face’ Journal of Cosmetic Dermatology (2022).
A summary of the latest clinical studies
Title: The Clinical Effect of Botulinum Toxin on Pigmentation
Authors: Erdil D, et al.
Published: International Journal of Dermatology, December 2022
Keywords: Botulinum Toxin, Pigmentation, Skin Lightening
Abstract: Botulinum toxin injection is a common cosmetic procedure often used to treat dynamic wrinkles, but it has also been observed to have a lightening effect on the skin. It is thought that this lightening effect develops due to muscle innervation blockage; however, the change in the amount of melanin levels has not been quantified. Thirty-one patients who presented for botulinum toxin injection for wrinkle treatment were included in the study. A standard dose of botulinum toxin was injected to each patient’s forehead, glabellar and crow’s feet region, and the melanin index (MI) was measured. After botulinum toxin treatment, a statistically significant decrease was found in the forehead and upper face MI. The upper face total baseline MI was significantly lower in the Glogau 1 group than in the Glogau 2 group (P = 0.033). On the 15th day, the forehead MI was significantly lower in the Glogau 1 group than in the Glogau 2, 3 and 4 groups (P = 0.030). This decrease was more pronounced in the forehead, which is a region particularly vulnerable to sun exposure. Botulinum toxin application to healthy skin for wrinkle treatment can cause facial skin lightening by reducing MI. Younger people, who are included in the Glogau type 1 group, may benefit more from this lightening effect.
Title: The Effect of Surfactant Type on Characteristics, Skin Penetration and Antiageing Effectiveness of Transferosomes containing Amniotic Mesenchymal Stem Cells Metabolite Products in UV-aging Induced Mice
Authors: Miatmoko A, et al.
Published: Drug Delivery, December 2022
Keywords: Growth Factors, Skin Ageing, Stem Cells
Abstract: Transfersome has been developed to enhance dermal delivery of amniotic mesenchymal stem cell metabolite products (AMSC-MP). AMSC-MP contains growth factors for managing skin ageing, thus improving the quality of an adjusted life year. This study aims to determine the effect of surfactant types acting as the edge activator on transfersome-loading AMSC-MP. Transfersome was prepared by thin-layer hydration method and composed of l-αphosphatidylcholine as a phospholipid and three types of surfactants, namely cationic (stearylamine), anionic (sodium cholate) and nonionic surfactant (Tween 80) at a weight ratio of 85:15, respectively. Transfersomes were evaluated for physical characteristics, penetration, effectiveness and safety. The results showed that sodium cholate, an anionic surfactant, produced the smallest transfersome particle size. The small particle size and low negative value of zeta potential enabled high dermal penetration by transfersomes containing AMSC-MP, while the positive charge of stearylamine hindered its penetration of deeper skin layers. Trans-SC and Trans-TW produced higher collagen density values than that of Trans-SA. All the AMSC-MP transfersomes were relatively safe, with 0.5-1.0 macrophage cell numbers invaded the dermis per field of view. In conclusion, sodium cholate, an anionic surfactant, demonstrated considerable capacity as the edge activator of transfersome-loading AMSC-MP for skin anti-ageing therapy.
Title: Clinical Outcomes After Lip Injection Procedures: Comparison of Two Hyaluronic Acid Gel Fillers with Different Product Properties
Authors: Hilton S, et al.
Published: Journal of Cosmetic Dermatology, December 2022
Keywords: Dermal Filler, HA Filler, Swelling
Abstract: Transient swelling is common after lip injections with hyaluronic acid (HA) based fillers. Swelling and other injection-site reactions may relate to the injection procedure itself, or to gel properties, which differ between fillers due to differences in manufacturing methods. In a study sample of 40 subjects, treatment with two soft tissue filler products (HARK or HAJUS) was randomly assigned. Subjects were injected with 0.5cc per upper and lower lip using a standardised injection procedure. Early-onset adverse events (AEs) were assessed by evaluation up to Day 14. Aesthetic improvement, subject satisfaction and AEs post-Day 14 were assessed up to 24 weeks. In subjects treated with HARK, the intensity of early onset swelling, erythema and pain/tenderness was lower than in subjects treated with HAJUS. Aesthetic improvement was achieved in both groups, and most subjects were satisfied with the appearance of their lips. Treatment-related AEs post-Day 14 mostly related to the implant site; most were mild-to-moderate, and none were serious. The intensity of early-onset swelling and other injection-site reactions was lower in subjects treated with HARK than HAJUS. Aesthetic improvement, subject satisfaction and AE profiles post-Day 14, however, were similar between filler groups.
Title: Rhinofiller: Fat Grafting (Surgical) Versus Hyaluronic Acid (Non-Surgical)
Authors: Gentile P.
