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VOLUME 8/ISSUE 8 - JULY 2021

NEW

NO FILTER. JUST YOU. M-BEL-UKI-1181 Date of Preparation June 2021

BELOTERO® Revive is the newest product in the BELOTERO® portfolio of fillers indicated to revitalise the signs of early onset

• Improves skin hydration1

photodamaged facial skin.

• Increases skin elasticity and firmness1 • Smooths skin texture1 • Reduces pigmentation2

merz-aesthetics.co.uk

@merzaesthetics.uki

Merz Aesthetics UK & Ireland

1. Belotero Revive IFU 2. BELOVE 2019 Facial skin revitalization with CPM-HA20G an effective and safe early intervention

Filler-related Vision Loss CPD An update to the emergency management of filler-induced vision loss

Non-Surgical Rhinoplasty

Practitioners outline how to prevent dermal filler complications to the nose

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

Dealing with an Occlusion Dr Sharan Uppal explores how to stay calm during complications

Starting Out in Aesthetics

Dr Joanna Hackney shares her guide to starting a career in aesthetics


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

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

Produced and Funded by Juvéderm®. UK-JUV-2150067 March 2021 ©2021 Allergan. All rights reserved. Model treated with Juvéderm®. Individual patient results may vary. Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/ Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.


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Contents • July 2021 08 News The latest product and industry news 18 Highlights of the Aesthetics Awards Announcing the Aesthetics Awards 2021 best dressed 20 News Special: Educating ED on Aesthetic Complications Aesthetics explores increasing awareness about aesthetic complications 22 CCR to Raise Industry Standards What to expect at CCR in October 2021

CLINICAL PRACTICE

News Special: Educating ED on Aesthetic Complications Page 20

23 Special Feature: Preventing NSR Complications Three practitioners share how to safely administer dermal filler to the nose 29 CPD: Retrobulbar Injections in Filler-related Vision Loss Miss Rachna Murthy and Professor Jonathan Roos explore the

management of filler-induced vision loss

33 Restylane Dermal Fillers Know our NASHAs from our OBTs to create a signature look with Restylane 34 Bruising vs Vascular Occlusion Dr Martyn King provides the difference between bruising and a VO 36 Addressing Photodamage Dr Kim Booysen details using BELOTERO Revive for photodamage 38 Understanding Ptosis Dr Aileen McPhillips introduces ptosis following toxin treatment 40 Advancing Your Non-surgical Rhinoplasty Results Dr Amrit Thiara shares his approach for treating the nose 41 Understanding Needle-free Pens Dr Ashwin Soni explores the trend of needle-free injector pens 45 Emotionally Dealing with a VO Dr Sharan Uppal advises on staying calm after causing a VO 48 Case Study: Correcting Facial Asymmetry Mrs Sabrina Shah-Desai uses filler to treat facial asymmetry 51 The Rebirth of CO2 How CO2 lasers can help combat signs of ageing 52 Exploring Mental Health and Aesthetics Claire Newman discusses non-surgical procedures and mental health 54 Introducing EMSCULPT NEO The revolutionary 2-in-1 HIFEM + RF combination 55 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 57 Starting Out in Aesthetics Dr Joanna Hackney shares her guide to starting a career in aesthetics 61 Getting Into Public Speaking Julia Kendrick outlines techniques to get your audience paying attention 65 Converting Social Media Followers Marketeer Emily Ruse explains how to turn followers into patients 69 In The Life Of: Dr Sophie Shotter The clinic owner and complications advisor gives us an insight into her life 71 The Last Word Dr Steven Land argues why complication management resides with the

treating practitioner

NEXT MONTH IN FOCUS: Devices • Acne Scarring and Lasers • Thinning Temples in Women

Special Feature: Preventing NSR Complications Page 23

Clinical Contributors Miss Rachna Murthy is a Cambridge and Londonbased consultant oculoplastic and aesthetic surgeon and co-owns FaceRestoration. Miss Murthy trained in Melbourne, Chelsea and Moorfields, and sits on the RSM Eye Council and IMCAS Alert Board. Professor Jonathan C P Roos is a Harvard, Cambridge and Moorfields-trained consultant oculoplastic surgeon and academic based in London at FaceRestoration. He lectures internationally on aesthetics. Dr Martyn King is the director of Cosmedic Skin Clinic, chairperson of the Aesthetic Complications Expert Group World, vice chair of the Joint Council for Cosmetic Practitioners and brand ambassador and KOL for several leading aesthetic companies. Dr Aileen McPhillips is a medical graduate of Queen’s University, Belfast, and currently works as a GP and aesthetic practitioner, running her own clinic ‘Aesthetics by Dr Aileen – The Skin Health Clinic’ based in Aughnacloy, Co. Tyrone. Dr Ashwin Soni is a US-trained plastic surgeon and the owner of The Soni Clinic. After attending Imperial College London, he relocated to the US completing his plastic surgery training at Cornell, Johns Hopkins, and the University of Washington. Dr Sharan Uppal entered the field of facial aesthetics in 2014. She runs her own aesthetic clinic in Huddersfield, Pegi Day Aesthetics, and is also the Clinical Lead at SkinViva Academy and Clinic. Mrs Sabrina Shah-Desai is an aesthetic oculoplastic surgeon with more than two decades of experience in micro-precision eye surgery. Previously based at Moorfields Eye Hospital, she now practises in Harley Street and North London. Claire Newman is a mental health nurse prescriber and the director of Soft Touches Aesthetics in Hertfordshire. She is a Level 7 assessor for Derma Medical and a brand ambassador for Intraline.


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

CERTIFIED LIGHT THERAPY TRAINING BY WYNYARD AESTHETICS ACADEMY Classes: 26 July 2021; 16 August 2021; 20 September 2021 Contact: helen@WynyardAesthicsAcademy.com www.international.celluma.com

+44 (0) 7767 367 070 MOBILE +44 (0) 203 981 3993 OFFICE

infoUK@biophotas.com


Editor’s letter Aesthetic complications. It wasn’t too long ago that they were completely unspoken about. However, with rising reports of cosmetic treatments gone wrong, it’s become hugely important that practitioners share experiences, update their knowledge and Shannon Kilgariff explore the latest evidence, which is why Acting Editor & we have dedicated this month’s journal to Content Manager aesthetic complications! @shannonkilgariff In this issue you will read about the importance of complication management, and why you shouldn’t rely on emergency departments for situations such as vascular occlusions (p.20). You will also learn tips for complication prevention from three expert trainers when treating the nose (p.23) and the latest guidelines for the emergency management of filler-induced vision loss (p.29) – plus much more. We were delighted to work with two different UK complication associations for this issue – the ACE Group World and the CMAC, both of which have collaborated with us to provide you

with some great insights. If you’re wanting to further enhance your complication knowledge, you should look to attend the International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) on September 3 (more info on p.8). Another must-attend event is the ACE Group World conference being held at CCR on October 14 – learn more on p.22 and for more info visit via ccrlondon.com! Finally, we are excited to release our summer issue of Beyond Beauty magazine! If you’re listed as a Full Member or medical professional subscriber within our database, you will have received a free copy with your journal. Sticking with the complications theme, we are delighted to feature an article explaining vascular occlusions, so the public can start to understand the importance of seeking a medically trained and experienced practitioner. We have other great content to enhance education, build trust and promote positivity around the world of aesthetic medicine, so we hope your patients love it! Get in touch with us if you would like to order more copies that you can retail from your clinic.

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

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

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

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

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

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

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

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

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

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

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

ARTICLE PDFs AND REPRO

PUBLISHED BY PORTFOLIO MANAGEMENT Alison Willis Director T: 07747 761198 | alison.willis@easyfairs.com EDITORIAL Shannon Kilgariff Acting Editor & Content Manager T: 0203 196 4351 | M: 07557 359 257 shannon@aestheticsjournal.com Holly Carver Journalist | T: 0203 196 4427 holly.carver@easyfairs.com Ellie Holden Content Writer | T: 0203 196 4427 ellie.holden@easyfairs.com DESIGN Peter Johnson • Senior Designer T: 0203 196 4359 | peter@aestheticsjournal.com

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ADVERTISING & SPONSORSHIP Courtney Baldwin • Event Manager T: 0203 196 4300 | M: 07818 118 741 courtney.baldwin@easyfairs.com Judith Nowell • Business Development Manager T: 0203 196 4352 | M: 07494 179535 judith@aestheticsjournal.com Chloe Carville • Sales Executive T: 0203 196 4367 | chloe.carville@aestheticsjournal.com Emma Coyne • Sales Executive T: 020 3196 4300 | emma.coyne@easyfairs.com MARKETING Aleiya Lonsdale Head of Marketing T: 0203 196 4375 | aleiya.lonsdale@easyfairs.com

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

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

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


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Virtual

Talk #Aesthetics

Lynton to present CoolPeel technology webinar

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Aesthetics will exclusively host a webinar on July 22 with laser and IPL manufacturer Lynton. Plastic surgeon Mr Ali Ghanem will be discussing the rebirth of CO2 lasers, how CO2 technology can help your practice to grow, its renewed power in the industry, and introduce the CoolPeel technology, which can only be performed by a DEKA SmartXide CO2 laser. Dr Samantha Hills, clinical director at Lynton, stated, “With the demand for skin resurfacing treatments on the rise, practitioners can enhance their business offering by integrating gold standard CO2 technology into their practice. Join this webinar to find out how, with the SmartXide laser, practitioners can profit from all the benefits of CO2 whilst also utilising CoolPeel technology to perform treatments.” The webinar will take place at 12pm GMT. Free registration for the webinar will open soon.

#AestheticsAwards Dr Dev Patel @drdevpatel1 Won Best Clinic South England in the #aestheticsawards2021. Proud of my team and we missed those who could not be with us on Friday evening! #Training Miss Elizabeth Hawkes @dr_elizabethhawkes Always learning! Such a great day learning new skills and meeting great colleagues @teoxane_uk

Complications

#Qualification Professor Firas Al-Niaimi @drfirasalniaimi_ I MADE IT! Becoming a professor was my goal and I will honour such a title and strive to academic excellence in my field #dermatology

#Education Avantage Aesthetics @avantageaesthetics What a fantastic two-day course! Two-day inject and dissert cadaver course with @leewalker_academy #anatomy

#Masterclass Dr Ash Labib @ashlabib Training again today in sunny Newcastle! Thanks @doctor_land for hosting the non-surgical rhinoplasty masterclass at your #novellusaesthetics clinic

IAPCAM announces live event The International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) conference will take place on September 3 at the Church House in London. Speakers will present live on key topics about the management and avoidance of classic and current complications. Practitioners can attend the event in person (in line with Government guidelines) or virtually using the new virtual conference platform. The programme includes experts from around the world presenting on the latest advances in complication management in aesthetic medicine, answering all questions directly through the live online chat, and discussing the key controversial issues of 2021. There are two attendance packages for delegates to choose from. The Hybrid pass holders will attend the conference live or virtually and have access to the sessions on-demand for an additional 30 days after the congress, whilst the Virtual pass holders will have access to all IAPCAM sessions and workshops virtually, as well as access to on-demand sessions for an additional 15 days after the conference.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Botulinum toxin

First ready-to-use toxin to launch Pharmaceutical company Galderma has confirmed the first ready-to-use liquid neuromodulator has completed its European decentralised trial. Unlike other botulinum toxins on the market, Alluzience does not require reconstitution before its use. The company claims that this will enable healthcare professionals to avoid complex calculations, allowing for more precision, optimised results and higher patient satisfaction. According to Galderma, Alluzience is intended for use in adult patients to temporarily improve the appearance of moderate to severe glabellar lines. The European Marketing Authorization Application of Alluzience supplied data from two trials of 372 patients with moderate to severe glabellar lines who were treated with either Alluzience or placebo. The data showed that more than 50% of patients reported an effect within two to three days, including 23% of patients within one day. An effect was demonstrated for up to six months after injection with Alluzience. The responder rate at day 29 was higher for patients treated with Alluzience compared to the placebo. Alexandre Brennan, head of the global business unit at Galderma, stated, “At Galderma we pride ourselves on developing innovative products that meet today’s needs. We know how advantageous it is for practitioners to have access to a ready-to-use liquid formulation in Alluzience. It’s for this reason that this news is an important milestone for both patients and healthcare professionals.” National approvals will now take place across Europe in-line with local processes in each country. Galderma confirms that it will likely be available in the UK by 2022 but is subject to change depending on the UK regulatory approval processes. Regulation

Speciality responds to JCCP 10-point plan Practitioners from across the field of aesthetic medicine have submitted a combined response to the Joint Council for Cosmetic Practitioners’ (JCCP) 10-point plan, released in March. The 10-point plan was designed to create a more regulated, monitored, and safer environment of practise for non-surgical aesthetics. Aesthetic practitioners Dr Steven Land and Dr Tapan Patel with aesthetic nurse practitioner Ness Griffiths, submitted the response on behalf of more than 100 fellow nurses, surgeons, doctors, and dentists. The group agreed with many of the JCCP’s points which included the need for more regulated advertising, safe and ethical prescribing, raising customer awareness and for transparent information to be supplied to patients. Despite this, the group outlined their differing opinions on point one regarding statutory regulation. The practitioners stated that doctors, dentists, and nurses are mandated to be on their statutory registers. However, the group believe that lobbying and political influence would be more useful than attempting to set up another compulsory register, which they believe is not needed. Instead, the practitioners believe working with regulatory bodies and developing their guidelines and policies would be more welcomed. The group also expressed their opinions on point four, which outlined the definition of medical and cosmetic treatments, contesting that any procedure using a prescription-only medicine or class III implantable medical device is medical. They argued that it may also be cosmetic, as the two are not mutually exclusive and to try and set a distinction would be unfair. The JCCP 10-point plan is available to read via the Aesthetics journal website.

Vital Statistics 41,000 botulinum toxin procedures are estimated to have been carried out on under-18s in 2020 (Department for Health, 2021)

In a survey of 1,000 women, 35% who previously had at least one cosmetic surgical procedure plan to spend more on treatments in 2021 (American Society of Plastic Surgeons, 2021)

32% of 2,000 Americans find acne scars to be their top insecurity (Mederma, 2021)

In a survey of 1,000 US consumers, 78% are more willing to buy from a brand over their competitor after a positive experience on social media (The Harris Poll, 2021)

In a nationwide survey, 44% of 600,000 respondents have reported feeling unwell from work-related stress during 2020 (NHS Staff Survey, 2021)

In a survey of 2,000 16-40-year-old men, 48% struggled with their mental wellbeing because of how their body looks (CALM, 2021)

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Events Diary 3rd September 2021 International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) symposium iapcam.co.uk

4 -5 September 2021 th

th

13th 5CC Virtual World Congress www.5-cc.com/en/2021/home/

10th-11th September 2021 British College of Aesthetic Medicine (BCAM) second virtual conference bcamconference.co.uk/

14 & 15 October, ExCeL www.ccrlondon.com Skin

Medik8 adds exfoliator to its Platinum Facial Skincare company Medik8 has introduced a new addition to its Platinum Facial. The new Scientific Mushroom Thermal Exfoliator works with the Platinum Mask to visibly lift, rejuvenate, and firm the skin for a more youthful appearance, explains Medik8. The company states that the exfoliator uses mushroom enzymes to work with the skin’s natural pH to help retrain the skin’s cell regeneration cycle, allowing it to function as it would at a younger age. Laura Ford, senior education manager at Medik8, commented, “The addition of the Scientific Mushroom Thermal Exfoliator to the Platinum Facial really elevates this as our signature facial and delivers incredible results with a sensorial experience to deliver beautiful skin for life. This exfoliator is extraspecial; it combines scientific mushroom enzymes with real heat to give the client an extra-memorable experience in clinic.” The new exfoliator launches globally on July 7.

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Devices

Cutera to hold radiofrequency microneedling workshop Aesthetic technology manufacturer Cutera will present a live workshop on its Secret RF radiofrequency microneedling device in July. The event will be open to all aesthetic professionals and will include a range of talks and live demonstrations from a panel of users, including aesthetic practitioners Dr Tapan Patel, Dr David Eccleston and Dr Sabika Karim. Country manager at Cutera UK, Tim Taylor, commented, “I am delighted to announce that we are back with live training events and will kick things off with a dedicated Secret RF workshop. Everyone is welcome as this is the perfect opportunity for any aesthetic professional introducing radiofrequency microneedling technology into their business, providing delegates with unrivalled knowledge and expertise with the opportunity to see our Secret RF in action and network with fellow practitioners.” The event will take place on July 19 at Church House Assembly Hall, Westminster. Charity

Alumier Foundation contributes to education The Alumier Foundation by skincare brand AlumierMD has donated $70,000 USD to the Nhlengelo Primary School in South Africa. For every sale of AlumierMD’s limited-edition summer kits, which launched eight months ago, the company contributed £5 towards the foundation. The Alumier Foundation is AlumierMD’s primary global philanthropic project. Its initiatives have enabled hundreds of students in South Africa to further their education. To date, the foundation has built eight classrooms, washroom facilities, and further infrastructure to support the education in this community. Dr Corey Hartman, director of the Alumier Foundation, commented, “I am thrilled with what we have achieved with our fundraising efforts. We have an obligation and opportunity to give back. We have much more to accomplish at the school, including building additional bathrooms, classrooms and common areas to reduce overcrowding.” Education

Acquisition Aesthetics improves new learning system Aesthetic training provider Acquisition Aesthetics has enhanced its Level 7 Learning Management System (LMS). According to the company, the programme promises to further support all delegates undertaking or considering the Level 7 Diploma. The system allows for flexible learning, personalised 1:1 advice and support, CPD points as well as no final formal examination. The LMS has been designed with guidance from Health Education England and the specification outlined by awarding organisation OTHM qualifications, regulated by OFQUAL (Office of the Qualifications and Examinations Regulation). Miss Lara Watson, director of Acquisition Aesthetics, winner of the CCR Award for Independent Training Provider of the Year at the recent Aesthetics Awards, commented, “We have always been proud of our offering to delegates, and the comprehensive programme of study they are provided with. We have a 100% candidate certification rate, and our academy recognises that continual, diligent evaluation and improvement is a contributor to success.”

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Conference

CCR announces Galderma as headline sponsor Pharmaceutical company Galderma will be the headline sponsor at CCR in October. Joanna Neal, brand manager at Galderma, commented, “We are thrilled to be headlining at CCR 2021. For us, this year’s CCR is a must-attend event, and we always look forward to hearing about the latest developments within the industry. Our brand is ever-evolving, and we are so excited to be sharing our news to all of the CCR attendees – we’ve missed attending events such as these and can’t wait to be face-to-face with old friends and colleagues once again!” Aesthetics and CCR event manager Courtney Baldwin stated, “We are thrilled to welcome Galderma to their first CCR as our headline sponsor. Galderma will be celebrating 25 years of Restylane as well as introducing Sculptra, so it’s a perfect opportunity for them to exhibit at CCR this year to educate and celebrate at the first in-person event. The world-class Galderma symposiums will be free of charge to all healthcare professionals but will work on a first-come, first-served basis, so register your interest now to avoid missing out!” CCR will be taking place in-line with Government guidance on October 14 and 15 at ExCeL London and you can register your interest by visiting the website.

Increasing

Your Clinic’s Brand Recognition Photographer Hannah McClune’s monthly tips on how to strengthen your business through branding Do you ever recognise who posted a faceless image before seeing their name? When we are scrolling through Instagram we often consciously, or unconsciously see a post that we recognise before our eyes travel down to notice the name of the account.

Eye care

Revision Skincare unveils new eye cream Skincare brand Revision Skincare has launched the D.E.J (DermalEpidermal Junction) eye cream. According to AestheticSource, UK distributor of Revision Skincare, the eye treatment is formulated to address the upper eyelid and create the appearance of a more lifted, firmer, and smoother skin around the eyes. The product aims to visibly reduce the appearance of wrinkles, redness and hooding around the eye area, provide hydration to help the skin’s ability to attract and retain moisture whilst shielding the skin against free radicals that cause premature ageing, explains AestheticSource. Vikki Baker, marketing manager at AestheticSource, said, “We are delighted to introduce the latest addition to the Revision Skincare range. The D.E.J eye cream is a one-of-akind, dermal renewing total eye treatment. The unique formulation contains alphaglucan oligosaccharide, a prebiotic that supports the growth of healthy organisms on the skin’s microbiome to promote skin health.” Filler

KYSENSE subscription launches Aesthetic distributor Circa Skin Ltd has introduced a subscription-based business model for its hyaluronic acid filler KYSENSE. The company explains that through the new subscription practitioners can register their professional details and select their monthly KYSENSE delivery amount. Practitioners can request filler on a weekly, fortnightly or monthly basis whilst changing the product lines and quantities they require, explains KYSENSE. Claire Williams, CEO of Circa Skin said, “Subscription ordering allows Circa Skin to keep a hold of our KYSENSE supply ensuring that the product is used by only trained medical professionals. Practitioners can be assured they are getting a quality product that they should never have to compete with on price.”