Published: Aesthetic Plastic Surgery, December 2022
Keywords: Fat Grafting, HA Filler, Rhinoplasty
Abstract: The author presented his experience using fat grafting (FG) and hyaluronic acid (HA) techniques in nasal remodelling. The paper aimed to evaluate the efficacy and safety of the use of FG and HA in nasal remodelling for aesthetic improvement. A randomised controlled trial was conducted. 15 patients affected by soft defects of the dorsum, low and boxy nasal tip and hidden columella were treated with FG (study group-SG), comparing results with the control group (CG) (n = 17) treated with HA. Post-operative follow-up took place at 1, 2 and 4 weeks, 3, 6 and 12 months, and then annually. 73.7% of SG patients showed excellent cosmetic results after one year compared with only 29.7% of CG patients. At one-month, a major part of people who underwent the treatments (FG and HA) referred to satisfaction with the resulting volume contours (p = 0.389). 88.3% of CG patients versus 53.8% of SG described the HA and FG injection, respectively, as a very comfortable and a noninvasive procedure. As expected, patient satisfaction with the appearance of nasal contouring was higher in the FG group at one year. FG and HA were safe and effective in this series of cases performed.
Reporting Complications in Aesthetic Practice
Dr Martyn King provides advice on how practitioners can report aesthetic complications
All healthcare practitioners working in cosmetic practice have a professional duty to report complications caused by prescription medicines and medical devices, which include dermal fillers.
The Nursing and Midwifery Council states ‘encourage a learning culture by reporting adverse incidents that lead to harm, as well as near misses.’1 The General Medical Council and General Dental Council also have similar statements in their guidelines.2,3 Reporting complications provides many benefits, including identifying issues that may not have previously been known about, providing an early warning system, identifying trends, product safety and counterfeit products, enabling closer scrutiny of a medicine or a device, further research conducted by the manufacturer and experts and ultimately patient safety.4
When working in isolation in private cosmetic practice, it is not always obvious what needs to be reported and where it should be reported to. It is also important to state that an organisation or practitioner, who reports no or very few adverse events or near misses are not necessarily ‘safer’ and similarly those who report many complications may not be ‘unsafe’, it may simply reflect a culture of more openness.6
What should be reported?
The Medicine and Healthcare products Regulatory Agency (MHRA) requests that healthcare practitioners report any serious reaction to a medication or a device, any medicine on additional marketing
highlighted by a black triangle (such as new products or devices), an unlisted reaction not in the summary of product characteristics, or if in any situation you are not sure to report.7 Similarly, if you are managing a complication caused by another practitioner or a non-medical person, you are still encouraged to report this to the MHRA. It is better that potential hazards are over-reported to ensure that issues can be identified and patient safety improved. Although most reputable insurance companies will indemnify you to manage these problems from other providers where you are competent to do so, it would be sensible to speak to your insurer before providing remedial treatment.
Where to report?
The MHRA is part of the Department of Health and is the Government agency responsible for regulating medicines, medical devices and blood products. They ultimately have the power and responsibility to investigate and enforce sanctions regarding medicines and devices. Reporting to the MHRA should be the first port of call for any practitioner experiencing a serious or unexpected adverse event and can be easily done via the ‘Yellow Card’ system.4,5 It is recommended to report adverse reactions to the MHRA via the ‘Yellow Card’ website, app or by the form included in the back of the British National Formulary. When completing a reporting form, as much information as possible should be included.
Information that should be provided includes (based on the Yellow Card reporting pathway):4
• Name and profession of person reporting the complication
• Contact details for the person reporting
• Date/time of complication
• Name and designation of treating practitioner
• Patient identification (ID number or initials)
• Patient age and gender
• The treatment performed resulting in an adverse event
• Type of complication occurring
• Severity of complication
• Has the complication been resolved?
• Medication or medical device leading to a complication, including batch number and expiry date
• Volume/dosage of product used and area treated
• Including a diagram of areas treated and amounts is useful
• Relevant past medical history, medication, allergies, vaccination, previous treatments and any previous adverse events
• Details of incident, including timeline of events, signs and symptoms, how the complication has been managed
• Summary of outcome at the current time
In aesthetic practice, the Aesthetic Complications Expert (ACE) Group World and manufacturers strongly recommend reporting complications that may be medicine or product related directly to the
step-by-step of complication reporting
1. Arrange early/immediate face-to-face review and identify the adverse event
2. Provide advice, reassurance or remedial treatment if appropriate
3. Seek advice from a more experienced practitioner or ACE Group World if needed
4. Ensure contemporaneous records and photographs are recorded
5. Contact the manufacturer and report to the relevant department
6. Complete a Yellow Card reporting system via the website or app
7. Provide appropriate follow-up and be available if the patient has further problems/concerns
8. Consider informing your insurance company
manufacturer. If this is a pharmaceutical supplier, it will almost certainly have its own pharmacovigilance department and a specific reporting form for you to complete to provide all the information required. If they do not provide their own reporting form, you should provide all the details recommended above and any other relevant information that is pertinent to the adverse event. Due to UK GDPR legislation, patient name and contact details should be omitted unless the patient has consented to this and requested direct contact or feedback. All manufacturers supplying medicines and devices are answerable to the MHRA and to be able to sell in the UK market, they will need to have provided evidence of safety and traceability.7 Manufacturers will usually work with the MHRA to investigate adverse events and provide evidence and feedback. Reporting a complication to a manufacturer will usually also help the practitioner on how best to manage and treat a complication and to provide support for the patient.
There are also other organisations that work specifically in non-surgical aesthetic medicine, such as the ACE Group World where members can report complications.8 This provides invaluable information to the organisation who works with manufacturers, stakeholders, patient groups, professional bodies and the Joint Council for Cosmetic Practitioners (JCCP). It also allows healthcare providers to receive evidence-based guidelines and advice on how best to manage the complication via an emergency helpline, online forum, email and messaging platform.
The importance of reporting
Point 7 of the JCCP 10-point plan specifically addressed the issue of reporting complications in the aesthetic sector on a national level, highlighting huge gaps in this area concerning the types and number of treatments in this field and the number of complications and adverse events.9 Several issues of concern have been brought forward by the JCCP, including evidence of under-reporting, unregulated providers having no duty to report complications, patients who have suffered an adverse event not having an idea on how to report their concerns, and products used in the aesthetic sector that do not have medical device approval, so do not benefit from medical accountability and traceability.9
The JCCP has also acknowledged the importance of complications
reporting as a fundamental element of a united quest to enhance patient safety and public protection. Professor David Sines, chair of the JCCP, noted that underreporting and the lack of a mandated requirement for all practitioners to advise the MHRA of complications and adverse events has led to a systematic failure of regulators, manufacturers and suppliers to construct a robust evidence-base from which to drive up service and product quality.9
Complications and adverse events in aesthetic practice are hugely under-reported and it is only by ethical and professional practitioners reporting these that, as an industry, we can improve patient safety, product safety and help shape our industry with regards to greater regulation. The introduction of a licensing scheme will possibly make it mandatory for practitioners to report adverse events, but this is hard to enforce and there is still the negative repercussions that a practitioner might feel if they report a complication on their own practice or from the manufacturer/supplier.
However, as practitioners we have a duty of candour and professional responsibilities. Reporting complications is a duty of care and a requirement of our professional bodies and we could be negligent by not doing so. Not only this, it helps to make our practice more professional, helps to eliminate non-authorised or counterfeit products, provides a further step to inhibit non-medical practitioners from performing non-surgical aesthetic treatments and finally, safer for patients. As a conclusion, I would recommend, if in doubt, report!
Dr Martyn King is the director of Cosmedic Skin Clinic. He is a national and international accredited trainer, key opinion leader, brand ambassador and has published multiple journal articles. He is medical director of the Aesthetics Complications Expert Group World, vice-chair of the Joint Council for Cosmetic Practitioners, a member of the British College of Aesthetic Medicine and chairperson for the British Association of Sclerotherapists. Qual: MBChB, MSc (Dist), PGDip, PGCert
1. Nursing and Midwifery Council: Read the professional duty of candour (UK: NMC, 2022) <https:// www.nmc.org.uk/standards/guidance/the-professional-duty-of-candour/read-the-professional-dutyof-candour/>
2. General Medical Council, Guidance for doctors who offer cosmetic interventions: safety and quality (England: GMC, 2022) https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/ cosmetic-interventions/safety-and-quality
3. General Dental Council, Principle 8: Raise concerns if patients are at risk (UK: GDC, 2022) <https:// standards.gdc-uk.org/pages/principle8/principle8.aspx>
4. Medicine and Healthcare products Regulatory Agency, Yellow Card: Making medicines and medical devices safer (UK: MHRA, 2022) <https://yellowcard.mhra.gov.uk/information>
5. Aesthetics Journal, Understanding the Yellow Card Scheme, 2019
6. Care Quality Commission, Reporting medicine related incidents (England: CQC, 2022) <https://www. cqc.org.uk/guidance-providers/adult-social-care/reporting-medicine-related-incidents>
7. Medicine and Healthcare products Regulatory Agency, Specific areas of interest for reporting suspected adverse drug reactions. (UK: MHRA, 2022). <efaidnbmnnnibpcajpcglclefindmkaj/https:// assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/403078/ Specific_areas_of_interest_for_adverse_drug_reaction_reporting.pdf>
8. Aesthetic Complications Expert Group World, Report a complication (UK: ACE Group World, 2022). <https://uk.acegroup.online/report-a-complication/>
9. The Joint Council for Cosmetic Practitioners, JCCP 10-Point Plan for Safer Regulation in the Aesthetic Sector (UK: JCCP, 2021). <https://www.jccp.org.uk/NewsEvent/jccp-10-point-plan-for-safer-regulationin-the-aesthetic-sector>
A History of Regulation
Regulation – it’s a big buzzword among aesthetic professionals working in the specialty. From untrained, non-medics conducting injectable procedures, to the use of unlicensed products, aesthetic practice can be a minefield or a ‘Wild West’ as tabloids have previously called it.1
At present, anyone in the UK, including lay people, can practise aesthetic medicine by enlisting onto a short training course. They can then begin injecting the next day. Currently, no medical qualifications are needed to administer treatments such as dermal fillers, threads and even botulinum toxin if the individual has a prescriber.2
As a result of a lack of regulation and training standards, complication rates have increased because many practitioners have limited knowledge of anatomy, danger zones, product placement and techniques, and are not equipped to manage a potential complication themselves.3 However, the aesthetics specialty has seen some developments in regulation over the last few years, namely, cosmetic injections becoming illegal to under-18s in 2021 and the proposed licensing scheme implemented in the Health and Care Act 2022.4,5
Development of regulation
It’s generally accepted that non-surgical aesthetic medicine as we know it was born with the introduction of dermal fillers and toxin in the 1980s.6,7 Many countries have since chosen to restrict the administration of such treatments to medical professionals; however, the UK has fallen behind.