Consistency is key!

If you have had a web designer or brand expert spend time working with you on your branding, they will tell you it is important to ensure consistency comes across in everything your patients see. Your photos are a key way to achieve this, from the type of photo you share, the way it is lit and styled, how it is edited, the colours and tones… all these elements combine to make the imagery you share consistent.

Be recognisable

If your photos are similar in style and are high quality, you’re helping your customers or patients recognise you. This cognitive process can begin to happen before they even spot your face, your logo or your clinic’s front door in a photo. This is relevant over all your platforms. This includes your website, your social media, if you include a footer image on your email and any marketing collateral you may print. Please do get in touch if you’d like some free tips on how you can achieve this too. This column is written and supported by Hannah McClune, owner of brand photography company Visible by Hannah www.visiblebyhannah.com

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Training

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

JUNE ROUND-UP In June, the BACN worked with Merz Aesthetics UK, looking at early signs of photodamage and how BELOTERO® Revive can help your patients. Emma Chan, regional leader for the north west, spoke to Julie Redmond detailing the considerations when treating early onset photodamage. It was fantastic to see so many members engage with the event. The full conversation can be found on the IGTV section of the BACN Instagram page. Julie and Aine Larkin also featured in June’s InFocus Live webinar, which had interactive elements and was well attended! Access to the recording, along with all webinars are available in the resources section of the BACN website.

JULY EVENTS July will be a bumper month – focusing on ‘Upskilling’. • In Conversation with Alice Hart-Davis – 20 July – the BACN chair Sharon Bennett will be speaking with Alice Hart-Davis from the Tweakments Guide and evaluating opportunities to improve online presence, brand and business • InFocus Live Webinar: Upskill to Succeed – 27th July – a 360 approach to enhance your aesthetic brand th

Management committee member Jenny Pabila will be discussing the importance of establishing your business as a brand and how to enhance your clinic with smart marketing. Aesthetics journal acting editor Shannon Kilgariff will be speaking to members about writing for trade publications. Shannon will be explaining where to begin, the editorial process, and how writing can enhance your progression within the field. The BACN vice chair Sharon King will be speaking about her experience becoming the first Advanced Level nurse practitioner to complete the credentialing process with the Royal College of Nursing within Aesthetic Nursing. • Peer Review – 29th July – this national peer review will be led by Rachel Nicholson, the BACN regional leader for the central region of England. Full agendas and details on how to book can be found on the events page of the BACN website. This column is written and supported by the BACN

Cadaver course dates released Training provider Anatomy and Aesthetics has introduced a two-day cadaver anatomy course at the Royal College of Surgeons in Edinburgh. The course will be run by consultant oral and maxillofacial surgeons Mr Jeff Downie and Mr Mark Devlin, and aesthetic nurse prescriber Jackie Partridge. The course involves a range of educational techniques including short lectures, small group discussions, practical exercises, and live dissecting on cadaveric heads. During the course, the team will demonstrate the common treatment areas for the head and neck using techniques to manage all aspects of facial aesthetics along with relevant products. The course will take place on September 17 and 18. Skincare

Croma-Pharma introduces Croma farewell Aesthetics manufacturer Croma-Pharma has launched a new skincare range called Croma farewell. According to the company, there will initially be facial serums for five specific skin types in the range. The serums will contain both high and low molecular weight hyaluronic acid, which aims to moisturise and hydrate the skin, improve elasticity, and plump the skin to reduce the appearance of fine lines and wrinkles. The products include farewell irritated skin, for those with sensitivities; farewell puffy eyes, to contour the periorbital area and reduce puffiness and dark circles; farewell dry skin, which aims to nourish the skin and strengthen the skin’s barrier; farewell ageing skin, formulated to hydrate and improve suppleness and firmness on the skin; and farewell oily skin to help oily and acne prone skin types, aiming to reduce facial sebum production. Managing director of Croma-Pharma Andreas Prinz said, “With the launch of Croma farewell, we are strengthening our focus on personalised skincare innovation. Croma farewell meets the high standard of our medical products and perfectly complements our existing portfolio.” Competition

iS Clinical contest opens Cosmeceutical distributor Harpar Grace has launched the iS Clinical World Star Contest 2021 for aesthetic practitioners. According to Harpar Grace, the international competition will be based on growth as well as revenue and will see the distributors select UK and Ireland World Star winners, plus a global Premier Star winner. The World Star winner – one from the UK and one from Ireland – will receive a round trip airfare provided by the distributor, advanced VIP education training, a personalised tour of the iS Clinical manufacturing facility and more. The Premier Star winner will be awarded to one account partner globally and is is a testament to their dedication and talent, explains Harpar Grace.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Collagen

LABthetics releases new collagen supplement Skincare company LABthetics has unveiled a new nutraceutical supplement for skin rejuvenation. The supplement has been formulated for aesthetic practitioners to recommend alongside aesthetic procedures, and aims to rebuild and support collagen in the skin, as well as providing support for skin rejuvenation, explains LABthetics. According to the company, the peach and mango supplement contains 10,000mg of peptan marine collagen, vitamin C and L-lysine solution for rebuilding collagen; hyaluronic acid to support extracellular matrix (ECM) and prevent water loss by locking in the water content; as well as added vitamins and minerals. Emma Caine, founder of LABthetics, commented, “The importance of a supplement in your patient’s skincare plan is a vital part of skin rejuvenation. Supplements and nutrition combined with aesthetic procedures and home care regimes are what work in synergy to treat and correct skin conditions, reduce the ageing process and maintain healthy skin.” The supplement is available in the professional home care retail section on the LABthetics website as the supplement requires an educational approach. Full product training will be provided by LABthetics. Vitamin C

Medik8 revamps day and night cream Skincare brand Medik8 has reformulated its r-Retinoate Day and Night cream. According to the company, the product now contains vitamin C derivative tetrahexyldecyl ascorbate, a stabilised form of vitamin C. The ingredient aims to enhance the skin’s luminosity and help prevent ageing. The company explains that the cream’s upgraded antioxidant protection will shield the skin from everyday free radical damage. The product also contains retinyl retinoate, which aims to help stimulate collagen synthesis; hyaluronic acid to provide hydration; and vitamin E to further protect the skin from free radicals. Skincare

AlumierMD introduces summer kit Skincare brand AlumierMD will launch the Summer Essentials Kit on July 1. The kit contains the EverActive C&E + Peptide, a vitamin C and E serum which aims to reduce the appearance of fine lines and wrinkles, and the EvenTone brightening serum, which aims to brighten complexion and reduce uneven skin tone, explains AlumierMD. Dr Beatriz Molina, aesthetic practitioner and founder of Medikas, said, “The new Summer Essentials Kit helps prevent hyperpigmentation, which is exacerbated when it is sunny. The kit is for everyone who wants to protect their skin, in addition to a broad-spectrum SPF. Both products are packed with effective ingredients and work synergistically to deliver results.”

J O I N U S AT CCR The UK’s only multidisciplinary event for surgical and non-surgical aesthetics

GALDERMA TO HEADLINE SPONSOR Swiss pharmaceutical brand, Galderma will make its first appearance at CCR where it will be headline sponsor, providing exciting news and world-class education. Galderma will celebrate 25 years of Restylane as well as Sculptra being under the Galderma umbrella. Practitioners can attend the Restylane and Sculptra symposium for free.

IMPROVING PATIENT SAFETY For the first time the Aesthetic Complications Expert (ACE) Group World conference will be taking place on day one of CCR, discussing the latest industry developments with the prevention and management of complications occurring in practice. ACE Group World aims to improve patient safety in medical aesthetics by producing evidence-based guidelines for the management of complications, making CCR the event to raise industry standards! Tickets are £125 and are sold on a first-come first-served basis.

MORE SURGICAL EDUCATION The esteemed ISAPS Symposium UK will be fully integrated into CCR’s new Surgical Arena. The international meeting will bring together aesthetic plastic surgeons under one roof, integrating surgical education and networking between surgical and non-surgical practitioners. The renowned faculty will put CCR and the ISAPS Symposium UK on the world stage, focusing on breast and body. CCR will also be featuring two afternoons of additional surgical content, curated in collaboration with ISAPS UK national secretary Mr Naveen Cavale (FRCSPlast) and assistant secretary Mr Mo Akhavani (FRCSPlast). Make sure you’re there on October 14-15 to discover the latest clinical developments and source new products from leading global brands. Head to

c c r lo n d o n . c om to register now

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Distribution

CosmeSelect to distribute MCCM Medical Cosmetics Aesthetic distribution company CosmeSelect has been appointed the exclusive distributor of MCCM Medical Cosmetics and Aethern in the UK. MCCM Medical Cosmetics is a global pharmaceutical manufacturer of aesthetic medicine and medical cosmetics, whilst Aethern is a nutraceutical antiageing supplement brand. MCCM Medical Cosmetics product portfolio includes specialist products used by medical clinics such as dermal roller devices and skin peels but also retail at-home products. Aminah Aboud, founder of CosmeSelect, said, “CosmeSelect provides practitioners and clinics in the UK and Ireland with results-driven products that can be utilised in clinic or as part of a home skincare regime. MCCM is an innovative brand to work with and my team look forward to developing effective treatment programmes for practitioners to implement in their clinics.” Surgery

Trial reveals scarring reduction after use of topical cream A clinical trial has indicated that the use of Science of Skin’s topical treatment, Solution for Scars, improves surgical scarring. The trial, conducted by Professor Ardeshir Bayat and plastic surgeon Mr Douglas McGeorge, compared the effect of the scar cream when applied to skin pre- and post-surgery. The product contains green tea phytochemical, and pheohydrane to improve scar thickening, redness, and moisture. The eight-week clinical trial looked at 40 volunteers; half of which applied the cream pre-injury, with the rest applying it immediately or 14 days post injury. The trial indicated that Solution for Scars, when applied pre-surgery, reduced the thickness and redness of scars and increased hydration. Professor Bayat explained that the product had a impact when applied a week in advance of surgery. The cream led to a reduction in healing time and the risk of inflammatory hyperpigmentation. Skincare

Swissline launches in the UK Skincare brand Swissline has extended its worldwide distribution to the UK through skincare distributor Skinbrands. Skinbrands explains that its agreement with Swissline entitles its consumer and professional products to be distributed through its network of 86 skincare clinics, including those part of sk:n, The Harley Medical Group and DestinationSkin. Skinbrands managing director, Amanda Coveney, commented, “We are delighted to be partnering with Swissline and adding this pioneering brand to our diverse and on-demand product portfolio. We are very proud to have been chosen as Swissline’s official UK distributor, both within our high street clinics and online. I am very excited to explore the unique opportunities this full debut into the UK market is sure to bring.”

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60 Dr Leah Totton

What new trends and advances in facial aesthetics have you embraced this year? Homecare is a trend which I am particularly excited about. I have been conducting remote skin consultations and have extended the footprint of my expertise to provide treatments to people in parts of the country which are less well served than London and Essex, where I have my clinics. I offer a mixture of medical grade and prescription strength skincare, supplements and sun protection (SPF) products. An enhanced skin condition provides the perfect canvas for pre- and post-facial aesthetics, so works beautifully in tandem with my clinic treatments. I have also been exploring the scope of new generation dermal fillers. Can you tell us why you are excited about Sinclair Pharma’s new MaiLi Hyaluronic Acid (HA) filler? MaiLi is the new HA filler I am now treating with. It is a premium HA gel designed for the treatment of fine lines, medium-sized skin depressions, the periorbital area* and volume loss. It helps rejuvenate, contour and sculpt the face, while acting like soft, flexible and elastic skin tissue, working with natural movement and expression. What makes MaiLi so different from standard HA fillers? I have been using MaiLi in the lips and cheeks and I’m very impressed with it, having achieved lovely results. MaiLi is especially effective for lip definition and enhancement. It is a great lip volumiser, thanks to its elasticity and I like its projection capabilities. I like that the results last for a year**. The thing which impresses me most is the fact that MaiLi integrates well within the tissues and doesn’t migrate from the vermillion border like many other HA fillers do, so I can create great definition on the border and know that it will be maintained. This is because the injected gel is in constant contact with the surrounding tissues, and returns to its initial shape due to smart spring properties. * The application of MaiLi Precise in the periorbital area is reserved to specialists specifically trained in this technique and having sound knowledge of the anatomy and physiology for this area **Data on file This column is written and supported by

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Stem cells

Lipocube SVF launches to the UK market Medical device supplier Advantech Surgical has introduced the Lipocube SVF stem cell isolation product to the UK market. According to the company, the product allows for fat tissue to be disaggregated and incubated by mixing it with the Lipocube buffer solution, enhancing the separation of regenerative cells from the fat tissue. The emulsion is processed in the Lipocube Cell-Drive and the stromal vascular fraction (SVF) is concentrated in a patented trap, with a specific cell coating and geometry. This SVF is then applied to the patient. Managing director of Advantech Surgical Ben Sharples said, “We are very excited to add Lipocube SVF to our already strong offering in regenerative medicine. We can now offer options to surgeons and patients across all budgets, and to suit all surgical requirements. This new addition makes our company leaders in regenerative medicine.” On the Scene

Success In Aesthetic Business The first Success In Aesthetic Business (SIAB) meeting was held at the Crowne Plaza in Solihull on June 4. Organised by Dalvi Humzah Aesthetic Training, the event provided aesthetic and plastic surgeons as well as doctors insights in how to set up a successful aesthetic business. Presenters at the event included managing director of DSL Consulting Danny Large, digital marketing professionals Mark and Alex Bugg, chartered accountant Jonathan Bardolph, editor Georgia Seago, branding professional Russell Turner, aesthetic consultant Vanessa Bird, financial advisor Adam Pollard, and consultant plastic and reconstructive surgeon Mr Jeyaram Srinivasan. Following the event, Mr Humzah said, “The first Success In Aesthetic Business (SIAB) meeting was a fabulous event giving practitioners a unique opportunity to discuss planning, enhancement and development of their individual practice with leading figures in the clinical and business field of aesthetic practice.” The SIAB is planning more events later in the year and will also be holding events for aesthetic nurses. On the Scene

Business of Hair Conference Practitioners met in Solihull to discover the latest in hair loss management at the Business of Hair Conference on June 5. The event was organised by the CEO of the British Association of Hair Restoration Surgery (BAHRS), Danny Large and covered many topics such as genetics testing for hair loss, micropigmentation, hair loss in menopause, business talks on marketing, and the impact of COVID-19 on the aesthetics specialty. Some speakers included Dr Ingrid Wilson, nurse prescriber Deborah Forsythe, micropigmentation practitioner Mark Smith, acting editor and content manager of Aesthetics and Beyond Beauty Shannon Kilgariff, and others. Large said, “Business of Hair goes from strength to strength with more people realising that the hair sector is developing and there are some fantastic products now that will help practitioners achieve fantastic results. It gives me great hope that this sector will continue to develop and make a massive impact in people’s lives who suffer from hair loss. It was also great that the delegates took advantage of the one-to-one sessions with the business experts and picked their brains on how to make their business efficient.” The Business of Hair Conference will return in May 2022.

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News in Brief Lynton appoints new ambassador Laser and IPL manufacturer Lynton has appointed plastic surgeon Mr Ali Ghanem as its new brand ambassador for the DEKA SmartXide device. Mr Ghanem is the medical director of the Cranley Clinic London and the Ghanem Clinic London and Bahrain. Mr Ghanem said, “SmartXide is a device that allows medical practitioners to perform both invasive and non-invasive dermatological procedures alongside surgical applications. I am loving it and my patients are too.” mesoestetic introduces new website Pharmaceutical company mesoestetic has launched a new website. According to the company, the treatment and homecare products are reorganised into a simple format focused on concerns to be treated and product groups. The goal of the new website is to provide visitors an easier way to learn about mesoestetic products and treatments. Adam Birtwistle, managing director at mesoestetic, commented, “Giving the brand a cohesive global presence through the website was a very important part of our recent new branding to offer both the consumer and the professional a simplified product layout.” Lumenis collaborates with Natali Kelly Aesthetic device company Lumenis UK has partnered with independent nurse prescriber Natali Kelly. Kelly is a new ambassador for the NuEra Tight device. The company explains that the new partnership aims to raise awareness of body tightening procedures and to encourage more patients to seek out treatments to increase their confidence. The device helps with skin tightening cellulite, and wrinkle reduction with five treatment depths. Kelly commented, “I’m really excited to be offering the NuEra Tight at my new clinic. We’ve seen such incredible results with little downtime and practically no discomfort.” VIVACY expands team Aesthetic product manufacturer VIVACY UK has appointed Chloe Cotterill as its new PR and marketing assistant. Cotterill has previously worked in fashion marketing, interning at ASOS and working as a sales assistant at Lacoste and Outfit Fashion. Cotterill commented, “I’m incredibly excited about joining VIVACY during this really exciting time for the business, whilst channelling my passion for the aesthetics industry.”

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


Special Focus Awards

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HIGHLIGHTS OF THE AESTHETICS AWARDS On May 28 the Aesthetics Awards took place, reflecting on the achievements of practitioners, clinics, products and companies over the last 12 months. The specialty was given the chance to be recognised and receive prestigious Winner, Highly Commended or Commended accolades. It’s been a tough time for the aesthetics industry due to the COVID-19 pandemic, and it was amazing to

finally see everyone come together to celebrate, with a total of 1,400 virtual attendees! The winners have been announced on the Aesthetics Awards website, as well as in the previous issue of the Aesthetics journal, but let’s take a look back at some of the highlights from the evening, as well as finally finding out who received the coveted Best Dressed Award!

C ELEBR AT ION S All over the UK and Ireland, individuals within the specialty took part in their own mini celebrations while they streamed the ceremony over Zoom. Here’s what some of our viewers thought of the evening!

CHURCH PHARMACY

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INMODE

“Although we missed seeing all our friends in person, our team thoroughly enjoyed the virtual Aesthetics Awards and felt engaged and included throughout. The professionalism, hard work and attention to detail that the Aesthetics Media & CCR team bring to every event certainly carried over to the virtual space. We were especially proud to win the Distributor of the Year Award for the third year running, and we want to thank all the people who voted for us and their kind words of support during what has been the most challenging year for our company and many others. Thank you to the Aesthetics team for a wonderful day!”

“We were over the moon to win an Aesthetics Award in the innovation category for Morpheus8! We all got together at our London head offices to watch the Awards and then went out for dinner to celebrate! We thoroughly enjoyed the ceremony – it’s an event that brings everyone together to celebrate the successes and achievements over the past year. It was also an honour to sponsor ‘Consultant Surgeon of The Year’ and we congratulate Mrs Sabrina Shah-Desai on her well-deserved win! She’s also been doing great things with the Morpheus8 in her clinic.”

Zain Bhojani, co-director of Church Pharmacy

Rosalie Nicholson, InMode UK marketing manager Aesthetics | July 2021


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YOUNIQUE AESTHETICS

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Special Focus Awards

DR NESTOR’S MEDICAL COSMETIC CENTRE

“Younique Aesthetics Clinic streamed the Aesthetics Awards live from the rooftop garden of The Merchant Hotel, Belfast! We were joined by some of our fellow Northern Ireland finalists and invited the local media to join us in celebrating. During the evening festivities, we helped to raise £700 for the Glow NI charity which empowers women and girls with life skills and to also supports those who have suffered from domestic violence. The evening created a marvellous opportunity for those who work in the industry to socialise and get to know each other on a personal level as well as strengthen bonds between other clinics and build a stronger community.”

“We hired a penthouse suite at the Edinburgh Grand Hotel overlooking the city. We had the dinner catered and everyone from the team dressed up as if we were heading to the real event. Though they were not in-person, this year’s Aesthetics Awards were a great event. It provided us with the opportunity to bring our team together to celebrate the end of our enforced slumber and getting back to the work that we love so much.” Dr Nestor Demosthenous, aesthetic practitioner

BEST DRE SSED AWA RD!

Lesley McGarrity, senior operations manager

WINNER: DR VINCENT WONG

AESTHETICS MEDIA & CCR

The team were all blown away by Dr Wong’s outfit – congratulations on being the most glamorous person in aesthetics in 2021! RUNNERS UP:

“Although, of course, we wish it could have been an in-person event, the digital Aesthetics Awards ceremony was incredible and a huge success. All the winners, as well as those who received commendations and high commendations, were well deserved, and we of course have to thank our wonderful judges and sponsors. We can’t wait to see you at our in-person event next year!” Nina Prisk

Shannon Kilgariff, acting editor and content manager

Miss Sherina Balaratnam

Mr Mo Akavani

SEE YOU NEXT YEAR! Entries for the 2022 Aesthetics Awards will open in September, so keep your eyes peeled for more details! We can’t wait to see you all again soon.