Interestingly, regulation developments in the non-surgical aesthetic sector actually began with updates in the cosmetic surgery world. Within the Care Standards Act 2000, practitioners were required to either be on the specialist register or to have undertaken relevant specialist training if they were practising cosmetic surgery after April 1, 2002.8 Within the Act, it was stated that patients should be consulted pre-operatively by the consultant and given a cooling-off period of two weeks pre-surgery to allow them to make a considered decision before going ahead.8
The Health and Social Care Act 2008 further emphasised the importance of consent, aftercare, sanitation and training within the cosmetic surgery sector, which was adapted by non-surgical medical professionals in the aesthetics specialty. Within the Act, the Care Quality Commission (CQC), which was established in 2009, began to play an adequate role in regulating healthcare practitioners and clinics performing surgical and non-surgical medical treatments.9
The impact of PIP
The Poly Implant Prothèses (PIP) scandal in 2010 was the first example of regulation being implemented for the cosmetic industry. It was revealed that a French breast implant manufacturing company had been using cheap industrial silicone that was not authorised for human use, instead of medical silicone, for years. Around 300,000-400,000 women in 65 countries were given a health scare as surgeons noticed an increased rupture rate post-surgery. Fears were raised that they could cause breast cancer and even death.10 UK patients were affected by a lack of insurance for removal/replacement, a lack of qualified surgeons to provide further surgery and a lack of an implant registry to inform patients whether they had PIP implants.11
The Keogh review
Following this scandal, the UK Government instructed the Department of Health’s medical director Professor Sir Bruce Keogh to lead a national review on cosmetic medicine. The 67-page ‘Keogh report’ published in 2013 noted that ‘dermal fillers are a crisis waiting to happen’ and that ‘non-surgical interventions are almost entirely unregulated’.
The report had several recommendations, including that anyone performing any harmful non-surgical cosmetic procedures should be accountable to a professional register, as well as that all non-surgical procedures must be performed under the responsibility of a clinical professional who has gained the qualification to prescribe, administer and supervise procedures. Furthermore, establishing a registry for
breast implants and other devices and developing an advertising code of conduct were also recommended.12,13 As a result, breast implants were to be manufactured to a Medicines and Healthcare products Regulatory Agency (MHRA) standard and registered in order to be tracked if complications arose.14 The Advertising Standards Authority (ASA) published specific advertising guidance on the marketing of both surgical and non-surgical cosmetic interventions in 2013, later updated in 2016.15
Developments in training
Training and education are at the forefront of efforts to assist practitioners to safely perform treatments. In 2014, Health Education England (HEE) began to develop standards for treatments. The team, including Professor Sines, worked together for 18 months with stakeholder groups including all professional regulators, CQC, Department of Health, universities and beauty industry representatives. HEE identified that many treatments could be risk-assessed and did not require scrutiny (e.g. manicures). Instead, six modalities were recognised as needing increased training and education, including: hair restoration, injectable toxins, dermal fillers, chemical peels and skin rejuvenation treatments and lasers/light therapies. The procedures were put into a risk stratification based on the high risk posed to patient safety and the significant medical proficiency and knowledge required to deliver them, making them Level 7 treatments which required the oversight of a prescribing professional.16
In 2015, two reports were published by HEE on qualification requirements – Part one and Part two of ‘Qualification Requirements for Delivery of Cosmetic Procedures’.17,18 Commissioned by the Department of Health, the reports set out requirements, from Level 4 (foundation degree) to Level 7 (postgraduate level) for practitioners who perform treatments like chemical peels, laser hair removal and botulinum toxin injections to ensure that practitioners are appropriately trained in the use and application of any products they use.19 The report further suggested that only practitioners with a Level 7 qualification should perform injectable treatments.19
A Level 7 qualification was built on a voluntary basis by some training organisations to standardise education. This was a vital step in progressing training standards; however, some training providers have found loopholes and do not offer the highest standard of Level 7 education,
Professor David Sines, Andrew Rankin and Sharon Bennett provide an overview of the development of regulation in aesthetic medicine
Regulation in Scotland
Scotland has stricter regulation of healthcare professionals working within aesthetics than other nations within the UK. In 2016, legislation was introduced meaning that Scottish aesthetic clinics run by a doctor, dentist, nurse, midwife or dental technician had to register with Healthcare Improvement Scotland (HIS).23 Furthermore, last month, HIS announced non-prescribing practitioners can no longer perform filler injections without a prescriber on-site (read more on p.17).
which is problematic. As the qualification is voluntary, it has not been taken up by many people, highlighting that it may not have had a significant impact on regulation as many non-medics still perform cosmetic treatments.
The launch of voluntary registers
With no regulation, voluntary registers were set up aiming to showcase practitioners and clinics with high standards. Save Face and Treatments You Can Trust were two such registers that were established, before the JCCP was set up in 2016. The JCCP was given ownership of the HEE framework and aimed to develop this as the basis of its standards alongside its roles in campaigning for better regulation, public protection and guidance for the public.20 The organisation also implemented a voluntary practitioner register for professionals who met the HEE standards. All standards were developed by the Cosmetic Practice Standards Authority (CPSA) which comprised of associations such as the British Association of Dermatologists (BAD), the British Association of Aesthetic Plastic Surgeons (BAAPS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), with the JCCP Competency Framework being established in 2018.21 In 2019, the JCCP announced that, due to a lack of appropriate qualifications, only registered healthcare professionals can join their register if they are delivering injectable treatments.
Consultations in parliament
In 2021, the JCCP 10-Point Plan was released, highlighting education, training and licensing updates, aiming to create a safer environment for patients.22 During the same year, the Parliamentary group began to consult with the Government to prepare the Health and Care Act.5 The JCCP lobbied with the Government to see if they could include a potential licensing amendment within the Act. The licensing scheme could introduce consistent standards, which individuals carrying out cosmetic procedures will have to meet, as well as hygiene and safety standards for the premises.5 The amendment
gained support from both the House of Commons and Government.
Last year, the amendment was approved by Parliament, and it became a clause in the Health and Care Act, which was given Royal Assent and implemented in July 2022. The Secretary of State will consult on what procedures will be within the scope of the new licence and the education standards required. This consultation will begin in 2023, with the expected implementation of the new licensing scheme to be in full force at the end of 2024.5
The beauty industry
A big question surrounding the debate on regulation is why the Government has not enacted a law to prevent non-medics from performing aesthetic treatments. It is likely that with many people employed in the aesthetics specialty, whether they are medically trained or not, the Government might want to keep them in jobs, particularly in areas of economic depravity. The Government is unaware of the costs associated with shutting down these businesses, and they likely want to avoid any economic uncertainty in this financial climate. Furthermore, the Government may not be able to address the growing number of non-medics performing these treatments as there is often no hard evidence of malpractice. If a trauma or complication happens due to cosmetic treatment, it may not have its own coding – instead, it would be described as a potential ‘lesion’. Therefore, when audits occur, regulators are unable to track how many patients have come in for a potential complication caused by a cosmetic treatment, making it untraceable.
The future of regulation
It is difficult to know what the future of aesthetics will look like in terms of regulation. It has been slowly progressing, with many practitioners believing more development is needed. It is unlikely non-medical professionals will be prohibited from performing these treatments in the UK. However, a possible best-case scenario, as outlined in the licensing act, would be that
if non-medics are permitted to inject or perform procedures, these are happening under the direct supervision of a healthcare professional.
From a political perspective, the industry represents an important part of the economy, so the Government may be reluctant to restrict its expansion. To justify this, healthcare professionals would have to evidence the fact they are part of the low-risk group and that unregulated practitioners pose a higher risk. For those who wish to help drive the industry forward, practitioners should report any complications that occur as well as those presented to them by others (read about complication reporting on p.58). They should also join industry associations and campaign for regulation, whilst ensuring that they continue to implement best practice in their own clinics.
Professor David Sines was pro vice chancellor and executive dean and professor of community healthcare nursing at the Faculty of Society and Health at Buckinghamshire New University. He was chair of the HEE Stakeholder Engagement Committee that produced the HEE Education and Training Framework for Non-Surgical Cosmetic interventions in 2015 and was appointed as independent chair of the JCCP in 2016.
Andrew Rankin is an independent nurse prescriber and joint owner of Regenix Medical Aesthetic Clinic in Worcestershire. He is the chair of the JCCP Practitioner Register Committee and co-chair of its Clinical Advisory Group. He has various roles with MHRA and UKAS and as vice-chair at that time he represented the BACN at HEE where he was nominated lead in the development of those qualifications and of the nascent JCCP.
Qual: RGN, BA(hons), NIP
Sharon Bennett is chair of the 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.
Qual: RGN, NIP, PG Dip
Identifying Body Dysmorphic Disorder
The rise of social media, reality TV programmes and influencer culture has changed the way people across the world relate to and seek to perfect their physical appearance. With the constant pressure to always look your best comes the rise of body dysmorphic disorder (BDD), a mental health condition where a person consistently worries about perceived defects or flaws in their appearance.1
BDD is most prevalent in adolescents and teens, as shown in the NHS Mental Health in Young People survey, which found that in 2017, more than one in 20 (5.6%) 17- to 19-year-old girls in the UK experienced BDD.2 While BDD is not covered in the recent Mental Health of Children and Young People in England 2022 report, a rise in eating problems was seen in 17-to-19-year-olds from 44.6% in 2017 to 58.2% in 2021, which could indicate a possible rise in BDD as well.3 As more of these individuals become of an age to present at clinic for aesthetic procedures, this increase in young people’s vulnerability is something aesthetic practitioners must bear in mind.