The ceremony will take place on March 12 after the Aesthetics Conference and Exhibition, so don’t forget to put the date in your diary!

28 & 29 MAY 2021 / LONDON

Aesthetics | July 2021

19


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Educating EDs on Aesthetic Complications Aesthetics explores why we need to increase awareness about aesthetic complications within hospital emergency departments According to aesthetic nurse prescriber and NHS emergency department (ED) nurse Julia Mansell, there has been an increasing number of cosmetic complications presenting to her ED at King’s College Hospital London over the last year. The NHS does not currently collect data on complications that present due to aesthetic procedures, but in Mansell’s hospital the rise was enough to enlist the help of the Complications in Medical Aesthetics Collaborative (CMAC), which has since set out a plan to deliver educational presentations to emergency departments across the UK. Mansell explains, “I was recently contacted by one of the emergency nurse practitioners because a patient had presented with periorbital cellulitis and hardening of filler, four weeks post tear trough treatment. The original injector was not able to manage the complication and referred the patient to their local emergency department, who weren’t aware of how to manage the complication. This was not the first complication I had been made aware of and it’s possible there may be many more as there are currently no audit requirements on this type of attendance.” After alerting CMAC founding board member and prescribing pharmacist Gillian Murray, they decided to arrange teaching to doctors and nurse practitioners in the ED, starting at King’s. She adds that the talks are designed to raise the awareness of certain presentations and symptoms that will occur following an aesthetic complication, which will deteriorate if not addressed. The rise in complications coming through

emergency department doors is not limited to King’s, according to aesthetic practitioner Dr Alexander Parys, who has been holding his own complication educational sessions for emergency staff. He comments, “I left the NHS a few years back and at the time I was still working as an emergency department registrar. Back then, filler complications were relatively unheard of. Unfortunately, this has completely changed now and my colleagues still in the department all repeat year on year increases in cosmetic procedure complications, and it seems to be showing no sign of slowing down.” With aesthetic complications becoming a growing concern, Aesthetics explores why practitioners believe it’s important for the specialty to be taking time to educate healthcare counterparts.

The problem Chair of CMAC and aesthetic practitioner, Dr Lee Walker, believes the main issue which surrounds aesthetic patients presenting to emergency departments is the risk of misdiagnosis – and consequently mistreatment. He comments, “Local emergency departments are not best placed to recognise and manage complications caused by dermal fillers, as the aetiology, pathology and management form no part of medical undergraduate or postgraduate training. NHS pathways for non-urgent cosmetic wounds may take time to receive wound care, when these wounds should be more efficiently and effectively managed by the clinician who caused the

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injury (if they are a clinician).” At the recent King’s College Hospital London CMAC presentation, the group presented a series of images to the attendees and invited thoughts on diagnosis, which reinforced this discrepancy. Dr Walker says, “It was acknowledged by the emergency staff that they may not recognise the specific signs of a vascular occlusion as the presentation is unique to the face and to vascular occlusions caused by dermal fillers. In addition, a recent history of dermal filler injections is not always disclosed by the patient and is not routinely asked when taking a history, so this is something we need to advise emergency department doctors to start doing.” Dr Parys has noted similar concerns, stating that when he’s presented to emergency department doctors, they are often surprised at the range of complications that can occur from aesthetic procedures and how similarly they can present to other diagnosis. Dr Parys adds that another problem is that emergency departments are not usually equipped to properly deal with a serious aesthetic complication, such as a vascular occlusion. He comments, “Even if the medics working there have trained in aesthetics and are aware of how to manage certain complications, many EDs do not have hyaluronidase to hand, nor would they know where to locate some. This means they’re unable to effectively treat patients who present with these concerns, which is why I always recommend they have some in stock.”

Improving practice The number of non-medically trained injectors in the UK is rising, which practitioners say is problematic. Dr Walker comments, “CMAC recognise that due to the lack of standards in education, and the absence of regulation, patients can either be sent to, or self-refer to, local emergency departments when complications arise. This is entirely inappropriate (with the exception of ocular symptoms)1 and can be avoided if clinicians are appropriately trained and competent in the diagnosis and management of their own complications. This can only be achieved if they are medically qualified. Medical practitioners also have a responsibility to seek complications prevention and management training.” Dr Parys emphasises that practitioners should ensure they are fully prepared and have thorough support in place for patients postprocedure so they know exactly what to do should a complication arise. He says, “This

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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should include things such as out of hours emergency contact details, perhaps teaming up with colleagues in the area to provide cross-cover support and maintaining our own education regarding complication recognition and management.” Dr Parys believes it’s also important for practitioners to reflect on any complications that arise, discover key learning points on how to prevent future occurrences, and share these with colleagues. It’s also important that practitioners stay in touch with their community, inside and outside the NHS, according to Dr Parys. He comments, “We should remember that even though one is private, and one is public, we need to still act as one and collaborate and coordinate with colleagues. Should a patient end up at your clinic needing treatment after attending an emergency department, the treatment, outcome and final diagnosis should be fed back to them so they can reflect and learn from the episode. In addition, joining groups such as CMAC and ACE Group World can help provide you with support from other aesthetic practitioners, and therefore hopefully reduce the chances of patients presenting to emergency departments.”

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Educating patients

ED’s shouldn’t be your first option

Dr Walker comments that the lack of patient education around the importance of seeking a medical professional who can perform a medical diagnoses and treatment plan is a contributing factor to the problem. He says, “The patient who has made poor choices is left unsupported by unregulated and unaccountable providers who are unlikely to be using evidence-based products and working in a medical clinic setting, which can reduce patient safety.” Dr Walker emphasises that the medical aesthetic specialty is key in helping to stop the rise in complications presenting to emergency departments by giving the patients the information they need. “Aesthetic patients (and practitioners) need to be educated to make safe decisions, respect the risks and to not rely on the NHS as a safety net. It is the responsibility of the speciality to raise awareness for our potential patients so that it’s clear to them that when they choose a provider, they should choose a healthcare professional who is accountable to their regulatory body,” he explains.

Aside from the danger that this poses for the patient, Dr Walker comments that the strain this may put on NHS resources is another issue, especially in the pandemic world. While many are dedicated to the education of hospitals, the CMAC emphasises that this should not be considered as an initial viable option for aesthetic practitioners, with the exception of vision loss. Dr Walker says, “It is not appropriate for the NHS to pick up a complication and allocate precious resources and funds, when complications should be managed by the provider. The function of an emergency department is to triage and stabilise sick patients. Aesthetic complications, whilst catastrophic to the patient, are mostly cosmetic and will be prioritised as such.” REFERENCES 1. Rachna Murthy, Jonathan Roos, Retrobulbar Injections in Filler Related Vision Loss, Aesthetics journal, May 2021, <https:// aestheticsjournal.com/cpd/module/retrobulbar-injections-in-fillerrelated-vision-loss>

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WWW.UTHAESTHETICS.CO.UK Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


CCR 2021 Complications

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CCR 2021 to raise industry standards and improve patient safety Patient safety, regulations and training are at the heart of CCR, the UK’s leading event, uniting surgical and non-surgical medical aesthetic communities. This is why the organisers are so excited to work with the Aesthetic Complications Expert (ACE) Group World to host their Group Conference at CCR on October 14 2021 at ExCeL, London. For the first time, CCR will host the ACE Group World Conference providing medical practitioners of all specialities with leading education to improve patient safety and discuss the latest industry developments with the prevention and management of complications occurring in practices. The packed agenda of well-renowned speakers is open to new and existing members of the ACE Group World to attend, providing an opportunity for all to learn more about the latest evidence and guidelines on the management of non-surgical aesthetic complications. Practitioners can expect a welcome drink on arrival, a jam-packed afternoon of education from leading KOLs, and opportunities to network with other delegates. Tickets will be £125 and will be on a first-come, first-served basis, so keep your eyes peeled in July for registration to open. So far the speaker line-up includes Dr Martyn King, Liz Bardolph, Dr David Eccleston, Dr Xavier Goodarzian, Dr Beatriz Molina, Mr Ash Labib, Mrs Sabrina Shah-Desai, Dr Harryono Judodihardjo and Helena Collier. Topics include botulinum toxin, chemical peels and sclerotherapy complications, delayed onset nodules and vaccines, vascular occlusions, dermatology lesions not to miss and much more!

HEADLINE SPONSOR

As always, CCR will incorporate an unparalleled and comprehensive education programme across its other conference agendas covering clinical and business training, all of which is CPD accredited. The education highlights include a one-day video cadaver training course with industry guru Dr Tapan Patel for £120, a free facial masterclass with Prof Bob Khanna, and practice management advice to help get aesthetic businesses back on track after a challenging year.

Tickets to ACE Group World: £125 | Thursday October 14 2021 | 13.30 – 19.30 PM

For more information about CCR 2021 on October 14-15, or to register for your complimentary pass, visit: www.CCRLondon.com @ccrldn 22

Aesthetics | July 2021

CCR 2021 brought to you


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Preventing Complications in the Nasal Area Journalist Allie Anderson speaks to aesthetic trainers Miss Priyanka Chadha, Mr Dalvi Humzah and Mr Ash Labib to explore how to safely administer dermal filler to the nose and avoid complications Most of us have spent more time than ever at home in the last 16 months, due to the COVID-19 pandemic. Working remotely has seen millions relying on video conferencing platforms to communicate with colleagues, forcing many to scrutinise the way they look on screen. In the article, ‘A Pandemic of Dysmorphia: Zooming into the Perception of our Appearance’, the authors outline that Zoom displays an unedited version of oneself in motion; a self-depiction very few people are used to seeing on a daily basis. This may have drastic effects on body dissatisfaction and influence a desire to seek cosmetic procedures.”1 The article, published in last November’s Facial Plastic Surgery and Aesthetic Medicine, highlighted that the nose is a feature of one’s appearance that holds up particularly poorly to harsh self-analysis. In fact, an image taken 12 inches away from the face increases a person’s perception of their nose size by 30%, compared with one from five feet.2 Similarly, the shorter focal length of a webcam tends to broaden the nose, as well as making the face appear rounder and the eyes wider set.3 At the same time, the link between social media and body dissatisfaction is increasingly evident – and again, the nose is the focus. On TikTok, for example, the hashtag #nonsurgicalnosejob has attracted around 16.4 million views.4 This is reflected in the demand for non-surgical rhinoplasty, which, according to one clinic, rose by 29%

between 2019 and 20205 – in contrast to the surgical equivalent, which steadily declined in popularity during the decade leading to 2020.6 Dubbed the ‘liquid nose job’, it is easy to see why dermal fillers in the nasal region are so widely sought after. They offer a quicker and comparatively more affordable alternative to surgical rhinoplasty, and require less downtime. However, they are certainly not without risk – some of which can be catastrophic – so aesthetic practitioners must be skilled masters in the practice of non-surgical rhinoplasty to prevent complications from occurring.

Complications from fillers in the nasal area According to Mr Ash Labib, ENT surgeon and founder of AL Medical Academy, minor problems are not especially uncommon. “The complications which arise from nose fillers vary from tiny areas of bruising, slight swelling and erythema to, rarely, something more serious occurring like a vascular occlusion, leading to necrosis,” he states. Swelling and erythema, reported in up to half of patients undergoing a non-surgical rhinoplasty,7 tend to be mild and self-limiting. Vascular complications are rare,7,8 but a recent case highlighted the potential severity of necrosis if an occlusion is not identified and addressed quickly.9 However, proximity of the treatment area to the eyes means nose fillers carry a small risk of eye-related

complications, including ophthalmoplegia, ptosis and even vision loss,10 as all of the practitioners interviewed attested. “The vascular anastomotic network around the nasal region and, indeed, the glabella region, is incredibly complex and intricate,” explains plastic surgery registrar Miss Priyanka Chadha, founder of Acquisition Aesthetics. “There are a variety of vessels which, if injected directly or through retrograde embolisation, can lead to an occlusion that can, in turn, lead to skin necrosis or even blindness,” she says. The 2015 paper Avoiding and Treating Blindness from Fillers: A Review of the World Literature, identified 98 reported cases of vision changes, of which 25.5% were from treatments in the nasal region – the second highest-risk area behind the glabella (38.8%).11 While almost half (47.9%) of complications were caused by autologous fat; almost a quarter (23.5%) were caused by hyaluronic acid fillers. Pain and immediate vision loss were the most common symptoms, and the authors reported that most cases of vision loss did not recover. In a 2019 update to their review,10 the authors reported that 48 new cases of vision complications caused by fillers had occurred between January 2015 and September 2018. The nasal region was the highest-risk site, accounting for more than half (56.3%) of cases, with treatment to the glabella region causing 27.1% of complications. Hyaluronic acid fillers were responsible for the overwhelming majority (81.3%) of problems, with 10 cases recovering vision completely and eight reporting partial recovery of vision.

Product selection Selecting the appropriate products for the procedure and, in particular, the exact area in which the nose is being augmented is an important factor in mitigating the risk of complications, the three practitioners say. Generally, hyaluronic acid is preferred for high-risk areas like the nose, because in cases of misinjection, vascular occlusions or other complications, hyaluronidase can be administered to rapidly break down the hyaluronic acid.8,12 Consultant plastic, reconstructive and aesthetic surgeon, Mr Dalvi Humzah, founder of Dalvi Humzah Aesthetic Training, says the product he chooses varies depending on which of the three main nasal regions he is treating. He comments, “The upper part of the nose is made up of nasal bone, so you need a product that can replicate that firmness and doesn’t

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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spread. Many people will wear glasses or sunglasses, so the product needs to withstand those pressures, not move around and last a relatively long time.” For that reason, he recommends a high-viscous filler that also has a high G-prime. He explains, “For this, the products are all ‘off-label use’ and I use either Belotero Intense or Radiesse. I would use Radiesse in a specific area where it has a bony defect or to lift the drooping tip.” For the lower part of the nose, Mr Humzah says, a filler that mimics the suppleness of that region is required. “You don’t want the nose to look and feel very stiff and not move, so the chosen filler needs to be slightly flexible to allow movement of the nose,” he says, adding, “The third part of the nose people are concerned about is the columella. Again, you need a product that can withstand pressure and provide support, so that product should have a high G-prime and low viscosity. I use Belotero Volume as an ‘off-label’ indication.” Miss Chadha points out the importance of conducting a thorough assessment of the patient and their individual needs in deciding which product to use. “It always depends on the patient, their overlying skin tissue envelope and their underlying structure, which must be examined by looking, feeling and touching the nose,” she says. Practitioners should do this while the patient changes their facial expression – smiling, for example – to enable dynamic, as well as, static assessment of the nose in relation to the other facial features, she advises. “This will help to ascertain how to proceed with treating the nose and connecting muscles. Generally speaking, when treating the nose, I choose fillers with a high G-prime and thus, a high lifting capacity, typically either Teosyal Ultra Deep or Restylane Lyft,” Miss Chadha explains. Mr Labib, conversely, chooses Juvéderm Voluma.

Techniques and placement of dermal filler As well as identifying the best products for each patient, the appropriate placement of the filler is essential. Mr Labib describes what he terms a ‘no-go area’ or ‘danger zone’, where one should avoid injecting completely. He states, “That is the quadrant on the lateral wall of the nose, between the medial canthus and the infraorbital frame. If you inject in the midline of the nose, which is less vascular and less anastomotic, and you stay deep to the bone and cartilage, that is the safest place to inject.” A systematic review of non-surgical rhinoplasty techniques, outcomes and complications reported that although multiple

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Before

After

Figure 1: Patient before and after non-surgical rhinoplasty using 0.65ml of Belotero Volume. Patient treated by Mr Dalvi Humzah

studies documented injections into the nasal sidewall without complication, it is generally advisable to limit injections to the midline of the nose to avoid the dorsal nasal arteries on either side.8 Debate surrounding the comparative merits and drawbacks of needles versus cannulas is ongoing. For Mr Labib, a needle is the preferable tool of choice. “I believe that, in my hands, a needle is safer because it’s more precise allows you to go down to the right plane (bone and cartilage) and it also enables you to use less product,” he says, adding, “I must have trained more than 2,000 people globally in this technique and I always teach them to use a needle with precision and safety.” Miss Chadha states that how and by whom a practitioner is trained often determines whether they lean towards needles or cannulas in their own

practice, but that ultimately, it is guided by personal preference. She comments, “The area is challenging due to the anastomosis and the proximity to important vessels around the eyes, and thus, the cannula is often considered to be safer.” However, like Mr Labib, she argues that the precision and definition required are best achieved with a needle. “If you are trained in performing the procedure with a needle you can often move to using cannulas with confidence, whereas the other way around can be more challenging; people may be more nervous to move from cannula to needle,” she adds. According to Mr Humzah, both cannulas and needles can be used safely depending on the area of the nose being augmented. When using a needle, he says, it is important to consider the angle at which you place it into the nose. “If you come in at an angle

Using ultrasound to prevent and manage complications There are emerging benefits to using ultrasound alongside non-surgical rhinoplasty to prevent, diagnose and treat complications. Ultrasound can help practitioners to:24 • • • • • •

Identify the depth and precise location of blood vessels Ascertain any variation in vascular anatomy Identify the exact position of any obstruction Trace the supply and flow of blood to and from the area Better understand the patient’s unique three-dimensional anatomy Recognise how tissues react with the filler upon movement

According to Mr Humzah, a lower-resolution, handheld device will often suffice in guiding the placement of dermal fillers before or during the treatment itself. He comments, “However, for treating complications you need a higher-resolution ultrasound head that you can dial up to a higher frequency, which allows you to look at the layers of skin at 2-3mm in depth.” These higher-frequency machines tend to be fixed, and are typically more expensive than handheld, low-frequency alternatives. But there are now some new, ultra-high-frequency handheld machines available that would be useful in these situations. “Ultrasound requires more specialist training to use and interpret what it’s telling you. But I believe there is a place for ultrasound in non-surgical rhinoplasty and complications management. It’s like following a roadmap while driving – it makes a lot of practical sense,” Mr Humzah says.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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1. TEOSYAL® PureSense Redensity 2 – instructions for use — 2. Berguiga M, Galatoire O. Tear trough rejuvenation: a safety evaluation of the treatment by a semi-crosslinked Hyaluronic Acid filler. Orbit, 2017; 36 (1):22-26. — 3. Teoxane Post Marketing Surveillance from 2016 to 2020-Q3 — 4. Data on File. Torsion and compression tests assessed on a rheometer. The measurement of the rheological parameter Delta index represents the balance between gel viscosity and elasticity. Physical analysis of HA fillers intended for infraorbital uses. RDRE 2023. — 5. TEOXANE Post Marketing Surveillance Survey. September 2020. 1504 respondents — 6. Teoxane internal data source. TEOSYAL® PureSense Redensity 2 deliveries from 2012 to 2020: 1’011’774 boxes. TEOSYAL® PureSense Redensity 2 is a trademark of the firm TEOXANE SA. This product is a gel that contains hyaluronic acid, and 0.3% by weight of lidocaine hydrochloride (local anesthetic can induce a positive reaction to anti-doping tests). In the case of known hypersensitivity to lidocaine and/or amide local anaesthetic agents, we recommend not use lidocaine-containing products and please refer to products without lidocaine. TEOSYAL® PureSense Redensity 2 is a class III medical device and is regulated health product bearing the CE marking (CE2797) under this regulation. For professional use only. Please refer to instructions for use. This product availability depends on registration, please contact your local distributor. Please inform the manufacturer TEOXANE of any side effects or any complaint as soon as possible to the following address: medical@teoxane.com.


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Before

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After

Figure 2: Patient before and after non-surgical rhinoplasty using Juvéderm Voluma. Patient treated by Mr Ash Labib

rather than at 90 degrees to the bone, you tend to be in a safer position because you can slide the needle into the deep space underneath the vessels,” he says, thereby minimising the risk of piercing a blood vessel and causing bleeding. This is straightforward when performing the procedure on the top part of the nose, Mr Humzah adds, because of the way the layers of tissue are arranged. “You have skin, then fat, then muscle, and a space on top of the bone. If you penetrate underneath the muscle, you can slide the needle at an angle along the

but a cannula sliding along the nasal bone is uncomfortable, but not painful for the patient.” Neither needle nor cannula are completely without risk, and one is not universally better than the other, Mr Humzah says. Understanding the complex anatomy and physiology of the nose and facial structures is paramount, and as such, comprehensive training is essential. Moreover, all the practitioners interviewed concur that nonsurgical rhinoplasty should only ever be carried out by highly skilled practitioners with a medically qualified background.