Those who are struggling with BDD have a distorted view of how they look, which is often focused on one part of their body.4 Research suggests that one in 50 people in the UK (2% of the population) will struggle with BDD, but between 5% and 15% of patients who present for aesthetic procedures meet the diagnostic criteria for the condition, showing a higher proportion of your patients are likely to have BDD in comparison with the general population.5,6
Whilst the exact cause of BDD is unknown, it has previously been linked to genes, chemical changes in the brain and even traumatic past experiences.7 When a person has BDD, they often intensely focus on their appearance, repeatedly checking the mirror, grooming or seeking reassurance, sometimes for many hours each day.8,9 Their perceived flaws, and these repetitive
behaviours surrounding them, may cause them significant distress and impact their ability to function in daily life. Some people living with BDD commonly seek out aesthetic treatments and plastic surgery in the hope of improving their self-esteem, correcting a perceived physical defect, pleasing a partner or overcoming past emotional trauma, among other things.4 It is crucial that aesthetic practitioners are aware and mindful of this propensity for their patients to have BDD, as it is essential that they are treated responsibly or referred on to a qualified clinician to receive additional help for their condition.
The dangers of BDD in aesthetics
If BDD is left untreated or unaddressed, it can trigger severe impairment to overall quality of life, and may lead to serious consequences including suicidal ideation and attempts, increased anxiety, depression and eating disorders. A survey by the Body Dysmorphic Disorder Foundation found that about 0.3% of all people with BDD take their own life every year.10
While cases you see in clinic may not be this severe, many people going through cosmetic treatments have unrealistic expectations that they will come out on the other side feeling differently about themselves, as if one procedure will cure all their insecurities and even additional mental health problems. It is this excessive optimism going into the aesthetic clinic which can subsequently cause disappointment if perfection is not attained, sometimes leading to renewed anxiety and a resumed search for other ways to ‘fix’ their perceived flaw. This underlines the importance of a screening process prior to procedures so practitioners can avoid patients’ disappointment negatively impacting your clinic’s reputation. Thankfully, recognition of the prevalence and severity of BDD is growing. The Health and Social Care Committee’s recent Parliamentary report on the impact of body image on mental and physical health has a section emphasising the detrimental impact of BDD. It also contains recommendations for a governmental strategy that brings together the Department of Health and Social Care, the Department for Digital, Culture, Media and Sport and the Department for Education to tackle the growing problem of body dissatisfaction and its related health, educational and social consequences.11 Research from the BDD Foundation included in the report found that 85% of people with BDD do not receive an accurate diagnosis, due to stigma around the condition and a lack of knowledge among healthcare professionals.11 This is something the Committee, and I, want to see change.
Red flags to consider
Medical practitioners who offer cosmetic and aesthetic services often take satisfaction in knowing that they are helping patients address physical issues that might impede their body image. However, it is important that they possess adequate knowledge about BDD and are attuned to potential red flags for the disorder, as offering treatment to vulnerable patients should be avoided. The common symptoms of BDD include:1
Psychological therapist Jacqui Beasley provides an introduction to BDD, its prevalence in aesthetics and how practitioners can respond to mental health concerns
• Constantly checking one’s appearance in the mirror, or avoiding mirrors altogether
• Trying to hide body parts under a hat, scarf or makeup
• Obsessively comparing themselves with others (this may present as a patient requesting to receive treatments to look like a particular individual or celebrity)
• Always asking other people whether they look okay
• Believing that others notice their perceived flaw in a negative way
Some other less common signs may include:12
• Making multiple visits to medical practitioners, especially to dermatologists
• Compulsive skin picking in an attempt to remove unwanted hair or blemishes
• Changing clothes frequently and excessively
• Constantly exercising or grooming
• Keeping obsessions and compulsions secret in fear of social alienation
Vulnerable patients might present to clinic with one or more of these symptoms, or a variation of them, so practitioners should be aware of what to look out for. If aesthetic practitioners are in doubt about whether a prospective patient is vulnerable due to this condition, a BDD screening may be a good option if conducted by those who are competent, trained and insured to deliver such a service. This often takes the form of a series of questions posed to the patient to help determine whether they need psychological treatment before aesthetic procedures should be offered, or indeed whether they should be carried out at all. Some practitioners may formulate these questions based on their insights or experience with their patients, or collaborate with external psychological expertise on this. Alternatively, questions such as these are generally accepted as best practice for screening prospective patients:13
1. Do you worry a lot about your appearance and wish you dwelled on it less?
2. What are your specific concerns regarding your appearance?
3. On a typical day, how many hours do you spend thinking about your appearance? (More than one hour is considered excessive)
4. What effect does this have on your life?
5. Does this make it hard to work or socialise?
Practitioners should refer a patient to a mental health expert when they are contemplating whether the psychological status of the patient may affect their satisfaction with the outcome of treatment. This could be because the expectations of the procedure’s outcomes are unrealistic cosmetic procedures, or their mental health history reveals co-existing psychological disturbances.