“Immediately stop treating as soon as you suspect any signs and symptoms of a problem, and make sure you have an in-date emergency kit ready” Miss Priyanka Chadha

bone and deposit the product,” he says. The nose tip, however, is more vascular and the arrangement of vessels less uniform, he highlights. “With a needle in the tip area, it’s very easy to inject into a vessel, so you need to exercise caution,” Mr Humzah adds. In general, Mr Humzah says he prefers to use a needle if correcting or augmenting a small area along the dorsum, where a single-entry point is used to deposit a column of product. However, with a ‘total nose’ augmentation – requiring multiple entry points on the dorsum, the tip and other regions – a needle is less ideal, he says, explaining, “If I’m reshaping and contouring several areas with a cannula, I can slide along the different planes to lay my products. The nose is a painful area to treat,

Managing complications A clinicians’ training must incorporate not just the safe use of products and techniques, but also how to recognise and manage complications should they occur, the practitioners highlight. That way, poor outcomes can be prevented. Miss Chadha suggests that aspirating before injecting the product can indicate whether you have inadvertently entered a blood vessel and thereby minimise the risk of vascular complications.13 She adds that observing, talking to, and listening to the patient while slowly and incrementally injecting small volumes of filler is crucial, as is watching for blanching of the skin which can indicate a vascular occlusion.14 “Immediately

stop treating as soon as you suspect any signs and symptoms of a problem, and make sure you have an in-date emergency kit ready,” she adds, which she states should include hyaluronidase, which should be administered swiftly to dissolve hyaluronic acid, together with syringes, needles, gauze, saline and adrenaline in case of anaphylaxis. “Full, continued assessment should be carried out after treatment with hyaluronidase, to note if the patient has pain or discomfort, to test their capillary refill time appropriately, note any discoloration or further blanching, and take well-documented photos for medical records,” Miss Chadha says. Evidence suggests that firmly massaging the area can eliminate any obstruction and encourage blood flow,15,16,17 while if an arterial embolus is suspected gently tapping on the area can help to dislodge it.18,19 However, if conservative measures like these are unsuccessful or the capillary refill time is greater than three seconds, Miss Chadha recommends reconstituting using the Aesthetics Complications Expert (ACE) Group World high-dose pulsed hyaluronidase protocol.14 If severe skin necrosis is a threat, hyperbaric oxygen therapy (HBOT) can be considered.20 It has been used posttreatment to encourage tissue healing following an occlusion,21,22 but local availability, cost, inconvenience and risks can preclude its use in worst case scenarios.23 Other problems which may occur posttreatment include infection and persistent pain, which, according to Mr Humzah, is often overlooked as a potential complication. “The nose has lots of nerves and if you inject close to those nerves, you can cause damage or neuropraxia,” he says. He explains that pain can be treated with appropriate analgesia and antibiotics prescribed for infection as needed. Most importantly – as all the interviewees highlighted – practitioners should have a clinical referral pathway in place, enabling them to act quickly, ensuring the patient has a smooth transition to emergency or specialist care if required.

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Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Retrobulbar Injections in Filler-related Vision Loss Miss Rachna Murthy and Professor Jonathan Roos explore the emergency management of filler-induced vision loss Modern hyaluronic acid (HA) based dermal fillers have the power to change lives. Their popularity has grown,1 and with it the concern around complications.2 Although exceedingly rare, none is perhaps more feared than the onset of vision loss after an injection.2 Not surprisingly, a brief internet search will find many courses offering training in retrobulbar injection with hyaluronidase – the enzyme that can break down HA. However, is there evidence to suggest that it works? This article explains the latest evidence for the emergency management of filler-induced vision loss, why retrobulbar injections could compound the injury and why this approach is best avoided.

eye). Haemorrhages behind the eye can cause further damage to nerves and muscles and a painful compartment syndrome. Introduction of infection can spread back into the cavernous sinus with devastating consequences. In fact, there is even danger to the opposite unaffected eye; ocular trauma can reveal antigens normally hidden from the immune system and cause an autoimmune disease against the previously healthy eye.4 When blindness in one eye becomes blindness in both eyes, medicolegal questions will arise – particularly if the clinician is inexperienced in the technique.

Basic research evidence for retrobulbar hyaluronidase Understanding retrobulbar injections A retrobulbar hyaluronidase injection is often advocated as an emergency treatment following blindness caused by HA dermal filler injection. It involves passing a sharp 23 gauge bevelled needle behind the globe.3 It is passed either through skin or conjunctiva at the outer third of the orbit and advanced straight back for 15mm and parallel to the floor, before changing to point upwards and inwards, passing through into the muscle cone behind the eye. As shown in the larger central image in Figure 1, the globe itself is 23.5mm and the orbit 4.8mm – so a needle length of 38mm (red) is more likely to hit the optic nerve than 24mm (green). However, optic nerve damage is not the only potential danger. Needles can penetrate the globe, causing glaucoma, retinal detachment and eventual phthisis (an unsightly shrunken

Retinal detachment intraocular haemorrhage

Iris trauma cataract

Given that there are courses available for teaching retrobulbar technique, one would have thought that there would be strong preclinical evidence for its use. Indeed, HA can be digested when a ligated cadaveric blood vessel filled with HA is suspended in a bath of hyaluronidase overnight.5 But when this experiment was repeated with living blood vessels the enzyme could not cross the wall into the lumen.6 The orbit and vasculature also have inhibitors of hyaluronidase activity which will deactivate any injected enzyme.7,8 Furthermore, the central retinal artery, which is blocked with filler in filler-related vision loss, enters inside the optic nerve and is covered with dura, pia and arachnoid mater layers preventing passive enzyme ingress.9,10 Despite the pre-clinical improbability – could retrobulbar hyaluronidase still work clinically?

Damage to optic nerve

Corneal opacity pthisis bulbi

Retrobulbar haemorrhage damage to muscles

Figure 1: Retrobulbar injections should be performed with a needle not of excessive length (centre image) but can nevertheless cause a myriad of complications to both internal and extraocular contents.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Treating dermal filler blindness

STEP 1: Confirm diagnosis Record vision using written text/Snellen chart on smart phone/laptop. Check pupil light reflex is direct and consensual and check for relative afferent pupil defect (RAPD). Check and document eye movements in cardinal positions of gaze – preferably with video. Check confrontation visual fields.

STEP 2: After diagnosis whilst other measures are being prepared Demonstrate ocular massage to patient and commence . Call local ophthalmology centre for help. Have their number readily available. Hypercapnia: rebreathing into a paper bag, limited by symptoms of dizziness. Consent patient for hyaluronidase treatment. Have resuscitation equipment available as hyaluronidase has 0.1% risk of anaphylaxis. Reconstitute 1500IU of hyaluronidase (Wockhardt) in 1ml bacteriostatic saline. To 0.5ml hyaluronidase solution add 0.5ml saline = 750 IU per ml. Ensure you and your staff know the location of your hyaluronidase. Inject hyaluronidase into area where hyaluronic acid was originally injected and all around angiosome distribution of vessel supply by serial puncture including supratrochlear/supraorbital area (75IU in 0.1ml up to 1500IU for vessel distribution). Review reperfusion and repeat every 15 to 30 minutes. If available: preferably IV rather than oral acetazolamide (Diamox) 500mg bolus and any topical ocular antihypertensives (e.g. beta blocker, iopidine, dorzolamide). Prepare transfer to ophthalmology . Send hyaluronidase with patient for ophthalmologist as they may not have any in stock.

STEP 3: Specialist ophthalmic interventions Consider inferotemporal quadrant retrobulbar hyaluronidase injection 1500IU in 4ml saline with 25G retrobulbar needle. Limbal paracentesis with removal of 0.1-0.2ml of aqueous from anterior chamber (remove the plunger on an insulin syringe to allow passive filling). Do not continue with ocular massage. Repeat hyaluronidase to vascular territory hourly till capillary refill time (CRT) less than four seconds (up to six cycles per day). Consider: 1. Repeat retrobulbar hyaluronidase 2. IV heparin/steroid if available 3. Hyperbaric oxygen if available 4. Scar management 5. Pain management according to analgesic ladder

To date, there is no documented evidence of an intervention resulting in complete vision rescue after central retinal artery occlusion with HA.16 The matter is further complicated by a not insignificant rate of recorded spontaneous resolution (22-87%) after central retinal artery occlusion (CRAO) due to other emboli.17 The mechanism of filler-induced blindness is also debated; it can likely be caused not just by filler blocking the lumen (inside passage) of the vessel but also perhaps by external compression of a vessel, or a vessel being sent into spasm from filler. In 2019 the AIIVL Consensus group published guidelines recommending retrobulbar hyaluronidase be performed by an ophthalmologist within a 90-minute window.16 This is also recommended in current guidance by the Aesthetic Complication Expert (ACE) Group World.18 However, we recently contributed to an international consensus group including colleagues from California, France and the UK which looks at new evidence.19 Whilst acknowledging the difficulty in analysing case studies, we devised a protocol, representing our best advice based on the available clinical and in vitro evidence (Table 1). This advice includes taking into account the relative risk of the intervention causing harm.

STEP 4: Ophthalmic investigations (but not if delay treatment) Consider neuroimaging with angiography. Fundus fluorescein angiography. Optical coherence tomography/ultrasound. Table 1: Recommended interventions for visual loss after HA filler treatment as per Murthy et al.19

Clinical evidence for retrobulbar hyaluronidase Unfortunately, here too the evidence is weak. Clinical certainty is elusive as our knowledge is gathered from sporadic case reports which differ in factors such as time of onset, delay to treatment, area affected, co-morbidities, and treatment type.11 A review of 44 cases has not found a single instance of successful retrobulbar treatment where the vision was objectively assessed before the intervention.12 Any successes have had multiple confounders preventing conclusions from being drawn.11 As retinal ganglion cells begin to progressively infarct after as little as 12-15 minutes of non-perfusion due to their high metabolic requirements,13 it is perhaps not surprising that there has been such little success in treating blindness. What is thought to perhaps help however, and much more safely, is pulsed hyaluronidase treatment into the affected vascular area, and in the area of the supraorbital artery, where there are anastomoses with the internal carotid circulation – some hyaluronidase may be injected intravascularly.14 There may, however, still exist a role for retrobulbar hyaluronidase. This is in the setting of orbital pain and changes in eye and lid position. Unlike the rapidly infracting retina, the muscles in the orbit are more resilient.15 The supplying vessels are not encased in dura and may be more amenable to treatment with prolonged ischaemia.10

A review of 44 cases has not found a single instance of successful retrobulbar treatment where the vision was objectively assessed before the intervention

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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4. Choose needle or cannulas appropriately. Though a recent study has suggested that cannulas, being less sharp, are safer than needles this need not be the case in every situation.27 A fine bore cannula may act as a needle. When injecting onto bone, needles can allow cleaner penetration, while cannulas may be preferable when injecting into soft tissues. A limitation to many complication reports is whether a cannula or needle was used at the time of injection, complicating analysis. But evidently, complications can occur with either.

Figure 2: Duplex ultrasonography can readily identify the supraorbital and dorsal nasal arteries. An ultrasound device such as the 18mHz Toshiba linear probe can be used to identify plane of injection and digital occlusion prior to injection.

What can we do to avoid filler-induced blindness? It is better to avoid complications than to treat them. We therefore also recommend employing the below prevention methods whenever possible. 1. Aspirate prior to injection when using a needle on bone. Blood in the syringe can suggest entry into a vessel lumen.20 Note that this method cannot be relied upon completely, depending on the filler rheology, needle diameter, fullness of syringe and aspiration time.21 2. Perform micromovements when injecting in soft tissue. This ensures that any intravascular injection is only short-lived and of a small volume.22 3. Use ultrasound. This can reduce risk by detailing local vessel anatomy (Figure 2)2 before and during injection,24 and with digital compression of vessels using pressure with your fingers. Applying pressure over the orbital rim can reduce anastomotic passage of emboli into ophthalmic circulations and alter flow direction of any potential embolus.25,26

Aesthetics Clinical Advisory Board Lead, and co-author of the new hyaluronic acid related vision loss guidelines, Mr Dalvi Humzah says… Iatrogenic induced visual loss is devastating to the patient, and when faced with this complication it would arguably be difficult for the practitioner to remain calm and provide appropriate treatments. Retrobulbar injections of hyaluronidase have for some time been proposed as a treatment modality; when considering this it is important that we address both the practitioner’s competence and the evidence of effectiveness. In this article Miss Rachna Murthy and Professor Jonathan Roos

5. Use correct volumes and force. Even a very small volume can obstruct the CRAO when flow is reversed at a circulatory anastomosis.28 The evidence does not suggest a safe or dangerous volume, rather the correct volume to achieve the desired clinical effect should be given slowly and with as little force as possible. With higher forces, an HA embolus can be propelled against the arterial current before release of pressure allows it to flow forward and block the CRAO.29 If at all possible, injection pressure should not exceed pulse pressure. Consider that ‘gentle and slow is the way to go’. 6. Choose the correct filler. There is no suggestion in the literature that a particular filler is more or less likely to cause occlusion and vision loss, but those with a higher cohesivity and cross-linking would be expected to be more likely to obstruct vessels. One should therefore use high G’ products where they are indicated, in areas for lift, and use the less cohesive products in the higher risk areas such as the tear troughs and orbit.

present the compelling view that this procedure should only be considered in a specialist setting. For practitioners faced with this complication, this article provides an updated pathway that they can use in clinic and transfer patients onto specialists for further interventions. As noted in this article the evidence base for retrobulbar injections is confounded by many variables and when considering appropriate treatments, we should all be mindful of, and evaluate, the evidence base and anecdotal reports that are presented. There are several studies looking at alternative treatment protocols for visual loss and hopefully these will come to fruition in the near future. This is an essential read and provides practical advice for all practitioners in aesthetics.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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More evidence is needed We believe the evidence for retrobulbar treatment is insufficient to advocate its use, particularly by those not routinely operating in or around the eye – a message that we, alongside the British Oculoplastic Surgery Society, are now trying to disseminate.30 The potential risks are significant, including to the other eye. Interventions depend not just on evidence but also a balance between their potential for benefit and harm. Weighing these up, we support ocular massage, rebreathing carbon dioxide, intraocular pressure lowering medication, as well as subcutaneous and supratrochlear hyaluronidase regardless of time of onset and delay to treatment.16 Only with further data can guidelines improve. We therefore urge practitioners who come across visual disturbance post filler, to ensure they inform the Medicines and Healthcare products Regulatory Agency (MHRA) through the Yellow Card System. Practitioners are also welcome, and encouraged, to assist in our further research on this topic by emailing FaceRestoration, so that we may help to inform further practice. Miss Rachna Murthy is a Cambridge and Londonbased consultant oculoplastic and aesthetic surgeon and co-owns FaceRestoration. She is regarded as an authority on thyroid eye disease, eyelids, skin cancer and is on Allergan’s Faculty for filler complications. Miss Murthy trained in Melbourne, Chelsea and Moorfields, and sits on the RSM Eye Council and IMCAS Alert Board. Qual: BSc(Hons), MB, BS, FRCOphth Professor Jonathan C P Roos is a Harvard, Cambridge and Moorfields-trained consultant oculoplastic surgeon and academic based in London at FaceRestoration. His work has been published in the world’s leading medical journals and he lectures internationally on aesthetics, eyelid diseases and thyroid eyes. With Miss Rachna Murthy, Professor Roos also runs a Cambridge dissection course for aesthetic filler safety called Aesthetic Clinical Training Academy. Qual: BA(Hons), MB BChir, MA PhD(Cantab), FRCOphth FEBO

Test your knowledge!

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

Possible answers

1.

a. b. c. d.

5 minutes 15 minutes 90 minutes 24 hours

2. Retrobulbar injections penetrating the

a. b. c. d.

Nasopharynx Frontalis muscle Facial nerve Other eye

3. Which of the following manoeuvres

a. b. c. d.

Ocular massage Back massage Facial massage Lymphatic massage

4. Hypercapnia or rebreathing into a

a. b. c. d.

Vasoconstriction Vasospasm Vasodilation Vasoproliferation

5. Which of these assessments are not

a. b. c. d.

Check eye movements Check pupil reaction Check vision in each eye Check iris colour

The retinal ganglion cell survival time is…

eye can cause damage to the…

can dislodge a hyaluronic acid retinal embolus…

paper bag causes…

necessary in the case of Hyaluronic Acid Filler Embolus related vision loss?

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REFERENCES 1. International Society of Aesthetic Plastic Surgeons (ISAPS) International survey on aesthetic cosmetic procedures performed in 2018. ISAPS Global Survey Press Release. 3 Dec 2019. 2. Murthy R, Roos J, Goldberg R. Periocular hyaluronic acid fillers: Applications, implications, complications. Curr Opin Ophthalmol. 2019 Sep;30(5):395-400. 3. Fahmi A, Bowman R. Administering an eye anaesthetic: principles, techniques, and complications. Community Eye Health. 2008;21(65):14-17. 4. Sympathetic ophthalmia. By: Chang GC, Young LH, Seminars in ophthalmology, 1744-5205, 2011 Jul-Sep, Vol. 26, Issue 4-5. 5. DeLorenzi C. Discussion: assessing retrobulbar hyaluronidase as a treatment for filler-induced blindness in a cadaver model. Plast Reconstr Surg 2019;144(2):321-324. 6. Hwang CJ, Mustak H, Gupta AA, Ramos RM, Goldberg RA, Duckwiler GR. Role of retrobulbar hyaluronidase in filler-associated blindness: evaluation of fundus perfusion and electroretinogram readings in an animal model. Ophthalmic Plast Reconstr Surg Jan/Feb 2019;35(1):33-37. 7. Fagien S, Carruthers J. Commentary on restoration of visual loss with retrobulbar hyaluronidase injection after hyaluronic acid filler. Dermatol Surg 2018;44(3):437-443. 8. Mio K, Carrette O, Maibach HI, Stern R. Evidence that the serum inhibitor of hyaluronidase may be a member of the inter-alpha-inhibitor family. J Biol Chem. 2000;275(42):32413-21. 9. Adulkar N, et al. An In Vitro Model Assessing the Penetration of Hyaluronidase through Optic Nerve Dura for Management of Hyaluronic Acid Facial Filler Embolism. Plast Reconstr Surg. 2019 Jul;144(1):43e-47e. 10. Paap M, Milman T, Ugradar S, Silkiss R. Assessing Retrobulbar Hyaluronidase as a Treatment For Filler-Induced Blindness in a Cadaver Midel. Plast Reconstr Surg. 2019 Aug;144(2):315-320. 11. Chestnut C. Restoration of visual loss with retrobulbar hyaluronidase injection after hyaluronic acid filler. Dermatol Surg Off Publi Am Soc Dermatol Surg 2018;44(3):435-437. 12. Kapoor et al (REF: Kapoor KM, Kapoor P, Heydenrych I, Bertossi D. Vision loss associated with Hyaluronic Acid Fillers: A Systematic Review of Literature 2020 Jun;44(3):929-944). 13. Yu DY, Cringle SJ. Oxygen distribution and consumption within the retina in vascularised and avascular retinas and in animal models of retinal disease. Prog Retin Eye Res. 2001; 2:175-208. 14. Wibowo A, Kapoor KM, Philipp-Dormston WG. Reversal of post-filler vision loss and skin ischaemia with high-dose pulsed hyaluronidase injections. Aesthet Plast Surg. 2019 Oct;43(5):1337-1344. 15. Chen HY, et al. Proteomic Analysis of Various Rat Ocular Tissues after Ischemia-Reperfusion Injury and Possible Relevance to Acute Glaucoma. Int J Mol Sci. 2017;18(2):334. 16. Humzah MD, Ataullah S, Chiang C, Malhotra R, Goldberg R. The treatment of hyaluronic acid aesthetic interventional induced visual loss (AIIVL): A consensus on practical guidance. J Cosmet Dermatol. 2019 Feb;18(1):71-76. 17. Hayreh SS. Central retinal artery occlusion. Indian J Ophthalmol. 2018 Dec;66(12):1684-1694. 18. Walker L, & King M, This month’s guideline: Visual Loss Secondary to Cosmetic Filler Injection, J Clin Aesthet Dermatol. 2018 May; 11(5): E53–E55. 19. Murthy R, Ataullah S, Cartier H, Galatatoire O, Humzah D, Malhotra R, Goldberg R, Roos JCP. Hyaluronic Acid Related Vision Loss: Pathophysiology, Prevention, & Emergency Interventions. (in submission). 20. van Loghem JAJ, Fouché JJ, thuis J. Sensitivity of aspiration as a safety test before injection of soft tissue fillers. Journal of Cosmetic Dermatology. 2018;17(1):39-46. 21. Kapoor KM, Murthy R, Hart SLA et al. Factors Influencing Pre-injection Aspiration for Hyaluronic Acid Fillers: A Systematic Literature Review and Meta-analysis. Dermatol Ther. 2020 Oct 1;e14360. 22. Goodman GJ, Magnusson MR, Callan P, et al. A Consensus on Minimizing the Risk of Hyaluronic Acid Embolic Visual Loss and Suggestions for Immediate Bedside Management. Aesthet Surg J. 2020 Aug 14;40(9):1009-1021. 23. Habib SM, Schelke LW, Velthuis PJ. Management of dermal filler (vascular) complications using duplex ultrasound. Dermatol Ther. 2020 Jul;33(4):e13461. 24. Loh KT, Chua JJ, Lee HM, et al. Prevention and management of vision loss relating to facial filler injections. Singapore Med J. 2016;57(8):438-443. 25. Tansatiti T, Moon HJ, Apinuntrum P et al. Verification of Embolic Channel Causing Blindness Following Filler Injection. Aesthet Plast Surg. 2015 Feb;39(1):154-61. 26. Alam M, Kakar R, Dover JS, Harikumar V, Kang BY, Wan HT, Poon E, Jones DH. Rates of Vascular Occlusion Associated With Using Needles vs Cannulas for Filler Injection. JAMA Dermatol. 2021;157(2):174-180. 27. Taylor G, Ian AO, Shoukath S, Gasgoine A, Corlett R, Ashtom M. The Functional Anatomy of the Ophthalmic Angiosome and Its Implication in Blindness as a Complication of Cosmetic Facial Filler Procedures. Plast Reconstr Surg 2020 Oct;146(4):745. 28. Cho K-H, dalla Pozza E, Toth G, Gharb BB, Zins JE. Pathophysiology Study of Filler-Induced Blindness. Aesthet Surg J. 2019;39(1):96-106. 29. BOSS, Retrobulbar Hyaluronidase to reverse CRAO following injection of facial fillers, 24th February 2020. <https://www.bopss.co.uk/bopss/retrobulbar-hyaluronidase-to-reverse-crao-following-injectionof-facial-fillers/>

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

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Advertorial Galderma

WHY is Restylane® the world’s most diverse range of HA fillers? The Restylane® range utilises two technologies to stabilise hyaluronic acid into a gel form. When injected, it adds volume to smooth wrinkles and enhances facial balance where needed. Restylane® dermal fillers contain hyaluronic acid that has been stabilised with a cross-linking technology. This makes the chains of the hyaluronic acid molecules form a three-dimensional network that is remarkably similar to naturally occurring hyaluronic acid but does not degrade at the same rate. The Restylane® range delivers results that last up to 24 months with one treatment.

Restylane® Dermal Fillers Know our NASHAs from our OBTs to create a personalised signature look with Restylane® hyaluronic acid fillers What is the science behind Restylane®? Restylane® is the original non-animal stabilised hyaluronic acid dermal filler offering an extensive range of effects.1-6 The complementary range of Restylane® dermal fillers can be tailored to any individual look to enhance and refine facial features.

What is the history of Restylane®? Galderma launched Restylane®, the world’s first non-animal hyaluronic acid filler, in Europe in 1996 and secured the first FDA approval in 2003. Experience is built on more than 50 million treatments,7 over two decades of safety data, and a robust clinical trial programme characterising the efficacy, safety profiles, satisfaction, and durability of Galderma’s hyaluronic acid-based treatments. Restylane® is the most well-established filler on the market with multiple decades of experience.7

NASHA for lifting and precision

OBT for contouring and expression

Firmer gels with minimal modification. Utilises the natural entanglement of hyaluronic acid strands creating unique gel properties with less synthetic cross-linking.12

Soft gels with high flexibility and varied degrees of cross-linking and calibration creating a range of gels providing natural looking effects.3,14

• Intended for projection and

structure8 • Suited for enhancing cheeks and filling lips, wrinkles and folds • When precision is needed8,13 NASHA can be used for nose chin, and jawline.

• Intended for contouring

and volumisation of the mid-face. • Suited for dynamic areas allowing for natural animation such as lips, nasolabial folds, and perioral lines.15,16

Types of filler 1. Restylane® NASHA gels

The Restylane® Non-Animal Stabilised Hyaluronic Acid (NASHA™) gels are firmer with minimal modification and are used to create projection and definition. The Restylane® NASHA gels are very close to the natural composition of hyaluronic acid. They offer a precise and pronounced lift, suitable for lifting the cheeks, enhancing the jawline or chin, or reducing the appearance of wrinkles.10

2. Restylane® OBT gels

The Restylane® Optimal Balance Technology (OBT™) gels are softer and more flexible enabling smoother integration into the tissue for naturallooking results. They are used, for example, to add volume in the mid-face, or to enhance contours for patients. Restylane® OBT gels are also used for dynamic areas of the face such as lips and cheek wrinkles.3,4,11 OBT gels are most useful for contouring and expression. REFERENCES 1. Data on File. REF MA-33939. Galderma Ltd. 2. Öhrlund A. Poster presented at AMWC 2019. 3. Philipp-Dormston WG et al. Dermatol Surg 2018;44(6):826-832. 4. Data on File. REF MA-34675. Galderma Ltd. 5. Segura S et al. J Drugs Dermatol 2012;11(1 Suppl:s5–s8). 6. Tezel A, Fredrickson GH. J Cosmet Laser Ther 2008;10:35–42. 7. Data on File. REF MA-39680. Galderma Ltd. 8. Andriopoulos B et al. Poster presented at AMWC 2019. 9. Data on File. REF MA-39364. Galderma Ltd. 10. Kablik J et al. Dermatol Surg 2009;35(Suppl1):302–312. 11. Data on File. REF MA-33947. Galderma Ltd. 12. Micheels P et al. J Drugs Dermatol 2016;15(5):600-606. 13. Lundgren B et al. J Drugs Dermatol 2018;17(9)982-986. 14. Data on File. REF MA-43049. Galderma Ltd. 15. Nikolis A et al. Aesth Surg J Open Forum 2020;2(1) ojaa005. 16. Solish N et al. J Cosmet Dermatol 2019;18(2):738-746.

For more information about the Restylane Range please contact your Galderma Key Account Manager or Medfx. ADVERSE EVENTS SHOULD BE REPORTED For Ireland, suspected adverse events can For the UK, report forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. be reported via HPRA Pharmacovigilance, www.hpra.ie; Adverse events should also be reported to Galderma (UK) Ltd. Email: Medinfo.uk@galderma.com Tel: +44 1 923 208950

Aesthetics | July 2021

This article is sponsored by Galderma (UK) Ltd.

UKI-RES-2100073 DOP June 2021

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overview, which are discussed in more detail below and in the ACE Group World paper titled ‘Management of a Vascular Occlusion Associated with Cosmetic Injections’.1

Pain Bruising is caused by extravasation of blood when a vessel is injured by trauma and often associated with some pain or discomfort at the time of injury; although, bruising on its own does not normally cause a significant or prolonged amount of pain when caused by facial aesthetic injections.1 When body tissue is starved of blood and oxygen, as in the case of a VO, this causes hypoxia and a tissue response which is a painful phenomenon. During or following a dermal filler treatment, if the patient experiences an undue amount of pain, the practitioner should be mindful of the possibility of a VO.1 It should be noted that dermal Dr Martyn King provides an introduction to fillers containing local anaesthetic and differentiating between a bruise and a vascular the use of topical anaesthetic prior to treatment can mask the pain sensation occlusion when performing dermal filler treatments of a VO. Therefore, if you are using these Bruising is not uncommon for patients when having a dermal pain management techniques, be mindful that this symptom is a less filler treatment and is usually mild and self-limiting. However, it is reliable marker when assessing for a VO.1 essential that bruising is not confused with a vascular occlusion (VO) or vice-versa. A VO needs immediate management and a delay in Colour the diagnosis or treatment could have devastating consequences If dermal filler is injected intravascularly, this will often initially flush for the patient. the blood out of the vessel, resulting in a change of colour and paler VOs are a rare complication of dermal filler treatments, with an appearance along the course of the vasculature in a reticulated or net incidence of 1 to 10 cases per 100,000 treatments.1 However, due like pattern. Practitioners need to be vigilant whilst injecting to look to the rising popularity of dermal filler treatments as well as nonfor this sign because at this stage, stopping injection and attempting medical practitioners, we are observing an increase in the number aspiration, as well as applying heat, and vigorous massage may be all of complications. The Aesthetic Complications Expert (ACE) Group that is required to prevent a VO.1 Blanching can be more difficult to see World is currently helping to diagnose and manage two to three VOs in darker skin types, but there will usually still be a change in colour each week – sometimes more. It is also worrying that there are many in a characteristic pattern which should not be missed. Additional practitioners who are wrongly diagnosing bruises as a VO. Even more signs and symptoms of a VO may need to be relied on more for skin concerning is when a practitioner has believed the skin’s appearance of colour. A VO will often initially result in a paler, dusky appearance to be bruising when in fact, it’s a VO and its correct management has to the skin along the course of the affected blood vessel. As hypoxia been delayed or missed causing severe long-term damage. and tissue compromise occurs over the following hours and days, the As medical aesthetic practitioners, it’s imperative that you educate tissue often becomes more reddish-purple due to the accumulation yourself about correct diagnosis. There are several signs and of deoxygenated blood cells and tissue death. Although it will still symptoms that can be used to help differentiate between a bruise and have a characteristic pattern, the area of colour change will not just a VO which all practitioners should be aware of. See Table 1 for an include the vasculature itself, but the surrounding tissue that had been perfused by the blood vessel.1 Characteristic Bruising VO In contrast, bruising will at first appear reddish-purple, before becoming purplePain At time of injection only Escalating discomfort and pain over time black in colour. As it resolves, it may Colour (immediate) Reddish-purple Blanching and pallor become greener then yellow.1

Bruising vs Vascular Occlusion

Colour (hours to days)

Green to yellow

Red and possibly crusting

Pattern

Well demarcated

Reticulated

Blanching with pressure

No

Yes

Timing

May be delayed

Often immediate

Table 1: Signs and symptoms to look out for when administering dermal fillers1

Pattern The hallmark of a VO is the pattern of discolouration which follows the blood supply and is often described as reticulated. It is important that practitioners performing dermal filler

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Figure 1: Typical colour and demarcation of bruising

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Figure 2: Typical reticulated appearance of a VO

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Figure 3: Late appearance of a VO (necrosis)

treatments have a good knowledge of the blood supply to the face to help them recognise this appearance. They should also have a better understanding of where to inject hyaluronidase in the management of this complication. Bruising, on the other hand, is more localised, and will follow the tissue plane and tends to run inferiorly because of gravity. Due to the differences in fat compartments and facial boundaries, bruising is often quite well demarcated, and practitioners should be familiar with facial anatomy to help them to identify bruising.1

Blanching One of the other characteristics of a VO is blanching and practitioners should be competent to perform a capillary refill test (CRT) if they suspect an occlusion. This is performed by applying firm digital pressure to an area of skin for at least three seconds and then assessing the reperfusion once pressure is released.1 Ideally, CRT is assessed prior to treatment, but in the case of a suspected VO, the area being tested can be compared to the opposite side of the face. Normal tissue will have a capillary refill time of less than three seconds, but in areas where the blood supply has been compromised, the amount of time for the skin to return to its normal colour will be longer. Changes in skin colour due to a VO will still blanch when pressure is applied, however areas of colour change due to bruising do not blanch and so provides further evidence to making the correct diagnosis to allow appropriate management.1 When it comes to darker skin types, although it is more difficult to visualise colour change, by performing a CRT, the practitioner should notice a lightening of colour after pressure has been applied in normal skin and this colour change will take longer to return to normal if there is a vascular compromise.

Time of onset A VO usually presents immediately upon injection and signs and symptoms start to appear rapidly, whereas bruising may not be obvious straightaway and may appear in the subsequent hours. However, in rarer instances, the ACE Group World have also helped diagnose VOs that have appeared several hours post-treatment and quite extensive bruising immediately post-treatment, which has mimicked a VO.

Other considerations There are also other factors that may make the diagnosis of a bruise or a VO more likely based on medical history, product used and the procedure itself. For example, patients who have been taking certain medications, including anti-inflammatories (such as aspirin, ibuprofen, naproxen or diclofenac), steroids or blood thinners are more likely to experience bruising.2 Similarly, patients who have been taking certain vitamins and over-the-counter remedies or recent alcohol intake may also be more prone to bleeding and

bruising.2 The procedure itself may be more likely to cause bruising if there are multiple injection sites, use of a needle in preference to a cannula and certain areas of the face being treated, such as the lips.2 As well as this, certain areas of the face are at a higher risk of VO and should raise a higher degree of suspicion if skin changes occur. These areas include the lips, nose and glabellar.1

Diagnosis uncertainty If the practitioner is unsure of the diagnosis, they should always seek the opinion of a more experienced practitioner or contact a complication association such as the ACE Group World. There is an emergency helpline for members who can speak to practitioners with a huge amount of experience and skill in managing these complications. Finally, it is essential that you consent your patients for all possible aesthetic complications, including bruising and a VO, prior to treatment and provide them with written aftercare. A reachable out of hours contact number should also be provided for them to use in the event that they are worried they are developing a complication and practitioners should be available to review them. Although this review may initially be via telephone or video, this is not a substitute for a face-to-face assessment. As time is of the essence, this may require an immediate appointment. Additionally, practitioners offering dermal filler treatments have a duty of care to their patients and if they will be unavailable to offer a face-to-face review if a complication occurs following treatment, they should make arrangements for a competent practitioner to be available.

Time is critical Practitioners performing dermal filler treatments must be able to differentiate between bruising and a vascular occlusion in a timely manner in order to manage a complication. Sometimes the appearance and onset are not typical, and practitioners should use a stepwise approach as outlined in this article to come to the right conclusion. If the practitioner is in doubt, they should seek a second opinion from a more experienced practitioner. Dr Martyn King is the director of Cosmedic Skin Clinic, chairperson of the Aesthetic Complications Expert Group World, vice chair of the Joint Council for Cosmetic Practitioners and brand ambassador and key opinion leader for several leading aesthetic companies. Qual: MBChB, MSc, PGDip, PGCert

Learn more at CCR! Dr Martyn King and the Aesthetic Complications Expert Group World facility will be presenting a one-day conference at CCR on October 14. Read more on p.22 and go to www.ccrlondon.com for more info. REFERENCES 1. King M, Walker L, Convery C, Davies E. Management of a Vascular Occlusion Associated with Cosmetic Injections. J Clin Aesthet Dermatol. 2020 Jan;13(1):E53-E58. Epub 2020 Jan 1. PMID: 32082474; PMCID: PMC7028373. 2. King M, Prevention and treatment of ecchymosis in non-surgical aesthetic practice. ACE Group guideline.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Addressing Photodamage Dr Kim Booysen explores the use of the new BELOTERO® Revive for skin dehydration and treating the sign of early onset photodamage BELOTERO® Revive, the latest product from Merz Aesthetics, is indicated for treatment of the early signs of photodamage, such as dehydration, fine lines and loss of elasticity.1 Dr Kim Booysen, shares with you her experience of using BELOTERO® Revive and introducing it into her clinic. What are skin revitalisers designed to do? Skin revitalisers designed to target skin roughness, pore size, fine lines, hydration, redness and increase elasticity through the stimulation of collagen and elastin synthesis.1 Most skin revitalisers require 2-3 treatments over several weeks to months to see a change in skin quality.1 Skin revitalisers usually contain a form of hyaluronic acid, for its hydrating ability, combined with other ingredients to target the signs of skin ageing and lost collagen and elastin. With the rise in younger patients being interested in combating signs of ageing,

I was very keen to find a product that specifically targeted these early signs of photodamage. The introduction of BELOTERO® Revive has met that need for this patient cohort in my clinic.

Why introduce a skin revitaliser to your clinic? Skin quality has become a marker for health, youthfulness and attractiveness. Many studies have been published to highlight the impact of skin disease on patient’s selfesteem, mental wellbeing and daily activities. The historical cause is due to the negative connection between skin conditions and social disgrace or a threat to physical health. The use of makeup, to cover skin conditions, and the associated increase in self-esteem and perceived attractiveness with use, has further underlined the importance of improving skin quality in facial rejuvenation. As a result, my consultations always start with a discussion on skin health and how healthier skin can influence the patient’s appearance, mental wellbeing and overall happiness with treatment outcomes. More and more patients are seeing the importance of treating both the skin’s appearance alongside any volume loss or fine lines and wrinkles as they age. The rise in interest amongst younger patients has also led to an increase in skin revitaliser use in my clinic.

How is BELOTERO® Revive different? BELOTERO® Revive, is the newest product in the BELOTERO® range from Merz Aesthetics. BELOTERO® Revive is an injectable product that combines both hyaluronic acid and glycerol to achieve an improvement in the early signs of photodamage.1 Photodamage is a change in structure, appearance and function of the skin after

Adapted from Hertz-Kleptow et al.

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Aesthetics | July 2021


immediately after treatment and a immediately after treatment and a reduction in the signs of photodamage Advertorial reduction in the signs of photodamage from the first treatment. @aestheticsgroup @aestheticsjournaluk Aesthetics aestheticsjournal.com from theMerz Aesthetics first treatment. BELOTERO® Revive has an excellent BELOTERO® has an side excellent safety profile1Revive and the only effect Before After in skin elasticity 1at 7 months from initial safety the only effect noted profile was theand bruising thatside reduced 6 treatment with BELOTERO® Revive, while noted was the bruisingand thatusually reduced over the 3 treatments skin firmness remained increased to 6 over the 3bytreatments and usually All resolved day 3 post treatment. months. Skin hydration increased for up to 9 resolved by day 3 post treatment. All patients were happy to complete Before After months and skin redness and roughnessthe was patients were happy to complete the full course of treatment reported Before After significantly reduced.⁶ Overall satisfaction was immediately after treatment and a and full course of of treatment and reported 6 no discomfort with treatment. In the Belove clinical study patients reported a 70% increase in satisfaction reduction 80%in atthe 6 months. signs photodamage 6 no discomfort witha palpable treatment. In the Belove clinical study patients reported a 70%Revive. increase in satisfaction from the in skin hydration up to 7 months with BELOTERO® treatment. Myfirst patients reported improvement in skin hydration up to 7 months with BELOTERO® Revive.6 in skin texture and hydration immediately Dr Kim Booysen is an independent In the Belove clinical study patients reported a 70% increase in

BELOTERO® Revive has an excellent satisfaction in mg/mL skin hydration up to 7 months withcase BELOTERO Revivie. afterKim treatment andowner aisreduction in the signs of Dr Booysen an independent A clinical study has shown a aesthetic clinic in South The combination of 20 1 safety profile and the only side effect photodamage from the first treatment. A clinical case study has shown a aesthetic clinic owner indegrees South The combination mg/mL increase in skin elasticity at 7 months East London. She holds cross-linked CPM of HA20 and 17.5 the bruising that reduced 6 repeatedof exposure harmful light rays. Glycerol BELOTERO® Revive has an excellent safety increase in treatment skin elasticity at BELOTERO® 7 months noted was East London. She holds degrees cross-linked CPMtoHA and 17.5 from initial with in Medicine, Law, International mg/mL glycerol in BELOTERO® 1 over the 3 treatments andside usually 6 component of Exposure can start early without visible signs Glycerol, the other major profile and the only effect noted was from initial treatment with BELOTERO® in Medicine, Law, International mg/mLtherefore of glycerol in BELOTERO® Revive, while skin firmness remained Health Management and All Business Revive makes an ideal skin resolved by day 3 that postreduced treatment. on the skin. As the exposure continues, BELOTERO® Revive, has multiple functions the bruising over the three Revive, while firmness Health Management and Business Revive therefore makes an target ideal skin increased to 6skin months. Skinremained hydrationpatients Management. special interests revitaliser that can actively the were happy toHer complete the Before After signs such as tanning, freckles and within the skin and is a well-known treatments and usually resolved by day three 1 sunthe increased to 6 months. Skin hydration Management. Her special interests revitaliser that can actively target for up to 9 months and skin are medico-legal aesthetics and early signs of photodamage. full course of treatment and reported spots emerge. Later signs such as1 fine to dermatological ingredient for skin renewal. post treatment. All patients were happy to increased forroughness up in to satisfaction 9 months and skin are medico-legal aesthetics andtime early signs of clinical photodamage. redness and was significantly aesthetic education. Her spare no discomfort with treatment. In the Belove study patients reported a 70% increase coarse wrinkles, skin laxity, dryness, rough Glycerol isand a trihydroxy alcohol, that helps with complete the full course of treatment and 6 redness roughness was significantly 6 education. Her spare time is spent travelling with her husband in skin hydration up to 7 months with BELOTERO®reduced. Revive. Overall satisfaction was aesthetic texture, patchy and uneven pigmentation skin hydration, by 6drawing water6in a similar reported no discomfort with treatment. is spent travelling withenvironmental her husband reduced. Overall satisfaction was and working on local 80% at 6 months. 2 Dr Kim Booysen is an independent appear over time. Hyaluronic acid (HA) has manner to HA, it also increases elasticity and Kim Booysen is an and working on 80% at 6 months. A clinical study has shown a6 causes. Dr Dr Booysen isenvironmental a Merz My patients a aesthetic clinic owner in local South The combination of 20 mg/mL been used to rejuvenate skin in multiple speedscase up skin barrier repair.reported Glycerol has independent causes. Drholds Booysen isaesthetic a Merz clinic increase in skin elasticity at 7improvement months My patients reported a East London. She degrees cross-linked CPM HA and 17.5 Innovation Partner. palpable in clinical studies. HA increases hydration, been reported to assist with skin irritation, owner in south east London. She 6 from initial treatment with BELOTERO® in Law, International Innovation Partner. mg/mL offibroblasts glycerol in(therefore BELOTERO® palpable inMedicine, 5improvement skin texture holds degrees in medicine, law, stimulates increasing accelerate wound healing andand act hydration as an antiRevive, while skin firmness remained Health Management and Business Revive therefore makes an ideal skin international health management skin texture and hydration collagen and elastin synthesis), promotes microbial agent. ®