If practitioners are concerned about an individual’s mental health following their consultation or a BDD questionnaire, they should not continue with treatment. Instead, patients can be directed to complete a self-referral to an NHS or private GP who can assist them with accessing the relevant talking therapy to help them through their difficulties.14 The BDD Foundation is also a great avenue, which can provide further help and support.15 Alternatively, practitioners may choose to refer directly to a specialist therapist or
clinic, or a psychological provider such as Onebright.16 The benefit of this is that once the patient is referred, they will go through a psychological assessment process and the specialist can provide insights which can help practitioners in further understanding patients’ wellbeing and suitability for aesthetic treatment. Referrals for further psychological will imply that commencement of treatment should be paused, deferred or refused altogether dependent on the individual’s circumstance.
Industry best practice
Referring suspected BDD sufferers to a mental health professional before offering treatment should be best practice across the industry in order to ensure vulnerable patients are looked after. Healthcare professionals can do this through setting up a screening/ questionnaire process for patients and having networks in place through which to seek external support. It is important for healthcare professionals to realise that it is not their responsibility to diagnose patients, but they must accept the cruciality of their observations during consultations in the process of getting patients the help they need. As well as potentially placing mentally unwell patients at risk by providing them with care or advice without adequate training, trying to help vulnerable patients yourself can lead to significant stress for you which is not conducive to best practice. It is of vital importance that aesthetic practitioners raise awareness of BDD by sharing scientific literature on the topic with both their clinic teams and patients, and signposting patients to specialist psychological providers who are trained to both screen and provide full psychological assessments and treatment if needed to ensure patient safety before any treatment is offered or performed.
Jacqui Beasley is a psychological therapist and head of partnerships at Onebright, which delivers mental healthcare to employees and their dependents. Since 2020, Beasley has been working alongside plastic, reconstructive and aesthetic surgeons to assess patients for BDD pre-treatment, and is an advocate for introducing these steps as industry best practice. VIEW THE REFERENCES ONLINE! AESTHETICSJOURNAL.COM
If BDD is left untreated or unaddressed, it can trigger severe impairment to overall quality of life
In The Life Of
Independent nurse prescriber Linda Mather details her typical working day and how she manages industry complications
A typical working day…
I usually wake up at 5:30am and check emails, banking or outstanding bits that urgently need my attention. At 6:15am, I go for a walk to the top of the hill near my house and give thanks for everything that is amazing in my life. This sets the tone for my day as it puts my mind in a good place. It’s a beautiful time of the day as the moon is usually still out! I arrive back home at 7am, have a shower, get ready and drink a cup of tea before loading the car and leaving at 7:30am.
Between 8-8.15am, I get to my clinic Chamonix Clinic in Gateshead. My staff and I set up the clinic rooms, do a stock take, sort orders for the next day, get my patient list ready and look at what staff we have in.
At 8.30am, my assistant Jess arrives, we have a cup of decaf coffee and conduct the ‘Head, Heart and Hands’ exercise. You have to say what’s in your HEAD – I can become overwhelmed so I can off load some things onto Jess, she can then make lists and we can see what we need to do that day. Next, your HEART is anything that is troubling or upsetting you – we can then get this out in the open. Finally, your HANDS are what tools you have at your disposal and what you need to complete each task. We try and be rigid with this as it sets the tone for everybody.
At 9am, the first patient will be in, and the day starts to become frantic and busy! I tend to see around 20-30 patients a day who are mainly seeking injectable treatments. Usually, around 10:30am I’ll try and run downstairs and have a vegan breakfast. Today, it’s oats with grated carrot and cinnamon. I continue seeing patients and performing treatments until 1pm when we stop for lunch. I will have a vegan lunch such as a Thai red curry with vegetables and rice. If there’s anything urgent that needs dealing with, I will do this in my lunch break. At 1:30pm, I will begin injecting again and it’s usually in the afternoon when the Aesthetics Complications Expert (ACE) Group World phone rings and the complications start.
Sometimes, I might have to go onto FaceTime to assist another practitioner. This needs to be logged and written up, so Jess usually inputs the data from the call, and we monitor both the patient and practitioner for the rest of the day. I finish my day at 6:30-7pm. We clean the clinic, update the stock and cash up. I drive home and arrive at 8pm, put another vegan meal in the microwave, do some housework and then by 9pm, I treat myself to one hour of Netflix before bed.
Other work commitments…
I’m a nursing director for the ACE Group World, which takes up a lot of my time. Myself, Dr Martyn King and Sharon King handle the majority of the complication calls. We also have a faculty and call handlers for when the phone rings, so one of us will answer and guide practitioners with any concerns or cases that have arisen. We tend to get around one call a day, but sometimes this can rise to three or four. I have noticed that there are periods of time when we receive more calls, such as Friday-Sunday and during December. I need to analyse the data as to why this might be happening, but it could be due to the busiest times of the week or year, so practitioners may be more rushed or stressed.
I also write some of the ACE Group World’s guidelines. I have recently finished one on blindness based on the latest research as this was out of date. These are reviewed
and updated accordingly. I also write lessons to upload onto the ACE website, covering topics such as anaphylaxis, to help educate practitioners on any complications and how to deal with these should they arise.
As well as the ACE Group, I’m a board member for the British Association of Cosmetic Nurses. We have a WhatsApp group where members can discuss any issues they may be facing. If any complication questions arise, I usually give advice on this. Once a year, I write an editorial piece for industry publications. I’ve published articles on work development and nurse prescribing previously. I also attend conferences, regional meetings and symposiums to increase my education and raise awareness on complications.