6

increased to 6 months. Skin hydration and business management. Her special Management. Her special interests revitaliser that can actively target the cellular growth factors and restores the The combination of 20 mg/mL cross-linked interests are aesthetics medico-legal aesthetics and 1 increased for up to 9 months and skin are medico-legal and early signs of photodamage. 3 dermal skin matrix. The use of Cohesive CPM HA and 17.5 mg/mL of glycerol in aesthetic education. Her spare time is spent redness and roughness was significantly aesthetic education. Her spare time travelling with her husband and working on Polydensified MatrixTM technology to cross BELOTERO® 6Revive therefore makes an ideal travelling with hercauses. husband reduced. Overall satisfaction was is spentlocal environmental link the HA in BELOTERO® Revive also skin revitaliser that can actively target the early 6 and working on local environmental 80% at 6 months. Dr Booysen is a Merz Innovation Partner. 1 leads to optimal tissue integration in the signs of photodamage. causes. Dr Booysen is a Merz My patients reported a dermal matrix.4 A clinical case study has shown a increase Innovation Partner. palpable improvement in skin texture and hydration

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

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References: 1. BELOTERO® Revive Instruction for use Version 3.0, 2018 References: 2. Aging Skin (v1.0) - Extrinsic factors, smoking and sun (p.1) 3. Wang 2007 - Stimulation of Collagen Production 4. Tran C et al. Dermatology 2014; 228:47-54 5. Fluhr JW, Darlenski R, Surber C. Glycerol and 1. BELOTERO® Revive Instruction for use Version 3.0, 2018 the skin: holistic approach to its origin and functions. Br J Dermatol. 2008 Jul;159(1):23-34. doi: 10.1111/j.1365-2133.2008.08643.x. Epub 2008 Jul 1. PMID: 18510666. 6 Merz BELOVE Study, 2019 2. Aging Skin (v1.0) - Extrinsic factors, smoking and sun (p.1) 3. Wang 2007 - Stimulation of Collagen Production 4. Tran C et al. Dermatology 2014; 228:47-54 5. Fluhr JW, Darlenski R, Surber C. Glycerol and the skin: holistic approach to its origin and functions. Br J Dermatol. 2008 Jul;159(1):23-34. doi: 10.1111/j.1365-2133.2008.08643.x. Epub 2008 Jul 1. PMID: 18510666. 6 Merz BELOVE Study, 2019

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Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be

found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. This advertorial is sponsored by Merz Aesthetics UK &Adverse Ireland

This advertorial is sponsored by Merz Aesthetics UK & Ireland

References: 1. BELOTERO® Revive Instruction for use Version 3.0, 2018 2. Aging Skin (v1.0) - Extrinsic factors, smoking and sun (p.1) 3. Wang 2007 - Stimulation of Collagen Production 4. Tran C et al. Dermatology 2014; 228:47-54 5. Fluhr JW, Darlenski R, Surber C. Glycerol and the skin: holistic approach to its origin and functions. Br J Dermatol. 2008 Jul;159(1):23-34. doi: 10.1111/j.1365-2133.2008.08643.x. Epub 2008 Jul 1. PMID: 18510666. 6 Merz BELOVE Study, 2019

c c

M-BEL-UKI-1185 Date of of Preparation MayMay 2021 M-BEL-UKI-1161 Date Preparation 2021 M-BEL-UKI-1161 of Preparation This advertorialDate is sponsored by May Merz2021 Aesthetics UK & Ireland

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occur when incorrect injection sites are used, with doses that are too high and/or inappropriate patient selection; commonly occurring with inexperienced practitioners.4 No medication has been found to effectively reverse the effects of botulinum toxin. There are various methods, physical and medical, which may provide some improvement prior to normal muscle function returning.

Treatments to improve eyelid and eyebrow ptosis

Understanding Ptosis Dr Aileen McPhillips introduces ptosis following toxin treatment and the relevant options for management Ptosis is derived from the Greek word for ‘falling’ and refers to the drooping of a body part.1 The term is commonly associated with drooping of the eyelid – more specifically called blepharoptosis. Ptosis can occur in all age groups and may be caused by various factors. With relevance to aesthetic practitioners, ptosis may occur as an adverse reaction following botulinum toxin treatment, and therefore is an important issue to be aware of. Botulinum toxin is administered to provide facial rejuvenation, which might result in muscle weakness and potentially lead to eyelid or eyebrow droop.

Where does ptosis occur? Upper eyelid ptosis may occur when treating the glabellar complex. Botulinum toxin diffuses through the orbital septum, affecting the lid elevator muscle as it transverses the pre-periosteal plane, or the toxin may track along the tributaries of the superior ophthalmic vein.2 Drooping of the upper eyelid causes a poor cosmetic appearance and can significantly impair vision. Various studies suggest an incidence of 1-5%, with

the lower incidence occurring when treatment is carried out by experienced practitioners.3,4 Therefore, injection technique and medical experience play a key role in the occurrence of this complication. Eyebrow ptosis is an adverse effect of treatment in which the forehead containing botulinum toxin causes reduced activity in the frontalis muscle.4 It tends to

Careful patient selection is key in avoiding complications post-treatment with botulinum toxin. Following a thorough consultation and full medical history, the practitioner should assess the face and patient’s anatomy noting in particular the brow position and pre-treatment asymmetry. Facial muscle tone should also be assessed and noted. Pre-treatment photography is important for future reference.5 Physical stimulation Physical stimulation including manual or electrical, such as using an electric toothbrush for several minutes daily has been shown to accelerate the return of muscle function in the region. It is anecdotally reported that this improves ptosis hastily and is commonly suggested by experienced practitioners as a useful ritual to follow, however, no formal studies have been conducted to assess this. Medication Anticholinesterase or alpha-adrenergic eye drops enhance cholinergic transmission by indirectly inhibiting the destruction of

Ptosis tends to occur when incorrect injection sites are used, with doses that are too high and/or inappropriate patient selection; therefore more commonly occurring with inexperienced practitioners

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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acetylcholine and therefore increasing or prolonging the effect of nerve impulses.3 The eye drops trigger Müller’s muscle contraction which causes eyelid retraction by 1-2mm, therefore improving the appearance of eyelid ptosis.3 There are several options available, such as apraclonidine 0.5%, brimonidine 0.2%, phenylephrine 0.12% and naphazoline 0.05%.3,6 Studies have suggested that apraclonidine 0.5% is more clinically effective than other eye drops.3,6 These medications may cause problems in patients who suffer from closed-angle glaucoma and should be used with caution.3 An overdose of anticholinesterases may cause hypersalivation, nausea, vomiting, abdominal cramps and diarrhoea.3 However, this medication is generally well tolerated and provides benefit to the patient with these complications.

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force pulling down on the brow (by the corrugator muscle therefore allowing increased upwards pull by frontalis muscle). The technique involves intradermal injection of 0.01ml toxin solution (Bocouture or Botox), laterally 2-3mm under the brow, and 0.01ml medially and deeply at the brow end.4 This has been shown to allow for brow reascent by 1-2mm.4

Summary Ptosis is a potential complication following administration of botulinum toxin, therefore is of relevance to aesthetic practitioners and their patients. Research has suggested that it is less common when procedures are carried out by experienced practitioners. This further highlights the importance of ensuring we, as aesthetic practitioners, have up to date knowledge and skills, whilst offering the highest level of safe patient care.

Dr Aileen McPhillips is a medical graduate of Queen’s University, Belfast and currently works as a GP and aesthetic practitioner, running her own clinic ‘Aesthetics by Dr Aileen – The Skin Health Clinic’ based in Aughnacloy, Co. Tyrone. She is a member of the Royal College of General Practitioners and has completed a Level 7 certificate in Injectables for Aesthetic Medicine. Qual: MB, BCh, BAO, MRCGP, DRCOG REFERENCES 1. Koka K, Patel B C, ‘Ptosis Correction’, StatPearls, Treasure Island, StatPearls Publishing, (2020). 2. King M, ‘Management of Ptosis’, The Journal of Clinical and Aesthetic Dermatology, 9(12), (2016) E1-E4. 3. Grillo R, Ribeiro E, Chaves A, ‘Blepharoptosis Treatment as a Complication due to Botulinum Toxin Application’, Biomedical Research and Clinical Practice, (2020). 4. Redaelli A, Forte R, ‘How To Avoid Brow Ptosis After Forehead Treatment with Botulinum Toxin’ Journal of Cosmetic Laser Therapy, 5(3-4), (2003), p.220-222. 5. King M, Management of Ptosis. J Clin Aesthet Dermatol. 2016;9(12):E1-E4. 6. Omoigui S, Irene S. Treatment of ptosis as a complication of botulinum toxin injection. Pain Med. 2005 Mar-Apr;6(2):149-51. doi: 10.1111/j.1526-4637.2005.05029.x. PMID: 15773880.

Botulinum toxin When eyebrow ptosis occurs following an injection of botulinum toxin, practitioners could inject a further dose to reduce the

Torbac advertorial.pdf

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Advertorial Tor-bac

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Introducing Tor-bac Alison Stevenson, managing director of manufacturer Tor Generics Ltd, introduces the single-dose bacteriostatic saline solution be familiar with the use of bacteriostatic saline solution to reconstitute medicinal products for intramuscular/intradermal injection. Those who use the Tor-bac brand will know that each millilitre of solution contains sodium chloride 9mg and 0.9% (9mg/ml) benzyl alcohol added as a bacteriostatic preservative, which is less painful at the site of administration.

www.tor-generics.com TOR-BAC EAN CODE: 5060219260072 Tel: 01923-825379 Available at Select Aesthetic Wholesalers, Boots Alcura & AAH Pharmacueticals

REFERENCE: 1. Centre for Disease Control, ‘Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injections’ < https://www.cdc.gov/ injectionsafety/providers/provider_faqs_multivials.html> Last accessed: 19 March 2018.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


Advertorial Intraline

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Advancing Your Non-Surgical Rhinoplasty Results Dr Amrit Thiara shares his approach for treating the nose The non-surgical rhinoplasty (NSR) is one of the most requested and performed procedures within my aesthetic clinical practice. The growth in patient awareness and advancements in dermal filler rheology, coupled with novel injecting techniques, has led to the transition from largely surgical to non-surgical approaches in the past decade. Performing upwards of 400 NSR yearly, from very simple nose shapes to more complex post-surgical or anatomically challenging noses, I have expanded my repertoire of techniques and tips for this procedure. Understanding the anatomy and principles behind this procedure in detail is the key to achieving industry-leading results. First of all, avoiding the concept of directly filling the nose and moving towards using the properties of a high-density dermal filler to re-shape the nose with minimal product volume is an important point to make. Remember, the ultimate aim is to reshape and restructure the nose and we can use light reflexes to our advantage to play optical trickery in making noses appear sharper, shorter and smaller. I often see patients who have previously had their nose treated but the end result is a much larger nose on the whole, which may be straighter and more lifted, but defeats the aesthetic proportions entirely.

My approach Precision and product rheology are important for best results. Precision I find is something that needle technique dominates, and I predominantly use 30 gauge Sterinject needles to allow more patient comfort as well as increasing my ability to

Case study Here’s an example of one of the many nose shapes I see and treat in my clinic. In cases like these, I find the key to treating is avoiding viewing the problem as being the prominent dorsal hump. The dorsal hump is often the point around which the rest of the nose should start to pivot. The lower half of the nose needs lifting and supporting to straighten up to the point of the hump, while the bridge above the hump requiring building up and transitioning better into the hump. Supporting the nasal spine and myomodulation are really important here as well as crus lifting. Before

After

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carefully place small droplets of product into the target area. Product rheology is another factor in advancing and perfecting my results. All highdensity dermal fillers do not behave the same and a product with high viscosity is something I look for. A product with a phase angle that allows more tissue projection with less volume is another key element. In clinic I use Intraline M4 Plus for all of my NSR cases and, having used a large selection of other leading high-density fillers, I find myself needing less volume to achieve the nose re-shaping and structural supporting that I need, which in my experience results in an overall smaller result than other products would achieve. I use a 4 anatomical point NSR technique, targeting the radix, anterior nasal spine behind the columella, middle crus, supra-tip lobule and upper lateral cartilages. Treating the radix allows correction of dorsal humps and indentations in the bridge, as well as building the top of a bridge in noses where there is a flattened bridge. I do this by laying small droplets in a bolus fashion onto the nasal bones at the periosteal level. The purpose of targeting the anterior nasal spine is to create additional support at the base of the nose to lift and anchor the columella. This also myomodulates the depressor septi muscle to prevent the nose tip being pulled down on expression/animation. I inject this area with, again, a small bolus against the nasal spine. Treating the middle crus allows lifting and creation of a new light reflex over the supra-tip lobule, which allows shortening of the nasal bridge as well as giving a sharper, and in most cases, a slimmer looking nose. Placing small droplet sized boluses of product between the crus and skin allows the tip to be projected and lifted in the direction of the bolus. Finally, in order to treat the lower nasal bridge and soften saddle deformities or bridge asymmetries, I place linear threads along the cartilage plates at the perichondrial plane. Dr Amirt Thiara graduated in 2014 from Keele Medical School with an Honours & distinction, he currently works as an NHS doctor specialising in small Anaesthetics alongside running his aesthetic clinics (Tiara Aesthetics) across the Midlands. Amrit is a KOL for Intraline along with a dermal filler trainer in the UK & internationally.

This advertorial was written and supplied by

(e) info@intraline.com Patient before and after non-surgical rhinoplasty

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Needle-free pens and fillers

Understanding Needle-free Pens Dr Ashwin Soni explores the rising trend of needle-free filler injector pens There has been a recent growing trend of needle-free filler injector pens. It is concerning that the use of such devices has gone viral on various social media platforms, including TikTok, with young women and even children injecting themselves with filler from injector pens, most commonly in the lips and the face.1,2 Many of these filler pens are readily available for any member of the public to buy across different websites and apps online, including Amazon and eBay. This article aims to explore the mechanism and science behind needle-free injector pens as well as their use both inside and outside clinical practice.

transported directly across the skin in the subcutaneous or intramuscular regions via a high velocity, which can disperse the drug over a larger area compared to a syringe technique.4,5 It has been shown in the literature that the molecules are dispersed more widely in the tissue.3 This has proven to be an effective treatment for insulin administration and other types of medications and this same technology is now being used for filler treatment, and other aesthetic procedures, such as botulinum toxin treatment and mesotherapy.

So how does the use of these types of needle-free injector pens translate to the aesthetic world, specifically for filler-based treatment? The advantages of this needlefree approach, which is being advertised, is that it is beneficial for those with a needle phobia, it causes little or no pain and there is no risk of needle-stick injuries. There are several studies that have demonstrated effective treatment with pneumatic administration of filler with needlefree pens.6,7 For example, one study involved 34 participants that were treated at three clinical sites each on the face, neck, chest, and dorsal hands (total of 69 sites). The authors concluded that pneumatic injection of hyaluronic acid under high pressure provides a safe, well-tolerated and effective method for improving the appearance of wrinkles.8 The papers referenced have small sample sizes but have demonstrated that it is possible to have safe administration of filler with needle-free pens, with good patient satisfaction. It should be noted that these studies were performed by medical professionals with excellent anatomical knowledge.

Treatment safety Many filler pens are being advertised on the internet as being risk-free, given that there are no needles on the device. Numerous websites, as well as some aesthetic training providers, also make the claim that there are no risks associated with injecting filler this way, and that no complications can result. There is a lack of data in the literature with regards to complications associated with needle-free filler injections, but does that really mean that there are no complications? The issue of complications and vascular occlusion could result as a consequence of a thicker and more viscous filler coming out at a

A background on needle-free injector pens Needle-free injector pens are commonly used in the management of diabetic patients who are treated with insulin and have been widely used in other areas of medicine, such as with vaccine administration. The mechanism of action of a needle-free injector works by forming and opening cracks in the skin due to the high pressure and velocity of these pneumatic air pressure devices, with the high-speed stream penetrating the skin.3 Subsequently, the molecules are

Figure 1: How the product of a needle-free filler pen disperses compared to a needle

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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high pressure,9 which can be the case with a needle-free filler pen device. It is logical to say that the filler could penetrate into the deep dermal layer, which can therefore cause the product to penetrate the wall of a blood vessel under high pressure, and thus causing a vascular occlusion. This is particularly problematic if the pressure of the device is unknown by the injector, which is often the case with internet-bought pens as they commonly do not specify this. They often also do not disclose the true components of the product, so we cannot anticipate how it will disperse. Specific cadaveric studies have been performed in order to examine the effects of needle-free injector pens. Seok et al. demonstrated in cadavers that there is a significant difference in penetration depth of materials with different viscosity and density when injected at the same pressure.9 Although these cadaveric studies do not use filler products, they use either latex or gelatin-based products at different viscosities and thicknesses, in order to simulate the mechanism. Another important point is that the depth of penetration of the product is variable depending on the size of the particles of the product, the velocity of the jet, and the nozzle diameter of the injector pen. Studies have shown that the depth of penetration can go beyond the dermis floor when the nozzle diameter is beyond a certain measurement.8,9 This means that it can be extremely hazardous to the areas of the face, for example around the lips and nasolabial creases, where there are superficial vessels. The specific dimensions and details of the injector pens are often not available, so it is challenging to predict what the outcome will be. Another consideration is that needle-free injector pens are releasing product at a high velocity and spreading the product over a larger area.3,4,5 This means the practitioner has no control over the exact location the filler is inserted and the force of the injection. It is not possible to account for how the product will move within the tissues and in which anatomical plane it will spread. As aesthetic providers, we are well aware that precise and very careful placement of product is required in the world of facial aesthetics. The primary reason for this is to minimise the risk of coming into contact with the facial anatomy danger zones. As providers, we need to have total control of where our needle tip is, as well as the

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need to have extensive knowledge of the anatomy and anatomical planes, and to know how much volume is being injected. An Instagram video created by US plastic surgeon Dr Michael Keyes provides an interesting comparison between dermal filler precision and needle-free filler pen precision, which all practitioners should watch before considering the use of these devices.10 Reported complications Complications have been reported globally from the use of needle-free injector pens, and these include vascular occlusion, haematomas, infections, and an increased risk of lumps and cysts.11-13 The two complications groups in the UK kindly shed light on this topic for this article as they have identified several reported complications as a result of needle-free filler injections. Gillian Murray, prescribing pharmacist and founding board member of the Complications in Medical Aesthetics Collaborative (CMAC) group, stated, “Volumising, cross-linked hyaluronic acid dermal fillers are not designed to be administered by needle-free devices. The pressure differential caused by the device, on expulsion of the product, may cause changes to the physicochemical and rheological properties, ultimately damaging these filler products. Excessive trauma and pain are likely to result from using this method of administration, and deposition is uneven and less accurate compared to needle delivery. It is also important to note this is an ‘off-license’ use of dermal fillers as a device. CMAC are aware of several cases of excessive trauma, bruising and haematoma, including a case of vascular occlusion and strongly advise against using these devices. Ultimately, claims of less risk and less pain cannot be substantiated or evidenced.” The Aesthetics Complications Expert (ACE) Group World has also reported complications following injections with needle-free injector pens. On behalf of the ACE Group World, chair Dr Martyn King stated, “The ACE Group World received a call on their emergency helpline from a GP seeking advice about a female patient who had received dermal fillers from a non-medical provider using an auto-injection device. Aesthetic nurse prescriber Linda Mather, who received the call, was concerned and agreed that the bruising was more severe than you would expect from a typical filler treatment.

Figure 2: Ecchymosis as a result of needle-free injector pen filler treatment. Image provided by the ACE Group World.

The conclusion was that the patient had extensive bruising, which did eventually fully resolve, but caused the patient considerable distress requiring a high level of support.” Figure 2, which has been provided by the ACE Group World, shows the ecchymosis present on the patient’s face as a result of the needle-free injector pen filler treatment. Another complication has also been reported by aesthetic nurse prescriber Frances Turner Traill, who treated a patient presenting with impending necrosis, haematoma and vascular occlusion following a needle-free filler treatment performed by a beauty therapist.11

Combining needle-free injector pens with self-injection Alongside the use of needle-free pens by practitioners comes the dangerous use by the public. I must emphasise the dangers of self-injecting, no matter whether it’s a needle or a needleless pen. Self-injecting is very challenging, even for experienced injectors. It is difficult to appreciate the angle and exact location of your injecting device. Alongside this, there is no level of precision with these devices, so it’s unclear to the injector where the product may end up. The importance of knowing your anatomy in detail, and being aware of your anatomical planes, is imperative and it is unclear to those selfinjecting where the danger zones lie. The concept of the public self-injecting filler into their faces even without needles, is quite frankly terrifying.1,2,12

More research is needed Some studies indicate that in skilled and trained, medical hands, needle-free filler injector pens can be effective; however, it

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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is important that if practitioners are to use these devices, they should be clear of the exact product’s characteristics, the device’s pressure, and have excellent anatomical knowledge. They should also know that the precision cannot be the same as a needle or cannula. It is important that both practitioners and the public are aware that it is inaccurate to say that the devices are complication-free and completely safe. These statements are luring the public, and certain aesthetic providers who use these devices, into a false sense of security. Further studies looking at the potential for complications are needed.

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Aesthetics Clinical Advisory Board Lead Mr Dalvi Humzah says… One of the main concepts in aesthetic treatments is the accurate placement of products in specific layers of the body. A needle-free delivery requires a high pressure to allow products to penetrate the skin; the higher the speed and pressure of delivery, the deeper the penetration; however, this is also determined by the relative tissue characteristics of the patient. The more compact and denser the tissue, the more resistance to deeper delivery of the product. This, therefore, makes it difficult to consistently deliver products at a specific depth in every patient. In time, this technology will be of use in specific situations and be a useful adjunct in the aesthetic sector. It does, however, raise the question of the use of new technologies in aesthetics; as a specialty this is a new field and before we start to use new technologies, they must be looked at critically and evaluated in clinical use in an evidence-based manner. This analysis and determination of use must be applied to all new devices now and in the future.

Dr Ash Soni is a US-trained plastic surgeon and the owner of The Soni Clinic, located in Surrey and Berkshire. After attending Imperial College London for medical school, he then relocated to the US completing his plastic surgery training at Cornell, Johns Hopkins, and the University of Washington. Qual: MBBS, MD, BSc

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

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Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021

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circulation, disability, exposure (ABCDE) approach with a critically ill patient. This allowed me to methodically make my assessment of my patient’s CRT and identify the arterial pathway that had been impacted. Below, I outline what I believe to be the prerequisites for making a calm assessment. Sound knowledge in facial anatomy I have undertaken many practical in-depth injectable and facial anatomy training courses and I have further supplemented my knowledge using online resources. As a visual learner, I found viewing the anatomy on a cadaver particularly helpful, consolidating my theoretical knowledge with a more threedimensional understanding.5

Emotionally Dealing With a VO Dr Sharan Uppal advises on how to stay calm and take care of your mental health after causing a vascular occlusion In 2020, after six years of aesthetic practice, I caused my first vascular occlusion (VO) during a hyaluronic acid dermal filler treatment. I had planned to address multiple facial areas, with the goal of achieving a rejuvenated, fresh-faced look. I began by treating both the patient’s temples with a needle to periosteum approach, 1cm along and down from the temporal fusion line (aspirations were negative). Following this, I wanted to create more seamless transitions, so used a cannula, entering over the zygoma to treat the lateral orbital fat compartment. Aspirations with a 25 gauge cannula were all negative too. The whole treated area looked perfect, with normal skin colouration and my patient was comfortable throughout. It was only as I retracted my cannula to remove it that an immediate swelling appeared just lateral to the tail of the brow, which I recognised to be a haematoma. I then noted pallor over this area and at the superior aspect of her forehead, just below the frontal hairline (nowhere near where I’d treated). I realised, from the geographical pathway of pallor, that I was dealing with an occlusion of the superficial temporal artery and one of its smaller branches.1 In retrospect, it was

most likely caused by my cannula having impaled a vessel en route to my treatment area, providing a path for the filler to enter an artery.2 Then the retraction of the cannula, at the end of treatment, allowed the previously impaled area to bleed (hence the haematoma). Only moments passed between the above signs and my next assessment, finding a delayed capillary refill time (CRT) of five seconds over the territory of the supraorbital artery.3 I knew what could happen next if there was further tracking of the filler emboli: the potential for blindness!4 I diagnosed and dealt with what I was seeing immediately, using hyaluronidase, as per my emergency reversal protocol.5 Thankfully, my patient had a good outcome, with no necrotic or visual sequelae. However, the week following the VO was definitely up there as being one of the more stressful weeks of my life. I imagine any clinician who has dealt with this type of complication, regardless of their level of experience, will be able to resonate with this.

Keeping calm After my initial shock, a surprising calmness followed. I can only liken it to the mode we go into when applying an airway, breathing,

Complications training I regularly refresh my knowledge in how to recognise and manage a VO. There are many great resources available to aesthetic clinicians, and I have attended a comprehensive complications training course and regularly review online training resources. Emergency kit and guidelines Your emergency kit and guidelines should be in an easy to access location. The very simple step of ensuring emergency drugs are in stock and in date makes a significant difference to one’s state of mind, and the clinical outcome when dealing with a complication.6 Complication acknowledgment A willingness to acknowledge a complication may have occurred is vital. We all have that little voice that wants us to bury our head in the sand and hope everything will sort itself out. That voice tends to be louder when we do not know how to handle a situation, risking one passing off findings as the result of a more minor inconvenience. Patient communication As per the General Medical Council guidelines, you should communicate openly and honestly with your patient.7 This begins during the initial consultation; for this patient I had explained the side effects and risks that can occur during and after a dermal filler procedure, using non-medical jargon and checked my patient’s understanding to ensure informed consent.8 This essential pre-requisite allows for easier explanation if a complication does later follow and also helps protect you medico-legally.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


A Natural Look is an Exact Science.

Patients today want a filler that naturally integrates into their tissue, so that they can retain their identity and express their emotions with confidence1. With BELOTERO®’s portfolio of fillers, it’s possible to tailor a personal treatment protocol for every patient, so they can feel empowered with natural-looking results2.

merz-aesthetics.co.uk/belotero

References: 1. BELOTERO® Lips Quantitative Market Research. 2. Sundaram H.et al. PRS Journal. Aug;136:149-163. Merz Pharma UK Ltd. Ground Floor Suite B, Breakspear Park, Breakspear Way, Hemel Hempstead, Hertfordshire HP2 4TZ MERZ AESTHETICS® is a registered trademark of Merz Pharma GmbH & Co. KGaA. www.merz-aesthetics.co.uk M-BEL-UKI-0744 Date of Preparation June 2020

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


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As I checked my patient’s CRT, I also kept talking to her about what I was doing and why I was doing it, which builds the patient’s confidence in the management strategy and reduces the element of fear created by the unknown. Clinical support Dealing with a complication as a lone practitioner can make even the most experienced clinician feel vulnerable. Forethought and planning into how and where you will access clinical support, should it be required, allows you to feel part of a network.

Patient anxiety During the emergency reversal procedure there was an added complexity – my patient told me she needed to return home for childcare reasons. I explained honestly that I needed to see the skin perfusion improve before it was safe for her to leave, otherwise her skin was at risk of necrosis, which could lead to scarring. At this point I could see the potential ramifications were beginning to register with my patient and she was becoming quite anxious. My inner voice was giving me good advice, telling me I needed to remain calm, stay professional, and keep showing her that I cared. I managed to get another half an hour with her to inject more hyaluronidase. Her CRT improved and I was happy for her to leave and for her to return within a few hours so that I could review again. When working with growing pressure and patient anxiety, clinicians need to ensure that they do the below, which are principles applicable to any aspect of medicine.9 • Keep the open, honest communication going, even if you know it might not be recieved well • Work in the patient’s best interest • Stay professional • Demonstrate empathy • Be prepared to seek external help/second opinion • Ensure the patient has been informed of signs/symptoms that would require urgent attention and provide the details of how they should contact you

Post-procedure feelings Once my patient had left the clinic, I slumped in my chair and took a moment to process what had happened, before reaching out to my colleagues with the before and after videos (permission was granted for this).

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They replied very quickly asking if I was ok, and instantly, I didn’t feel alone! Then came their clinical reassurance that I’d taken the correct steps and giving me emotional support, making me feel relieved and grateful. I appreciate that I am in a fortunate position, as although this complication occurred in my aesthetic clinic (where I work solo) I also work for a larger clinic, hence I’m part of a clinical team to whom I was able to reach out to. Further to this I hold a membership with complications networks, which I recommend all aesthetic clinicians join.10,11 The worry for my patient didn’t just end there. At the review later that day, I added further hyaluronidase to the couple of localised areas where the CRT was four seconds, with a positive outcome.

My advice

The psychological fallout That night I barely slept, my internal dialogue questioning myself: was it my technique? What could I, and will I, do differently in the future? Then there was an additional anxiety. I had a busy couple of days ahead, including more temple hollow treatments. I wondered whether I wanted to risk putting myself through this again, and if I didn’t treat, what would that mean for me going forward? I considered never treating any of the higher risk areas ever again. Especially because I had followed ‘the safety rules’ – aspirating and using a 25 gauge cannula with comprehensive training, knowledge and ample experience treating this area. While we all know these are not going to 100% guarantee prevention of a complication, deep down we don’t think it will happen to us. As acknowledged by nurse prescriber Linda Mathur in another Aesthetics journal article, aesthetic complications can have a huge impact on not just the patient, but the practitioner.12 Whilst my internal dialogue was running, so was the higher part of my consciousness. I reminded myself that I love my job, that aesthetics has given me a sense of purpose, and that I make a positive difference to the lives of my patients. The concern for my patient remained in the background all day, every day for about a week. Until I could see her come through the other side, with no further sequelae. I reviewed her daily in the first week and the lines of communication were open for her through calls/text. I’m happy to add that I have since completed her treatment and she has remained under my care for future treatments.

Dr Sharan Uppal entered the field of facial aesthetics in 2014. She runs her own aesthetic clinic in Huddersfield, Pegi Day Aesthetics, and is also the Clinical Lead at SkinViva Academy and Clinic. Qual: MBBS (merit), MRCGP

Most of us arm ourselves with knowledge, techniques and protocols to reduce the risk of complications like VO and to be able to need to. This is absolutely the correct thing to do. However, what’s not often talked about is how mentally and emotionally drained you feel in the week(s) following a VO, even when successfully managed. Your knowledge and skills are tested, your professionalism and ethics are tested, but more than any of that it’s your RESILIENCE that is truly put to the test. In order to manage this event correctly, practitioners need to learn how to recognise and manage a VO, build up a strong support network, and maintain a strong sense of self and purpose through self-development practices.

REFERENCES 1. AP Sclafani, S. F., 2009. Treatment of Injectable Soft Tissue Filler Complications. Dermatologic Surgery, 35(2), pp. 1672-1680. 2. Murad Alam, R. K. J. D., 2021. Rates of Vascular Occlusion Associated With Using Needles vs Cannulas for Filler Injection. JAMA Dermatology, pp. 174-180. 3. Martyn King, L. W. E. D., 2020. Management of a Vascular Occlusion Associated with Cosmetic Injections. The Journal of Clinical and Aesthetic Dermatology, 13(1), pp. E53-E58. 4. Beleznay, K., 2019. Update on Avoiding and Treating Blindness From Fillers: A Recent Review of the World Literature. Aesthetic Surgery, 39(6), pp. 662-674. 5. ACE Group, 2021, Guidelines. <http://acegroup.online/ guidelines/> 6. Pearce, T., n.d. Dermal Filler Complications Online Training Course, <https://drtimpearce.com> 7. GMC, Duties of a Doctor, <https://www.gmc-uk.org/ethicalguidance/ethical-guidance-for-doctors/good-medical-practice/ duties-of-a-doctor> 8. GMC, Decision Making & Consent, <https://www.gmc-uk.org> 9. Martyn King et al., 2021, ‘This month’s guideline: The Use of Hyaluronidase in Aesthetic Practice (v2.4)’, The Journal of clinical and aesthetic dermatology. 10. CMAC: Complications in Medical Aesthetics Collaborative, <https://www.cmac.world> 11. ACE: Aesthetic Complications Expert Group World, <https:// www/acegroup.online> 12. Linda Mather, 2020, Understanding the Second Victim in Complications, <https://aestheticsjournal.com/feature/ understanding-the-second-victim-in-complications?auther>

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Case Study: Correcting Facial Asymmetry Mrs Sabrina Shah-Desai uses collagen-stimulating filler to treat a patient with the after-effects of partial facial paralysis Facial symmetry is a fundamental goal of many facial aesthetic treatments, and yet some asymmetry is inherent in any face and a natural part of the ageing process.1 Paresis of the facial nerve after a stroke causes functional and aesthetic defects, manifested by facial asymmetry, which is exacerbated by the passing of time as collagen levels deplete and disproportionate deflation occurs. Patients experiencing pronounced asymmetry to the face typically present to aesthetic clinics with a number of concerns, which usually include the brows, eyelids, jawline and cheek areas.

Case study Patient presentation A 59-year-old Caucasian woman presented to me with pronounced asymmetry and a tired, gaunt appearance, sagging jowls, thin skin and subcutaneous tissue. The patient had experienced a brain tumour 13 years previously, which had been debulked, however during surgery she had suffered a stroke which had resulted in left-sided paralysis. Whilst she had recovered movement she ended up with pronounced

asymmetry to the left side of her face and a particular complaint regarding the ptosis of her left eyelid. Consultation The degree of asymmetry was carefully assessed during an initial 40-minute consultation, with careful note taken of past treatments. The patient’s thin skin was prudently noted and presented additional challenges to be considered. The elasticity of the skin was evaluated by pinching the skin, and it was apparent that there was a moderate degree of volume loss and tissue sag, leading to a tired appearance. The tiredness was permeating from the temple area and through to the side of the face, resulting in a sagging jawline which the patient explained was one of her main concerns. The asymmetry of her face, specifically the disparities in the size of each eye, was a particular challenge. It was important to ensure significant consideration of the patient’s underlying medical considerations, which has resulted in a number of limitations to facial movement. The patient exhibited a degree of asymmetry from soft tissue loss as part of the natural ageing process, however the patient’s facial muscle movement exhibited

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inconsistencies on each side of the face, resulting in a greater degree of unevenness to the face than would typically be expected. It is always of the upmost importance to consider the functional element to any treated area and, as such, careful planning was required to address both the static and dynamic presentation of the asymmetry. At all consultations, I believe it is imperative to photograph the patient’s face from a multitude of angles. This not only ensures the patient can view their concern from a number of angles, but also enables strong, clear, measured discussion about treatment options and results that can be expected. Photographic imagery also ensures that a patient will have clarity around both what a treatment can and, often more importantly, cannot achieve, so reasonable expectations are set. Time was taken to photograph the patient’s front, three quarter and side profiles, ensuring the background was free of objects. During the consultation, it was apparent that a non-surgical, minimally-invasive treatment was the patient’s preference. A number of treatment options were discussed including thread lifts, plasma technology treatment and also surgery. The patient advised that they had experienced a serious inflammatory response following plasma treatment in recent years, and therefore ruled this option out. She also did not want to undergo surgery at this time, as she works full time in an industry where appearance is important and did not have the luxury of downtime to recover from a treatment. It was therefore recommended that the use of a collagen-stimulating filler would be the most effective course of treatment, addressing both soft tissue laxity and volume

A collagenstimulating filler was the most effective course of treatment, addressing both soft tissue laxity and volume loss

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Before

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After

Before

After

Post procedure and follow up At the 12-week review, the patient was delighted with the final results and reported no side effects from treatment. There was significant improvement to the overall balance and harmony of the face, even when at rest. Of particular significance, she felt less conscious about the asymmetry which had reduced significantly. An additional round of photographs, carefully constructed to mirror both the pre- and immediately post-treatment images, were taken to capture the degree of change that was able to be achieved. The patient was advised to attend a routine follow-up appointment to assess her progress a year after treatment, and to repeat the treatment after 16-18 months to maintain her results.

Conclusion

Figure 1: A 59-year-old patient before and one year after treatment using 8ml of collagen-stimulating filler Ellansé S

loss, while improving the quality of the thinning skin in the ensuing months post-treatment. Following the consultation, a letter detailing the patient’s main concerns and agreed treatment plan was handed to the patient. I then allowed for a cooling-off period of two weeks to ensure that the patient had ample opportunity to ask follow-up questions. The patient was instructed not to consume alcohol or take blood-thinning medication for three days prior to treatment. Treatment Makeup was removed before the procedure and the area was carefully disinfected with Clinisept+ Prep and Procedure. The patient was offered topical anaesthetic cream, and both sides of the face were evaluated carefully once more. Over the course of an hour, 8ml of the product, Ellansé S, was judiciously administered. Typically, treatment to address concerns pertaining to menopausal skin takes around 30 minutes, but due to the complexities of the case, it was necessary to take extra time and precautions throughout. Treatment commenced in the dips of the temple region, moving downward to the mid and lower face, and finally the jawline; a

particular area of focus due to the patient’s concerns relating to the degree of sagging she was exhibiting. A needle was used to treat the deeper fat pads, while a 25 gauge 38mm TSK cannula was used extensively to treat the subcutaneous and more superficial fat pads with a fanning technique. A cannula was chosen for this part of the treatment as I believe that it is safer and also causes less bruising for the patient, because it only requires one entry point from which product can be distributed evenly. At regular stages during the treatment, it was important to assess the changing symmetry to the face and ensure natural and full muscle movement. As a result of this careful monitoring, no additional challenges became apparent during the treatment period. Immediately post-treatment, photographs were taken ensuring the same front, three quarter and side profile angles were captured. The patient experienced an immediate change in her symmetry and was thrilled with her results. Increased volume occurs immediately post-injection, however volumisation continues to develop for up to four months, as the ingredients within the filler encourages the body to produce Type 1 collagen in response.

My experience over two decades as an aesthetic ophthalmic plastic and reconstructive surgeon has taught me to appreciate that patients have to ‘wear our work.’ When mature patients with volume loss and tissue sag insist on achieving a lifting effect with hyaluronic acid fillers alone, they are at risk of developing ‘facial overfilled syndrome.’ This is where I find administration of collagen-stimulating dermal fillers a more effective option, by providing natural volume restoration and structural skin support. In this case specifically, where the patient’s asymmetry required a firmer level of structural support on one side, I was able to tailor her treatment more readily using the tuneable collagen stimulator, delivering a result the patient was delighted with. As clinicians, it is critical that we invest sufficient time to discuss the patient’s aesthetic priorities, social needs and tailor our approach. I have found that when patients are better educated on the ageing process and the results that treatments are able to achieve, it helps minimise complications and achieve natural results by ensuring realistic patient expectations. Mrs Sabrina Shah-Desai is an aesthetic oculoplastic surgeon with more than two decades of experience in micro-precision of eye surgery, with the aesthetic concepts of facial plastic surgery. Previously based at Moorfields Eye Hospital, she now practises in Harley Street and North London. Qual: MS, FRCS(Ed), Ophth REFERENCES 1. Olivia E. Linden, Jun Kit He, Clinton S. Morrison, Stephen R. Sullivan, Helena O. B. Taylor. The Relationship between Age and Facial Asymmetry. Plastic and Reconstructive Surgery, 2018; 142 (5): 1145.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


Redefining the science and aesthetic of facial anatomy

Not the usual suspects

Meet the new line up. The CE marked, quality, intelligent HA dermal filler KYSENSE®. Designed using advanced technology to bring improvements in precision, projection and patient satisfaction. KYSENSE® has been developed by scientists in collaboration with doctors with decades of experience in the HA dermal filler market and who contribute to peer reviewed publications in HA dermal filler technology and in facial aesthetics. The KYSENSE® manufacturing process HA-Protect, removes destructive oxygen species from the crosslinking stage, meaning the long HA chains are intrinsically more protected and preserved leading to advantageous rheological properties for a more natural look and feel to the tissue.