Most memorable day…
This is really hard as I’ve had so many memorable days throughout my career. I would have to say when I got asked to help design the Master’s level aesthetics programme for Northumbria University. Afterwards, I got asked to sit on the validation panel which was phenomenal. Although the programme isn’t running anymore, I feel being part of this reflected my whole aesthetic journey. I’m so proud to have been a part of this!
Walking and hiking. It’s great exercise, makes you feel good and you get to see beautiful scenery on your own two legs.
Cake and chocolate, which isn’t very healthy! My absolute favourite is Vietnamese pho – I could live on that every day.
Couldn’t live without…
My partner Kevin! He does so much to help me run everything that I do. He is the lynch pin to my current existence.
The Last Word
“The process takes much longer”
This may be true, however, taking the time to educate and justify your treatment plan will create trust, and patients will understand what is causing their original concern.
When conducting a consultation, do you usually get your patient to look in a mirror while discussing your assessment? If so, do they see exactly what you see? I’ve found that the answer to this is usually a resounding ‘no’. With this in mind, have you considered taking photos of your patient and assessing them together in your consultation? This could be used to educate your patients, as well as discuss treatments and their justification. Since implementing the use of images in March last year, I have lost count of how many times patients have looked at a picture I have taken and say they had never noticed an area I had pointed out – even though they didn’t when they looked at themselves in the mirror earlier during the same consultation.
I believe that using patients’ photos can be a very powerful way of holistically examining your patients and showing them all the areas you could help with.
The benefits of using mirrors
Asking patients to use a mirror during a consultation is of great value, as it is a quick and easy way for patients to express what areas they are concerned with. They will usually be familiar with the process of examining themselves in a mirror at home, with patients commonly saying they ‘pull back’ their cheeks at home to obtain a lift, as an example.1 This is a great way to start to work out what your patients’ concerns are, and what they would like to achieve.
Improving patient insight
However, it has been identified that patients’ self-perception can be different when looking in a mirror compared to a photograph.1 Rather, when being shown a mirror image, people see what they want to see. This can be positive or negative, however, it definitely means that it is a more subjective process.2 Alternatively, when we look at a picture, we tend to see things in a much more objective way. One of the reasons is that our faces are asymmetrical, and a photograph shows this differently when compared to looking into a mirror.2 A good example of this is a patient seeing nasolabial lines in the mirror, when in a photo of themselves, they can easily see the hollowing of the medial cheek, especially from different angles. This is one reason why it can be beneficial to use imagery as it could be easier to demonstrate to patients what is really causing the concerns they have.
Therefore, while the use of a mirror can be a good starting point for the patient to communicate concerns, in my view, photographic imagery is important when getting practitioner perspective across.
Personally, I have found that one powerful technique is to draw on and annotate your patient’s image, which I do using patient management system Pabau on my iPad. Drawing where there are treatable areas, volume loss, pigmented areas, for example, can bring attention to that indication. Therefore, I find that it helps to educate the patient on the reasons why treating this area could create an optimised result, getting them to understand your treatment plan in more depth. You could also consider listing the treatments on the image as well as the products used. Once the image is saved in the patient’s records, it can help to plan once the patient has left the consultation. This is extremely helpful in a very busy clinic, or where a practitioner writes their notes at the end of the day.
While taking photographs, you should ensure you take images from all angles and several expressions to show dynamic movements that could be potentially treated. It is important to try to help our patients see themselves in a three-dimensional way, as this is how we see each other, and using photographs can certainly help to achieve this.3
Arguments against imagery
Of course, there are many reasons why practitioners currently may not use images. Throughout my time using this technique, I have heard the following arguments.
“Patients don’t like seeing themselves in photos”
You should always ask permission to take and use photos, along with an explanation as to why this would be helpful. If patients strongly refuse, there could be an element of body dysmorphic disorder (BDD). If this is suspected, the practitioner should explore it further. Tips for dealing with suspected BDD can be found on p.62
“My consultation is already comprehensive”
As professionals, we continue to evolve, and perhaps this could provide a small positive improvement in your patient journey. Try it and see if it helps – if it doesn’t, nothing is lost. If it does, it could help create much larger treatment plans, and therefore more transformative results.
The patient journey is something we continually strive to enhance, and is one of the things that makes us different from our competitors. Using photos of your patient in their consultation to educate is an important part of their journey, as it will help them to understand their own ageing process better, as well as understand why you recommend a specific treatment plan for them.
Dr Manav Bawa is a multi-award-winning aesthetic and medical director of Time Clinic in Essex. He is a member of the Allergan Medical Faculty and is currently on Dr Mauricio De Maio’s Global Mentee Program. He also works at PHI Clinic on Harley Street and has been an injectables trainer for five years. He completed a PGDip in Medical Aesthetics and is on the board of BCAM and SaveFace.
Qual: MD, PGDip(ESSQ), MRCS(Eng), M Ed SE & DIC, MRCGP, PGDip(CAIT), MBCAM.
Bawa debates the use of photos over mirrors when assessing patients
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