Find out more by booking onto one of our free webinars. Email: janey@circaskin.co.uk

KYSENSE® with it’s unique rheological properties and an ergonomic syringe and ultra-sharp TSK HCP needle, KYSENSE® allows for a more comfortable treatment experience without the need for lidocaine. I love using Kysense® because of its natural results. My patients love the minimal swelling and are amazed they cannot even feel the products in the lips like other fillers they have tried. Caterina Alverez Independent Nurse Practitioner


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The Rebirth of CO2 How CO2 lasers can help combat signs of ageing According to the American Society for Dermatologic Surgery more than 70% of patients are bothered by signs of ageing, such as fine lines and wrinkles as well as skin texture and discolouration.1 Since its introduction onto the market in the mid-1990s, CO2 laser skin resurfacing has been the ‘gold standard’ for cutaneous facial rejuvenation of photo-damaged skin.2 CO2 lasers have long been relied upon by medical professionals as a powerful weapon in the treatment of many skin conditions and the technology has only advanced with time.3 Over recent years, consumer demand for less invasive and problematic procedures has led to a myriad of non-ablative devices for reducing wrinkles and improving photodamaged skin. Although the act of ablation should not be discounted; ablative treatments have been shown to offer superior clinical results with lower risk profiles verses non-ablative therapies.4

The evolution of CO2 As with most technologies, innovation creates improved outcomes. In difference to other CO2 systems currently on the market, the DEKA SmartXide CO2 offers a practitioner the opportunity to decrease patient downtime, whilst maintaining the high clinical efficacy of traditional CO2. This is achieved with their unique Pulse Shape Design (PSD®) technology, offering extreme flexibility in pulse shape selection, output power, dwell time, stacking power, density, scanner shapes, and spray mode emission which removes the concern of demarcation lines typically found with many CO2 devices currently available. With the advent of PSD® technology the range of super pulses, ultra-pulses, and hyper pulses are now outdated; opening up a new frontier for CO2 lasers. The new pulse control allows specific layers of the dermis to be targeted while the high pulse delivers ablation with minimal thermal damage protecting the skin from unwanted heat and stimulating the basal layer without associated risks. SmartXide has a proven efficacy profile in a whole host of indications such as: periorbital rejuvenation,5 postpartum abdominal laxity,6 rhinophyma,7 and scars even in darker skin types.8

The newest addition to the SmartXide range PUNTO is designed to be an affordable CO2 device that meets the needs of the practitioner who demands efficacy in rejuvenation but also wants a highly flexible toolbox for a range of non-invasive procedures and minor surgical ops such as blepharoplasty. The innovation in PSD® technology, in particular the H-PULSE and SPRAY mode allows a ‘cool’ treatment protocol; COOLPEELTM. Renowned US dermatologist, Dr Emil Tanghetti, says, “With COOLPEELTM, we are using much lower energy, but it’s achieving comparable results to other more aggressive treatments. The other advantage is less pain and discomfort during treatment; most patients don’t need topical anaesthesia at all.” A COOLPEELTM treatment doesn’t require any social downtime, it takes only 15 minutes to perform due to the ultra-fast scanner, and it effectively treats photoageing, fine lines, open pores, pigmentations and telangiectasias.

Advertorial Lynton loving the results and patients are too.” Depending on desired treatment options, practitioners can utilise DEKA’s latest launch the SmartXide PUNTO, an affordable device for scarring, rejuvenation, and minor surgical applications. Alternatively, they can choose the SmartXide TOUCH for advanced surgical, gynaecology, and hair restoration applications. Existing SmartXide users can contact Lynton today to find out how they can upgrade their existing device. Advanced features • PSD® technology for variable pulse shapes, duration, energy and peak powers • Maximum control over results and recovery time • SmartStack function makes SmartXide one of safest and most effective systems in the market • Coolpeel treatments are comfortable and well tolerated by patients, with most not requiring topical anaesthetic and virtually no downtime • High patient satisfaction • Highly flexible toolbox for a wide range of indications • RF CO2 source for enhanced lifetime performance REFERENCES 1. American Society for Dermatologic Surgery (ASDS). asds.net <https://www.asds.net/medical-professionals/practice-resources/ asds-consumer-survey-on-cosmetic-dermatologic-procedures> 2. Gotkin, R. H., & Sarnoff, D. S. (2014). A preliminary study on the safety and efficacy of a novel fractional CO₂ laser with synchronous radiofrequency delivery. Journal of drugs in dermatology: JDD, 13(3), 299-304. 3. Conforti, Claudio, Vezzoni, Roberta, Giuffrida, Roberta, Fai, Annatonia, Fadda, Sara, Marangi, Giovanni Francesco, . . . Dianzani, Caterina. (2021). An overview on the role of CO2 laser in general dermatology. Dermatologic Therapy, 34(2), E14692-N/a. 4. Mirza, Humza N, Mirza, Fatima N, & Khatri, Khalil A. (2021). Outcomes and adverse effects of ablative vs nonablative lasers for skin resurfacing: A systematic review of 1093 patients. Dermatologic Therapy, 34(1), E14432-N/a. 5. Guida et al. (2018). Resurfacing with ablation of periorbital skin technique: indications, efficacy, safety, and a 3D assessment from a pilot study. Photomedicine and Laser Surgery, 36(10), 541-547. DOI: 10.1089/pho.2018.4479 6. Bonan, Paolo, & Verdelli, Alice. (2021). Combined microwaves and fractional microablative CO2 laser treatment for postpartum abdominal laxity. Journal of Cosmetic Dermatology, 20(1), 124-131. 7. Bassi, Campolmi, Dindelli, Bruscino, Conti, Cannarozzo, & Pimpinelli. (2016). Laser Surgery in Rhinophyma. Giornale Italiano di Dermatologia e Venereologia, 151(1):9-16. <http://www. minervamedica.it> 8. Ibrahim, Shady M, Saudi, Wael M, Abozeid, Mohamed F, & Elsaie, Mohamed L. (2019). Early fractional carbon dioxide laser intervention for postsurgical scars in skin of color. Clinical, Cosmetic and Investigational Dermatology, 12, 29-34.

Why SmartXide? Present in more than 120 countries, DEKA has always been an epicentre of innovation for the entire global medical sector; they have been manufacturing both medical and aesthetic CO2 lasers for over 35 years. Used by both private hospitals and aesthetic clinics, the SmartXide is operated by some of the world’s most renowned medical practitioners. Mr Ali Ghanem, Medical Director of the Cranley Clinic in London says, “Built on science and innovation DEKA are true innovators of CO2 lasers. With the SmartXide I can bridge the gap between traditional aesthetic procedures and surgical applications for ageing skin. Delivering high impact results, patient satisfaction is extremely high, I am Aesthetics | July 2021

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Exploring Mental Health and Aesthetics Nurse prescriber Claire Newman provides an overview of motivations for non-surgical cosmetic procedures and mental health The importance of physical appearance is not a new concept and has links to evolutionary theories relating to youth, attractiveness, and reproduction.1 According to Darwin’s theory of sexual selection, specific physical characteristics have evolved not because it helps with survival, but because of the benefits of reproduction, with reproduction being the main aim.2 Through the ages, cultures and generations have sought ways to improve their appearance, consequently influencing the abundance of procedures available today. This article will explore the motivations for aesthetic treatment, and how mental health considerations impact these decisions.

Factors for treatment motivation A person’s mental state fluctuates resulting in a changeable perception of how they perceive themselves, from day to day or week to week. This perception of oneself can have a significant impact on procedures both pre- and post-treatment. It is important to understand a person’s motivations for seeking out cosmetic procedures to ensure safe practice. Having said that, Maisel et al. claim there is little known information surrounding the motivations behind the pursuit of cosmetic procedures.3 The authors of this study, consisting of 511 participants, concluded that reasons for seeking treatments were for themselves rather than to please others. Some motivations included a desire to improve confidence and wellbeing (67.2%), seeking procedures to treat themselves (61.3%) and seeking preventative treatments or to minimise the risk of further ageing (53.3%). Note this study used a small sample size and did not include men.3 In his book, plastic surgeon Dr Panagiotis Milothridis claims that motivations to undergo cosmetic procedures are multifaceted, stating that previous theories on vanity and psychopathology are obsolete.4 In his 2020 paper he also proposes that personality traits and how people perceive themselves impacts on reasons for undergoing cosmetic procedures.1 According to Walker et al., research demonstrates the impact of older media systems such as television and radio having an influence on cosmetic procedures.5 The authors claim there is less research on more modern forms such as Instagram, Facebook and Snapchat, but acknowledged it is a powerful influence focusing on the perfect body image. This is turn can lead to dissatisfaction in a person’s appearance and therefore influencing and motivating to undergo cosmetic procedures.5 The American Academy of Facial Plastic Surgery assert that social media is a crucial element when deciding to undertake cosmetic procedures.6 Other motivations include pressure from peers and the media.7 Thompson et al. claim that the perception of beauty is strengthened and communicated through the combined influence of social and cultural factors which includes the media, peers, and family.7 Hopkins et al. propose that celebrities have an impact on people choosing to undergo cosmetic procedures.8 An example of this is Kylie Jenner – when she revealed that she had lip fillers it resulted in a considerable increase in searches for the procedure online.9 It should be noted that celebrities/influencers can project unobtainable goals, which is further complicated with the use of filters on photos to idealise appearance such as Snapchat and Instagram filters. Taking all this into consideration, a person’s motivation for seeking out non-surgical cosmetic procedures is not simple and varies from individual to individual and day to day. Consequently, the treating practitioner needs to take all these factors into consideration during the pretreatment consultation and formulate a realistic treatment plan which combines a holistic mental health assessment whilst ensuring that the patient is suitable for treatment.

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The complexities of mental health Mental health is not a new concept and is a fundamental component of a person’s physical health. Historically, there has been a lot of stigma associated with mental health, and people still sadly hide their illness and do not wish to talk about it. The stigma is slowly reducing, but still exists, and, for whatever reason, patients coming into our clinics may not always disclose that they have an illness and/or are receiving treatment for their illness. According to the World Health Organization, ‘Mental health is related to mental and psychological wellbeing. Mental health includes our emotional, psychological, and social wellbeing. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices.’10,11 According to NHS England, one in four people experience mental illness at some point in their life.12 This means if you are seeing 12 patients a day, potentially three of those patients would have a mental illness or would have had a mental illness as some point in their life. In a 1960 study of 98 patients reporting minor flaws, 72.4% undergoing plastic surgery suffered with mental illness.13 In 2007 study of 140 patients undergoing cosmetic surgery, 43% had a suspected psychiatric disorder.14 In 2008 other authors claimed that patients requesting cosmetic procedures have a history of mental illness, however, their research is limited to body dysmorphic disorder (BDD), narcissistic personality disorder and histrionic personality disorders. They neglect to discuss all mental health conditions within their research.15 This research is limited and not representative of the general population as well as being out of date. In 2019, Jang et al. proposed that having a mental illness is linked to dissatisfaction following cosmetic procedures, therefore, assessing patients for predictors prior to treatment optimises results. They conducted a study comprising 1,000 patients and found that 44.1% of the patients wanting plastic surgery had/has a history of mental illness. They concluded that mental illness is common with patients seeking cosmetic procedures and advise awareness.15 A 2021 study by Bascarane et al. reviewed 120 articles looking at the prevalence of mental illness and cosmetic procedures. Despite the research being predominantly focused on BDD, they found that 4-57% of

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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According to NHS England, one in four people experience mental illness at some point in their life patients were diagnosed with BDD, 4.8-25.8% for depression, 10.2-22% for anxiety, and 0-53% for personality disorder.17 The authors concluded that there is a relationship between mental health and cosmetic procedures, but acknowledged and recommended that more research within this area is required to establish a correlation between all mental health diagnosis and cosmetic procedures. It can be noted that research studying mental health within aesthetic medicine is mostly focused on BDD. The research not only neglects other mental illnesses such as mood disorders, substance misuse, psychotic illnesses and organic disorders, but fails to address the impact both positive and negative of non-surgical procedures on a person’s mental state. The lack of research, and research with small sample sizes makes it difficult for practitioners in clinic, as without the research there is no guidance to support a person in safely managing this patient group.

Considerations for practice Having a mental illness is not necessarily a diagnosis of exclusion and everyone should be assessed holistically. However, patients with certain mental illnesses may be attracted to cosmetic procedures due to the increased worry about their physical appearance which, in turn, leads to an increase in dissatisfaction and post-procedure regret following treatment.3 Therefore, some mental illnesses such as BDD are a contraindication to cosmetic procedures due to their abnormal perception of themselves. However, Felix et al. proposed that patients presenting with mild to moderate symptoms of BDD could benefit from cosmetic procedures.18 Similarly, Ericksen et al. proposed that those presenting with a mental illness that is being managed, and under control, could potentially benefit from cosmetic procedures, which could enhance their quality of life.19 As medical professionals we have a duty of care, which includes ensuring that we do not cause any harm to our patients; the safeguarding of a patient’s mental health

should be included within this. Mental health is a specialty and most practitioners working within medical aesthetics do not have a background in mental health, hence their knowledge and experience is limited. Without adequate skills and training, it could be argued that as a profession we are failing patients. There is no industry standard with regards to training and training providers have often neglected mental health. Although with the emergence of the Level 7 in aesthetic medicine there is a module on mental health, it is limited, and the Level 7 is certainly not compulsory. As well as this, aesthetic trainers often do not have a background in mental health and therefore lack experience and knowledge in this specialist subject area and only cover the basics. Without adequate training and support the consequences could be damaging to the patient; this damage can also be caused by a refusal to treat due to their diagnosis and how that refusal is managed. Mental health is not always clear cut or apparent and mental states can be unpredictable and can fluctuate, with triggers not always known. This in turn impacts on a person’s capacity and ability to provide informed consent. The little training that is out there is usually limited to BDD, neglecting all aspects of mental health. This is further compounded by the lack of regulation within the UK, which makes it difficult to propose a minimum standard of training. Industry standard training with an emphasis on mental health will be a start in protecting all patients, in particular those with mental health needs. There are a few screening tools used within medical aesthetics and again, they are limited to BDD. These tools are modality specific; not all practitioners use them and without the right training could cause more problems. It could also be argued that asking a few questions does not give a true picture of what is going on for the individual. It is also easy to lie when answering questions. Spending time with patients during the pre-treatment

consultation is imperative, building a therapeutic relationship and getting to know them is beneficial. Patients are more likely to be open, honest and to engage, which in turn minimises risk. Inarguably, it is essential that the treating practitioner has a good understanding of mental health and has an ability to assess and formulate treatment plans to minimise the risk of harm to the patient. Cooling-off periods are particularly important for those with mental health conditions to be able to weigh up the benefits versus the risks of the treatment, and to acknowledge and digest the realistic expectations set out by the practitioner. Two weeks should be offered to all patients as per guidelines set by the General Medical Council.20

Consider mental health Whilst undertaking cosmetic procedures improves a person’s appearance it is important to understand their motivation for treatment. Practitioners need to ensure they are educated in this area and training providers need to ensure that healthcare professionals are trained to manage patients with mental illness within their clinics. This includes recognising a range of mental illnesses, how to assess for mental illness, communication skills and motivations for treatment and management of this patient group. Having the skills to assess mental illness assists the practitioner with the decision-making process. By doing this the practitioner will be well equipped to offer support by signposting to relevant agencies if there are any causes for concern. Claire Newman is a mental health nurse prescriber and the director of Soft Touches Aesthetics in Hertfordshire. She is a Level 7 assessor for Derma Medical and a brand ambassador for Intraline. She is passionate about mental health, promoting confidence and wellbeing. Qual: Bsc (Hons) Psychology, RMN, Msc Nursing Practice, NIP, Level 7 Aesthetic Medicine Injectables

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Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


Advertorial BTL Aesthetics

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Introducing EMSCULPT NEO® The revolutionary 2-in-1 HIFEM + RF combination offers a new level of aesthetic outcomes, versatility, and commercial success What is EMSCULPT NEO®? In 2018 body contouring changed forever with the introduction of EMSCULPT® into the non-surgical aesthetic arena. The EMSCULPT brand is recognised by peers around the world, it has won numerous awards, and since its introduction in 2018, performed more than 800,000 treatments in more than 2,500 clinics globally. Pushing the boundaries within the aesthetic industry, EMSCULPT NEO® takes the ground-breaking EMSCULPT® brand to the next level, and beyond. BTL Industries presents the first 2-in-1 solution to help patients achieve the next level in body shaping results. It is the world’s first noninvasive procedure that simultaneously combines HIFEM+® and synchronised radiofrequency, treating the fat effectively in addition to the muscles. Recently, BTL further introduced new applicators, enabling EMSCULPT NEO® to treat fat and muscle in nine body areas, including abdomen, buttocks, thighs, arms and calves. The synergy of HIFEM+ and RF, delivered simultaneously, creates consistent results; it is a faster, more economical and more efficacious solution than any combination of multiple procedures.

Practitioner feedback Dr Rita Rakus, the first EMSCULPT NEO® adopter in the UK, commented, “In my 30 years in the medical aesthetic industry I have never come across a machine like this. I have used three EMSCULPTs in my practice with consistent fantastic results and very happy patients. These systems are all fully booked, generating very substantial revenues, which would not be happening if we weren’t delivering patient satisfaction; it’s as simple as that. If EMSCULPT revolutionised my practice, then EMSCULPT NEO® has raised our performance both clinically and commercially. In fact, I’ve recently taken delivery of my second EMSCULPT NEO® system.” Dr Rakus adds that the addition of RF has created even greater fat reduction and improved the comfort of the treatment by heating the muscle before it receives its supramaximal workout. “We are definitely also seeing an improvement in skin quality in the treated area which logically must come from the RF heating component.” Mr Kambiz Golchin, consultant surgeon and the first owner of EMSCULPT NEO® in Ireland, was also keen to raise the bar in his non-surgical offering. He said, “I was very impressed with EMSCULPT outcomes, as were my patients, so for me to upgrade to EMSCULPT NEO®, BTL would have to raise the bar considerably. They did, and I am incredibly happy to report that patients are even more elated with the results. This drives greater commercial success as all of my team love using the device, because it creates highly elated clients which raises enthusiasm in the clinic even higher.” 54

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Clinical studies The FDA-cleared and medically CE marked EMSCULPT NEO®, removes on average 30% of the fat in the treated area and increases muscle by 25%. These statistics are drawn from extensive clinical research and clinical publications. Dr Rakus states, “BTL always carry out extensive research and development with extensive clinical publications prior to commercial launch. They use methods normally reserved for medical and surgical devices including MRI, CT scans, histology and ultrasound to accurately record what is actual happening anatomically.” Dr Rakus continues, “Working with BTL for over a decade I always feel we are offering treatments at the forefront of the technology curve. We all know that this can be a hazardous place to be, I like many others have adopted technologies early to find they really didn’t meet expectations or manufacturers marketing claims. The reason I love working with BTL is that with 300 R&D engineers, always without fail, their new technologies are so extensively tested in the clinical environment that you are always 100% sure they will deliver the results claimed. This has proven to be very much the case with the EMSCULPT NEO®.” There are now more than 40 published papers on HIFEM technology, making it the most intensively researched non-invasive body shaping modality in recent years. However, the attraction of EMSCULPT NEO® goes beyond these simple statistical increases, and Dr Rakus notes that she’s seeing substantial increase in interest from both slimmer patients and men, especially for the legs and arms with the new small applicators. Mr Golchin added, “As a surgeon using surgical equipment, I rely heavily on the manufacturer to deliver the tools to do the job. I put the same emphasis of evidencebased medicine on tools used in my non-surgical work, and the creditability of the BTL publications gives me that confidence.”

This advertorial was written and supplied by www.btlaesthetics. com/uk


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A summary of the latest clinical studies Title: Ophthalmic Adverse Events Following Facial Injections of Botulinum Toxin A Authors: Skorochod R, et al. Published: Journal of Cosmetic Dermatology, June 2021 Keywords: Botulinum Toxin, Injectables, Complications Abstract: Over the years, botulinum toxin has found its place as a neuromuscular blocking agent in numerous medical fields. Since the approval of botulinum toxin by the FDA for cosmetic indications in 2002, it had become the most performed aesthetic procedure worldwide, with ever-growing demand. The characteristics of the toxin, along with the facial areas it is injected to, could possibly account for a wide array of complications. The authors conducted a literature search for reported cases of ophthalmic adverse events following botulinum toxin facial injections. 25 publications reported 49 cases of ophthalmic adverse events following botulinum toxin injections. Injections for cosmetic indications accounted for 51% of all injections, treatment of blepharospasms for 22% of cases, protective ptosis for 11% of cases, and treatment of hemifacial spams for 8% of cases. The average quantity of botulinum toxin injected to a single patient ranged between 1.25 to 75 units, with a median of 13.75 units. Majority of injections for cosmetic indications were performed to the lateral canthal area (56%), followed by the glabella (28%) and the forehead (20%). Adverse events following injections included diplopia (64%), ptosis (14%) and decrease in visual acuity or vision loss (8%). Botulinum toxin is gaining extreme popularity in the management of a wide area of diseases and for cosmetic indications. Knowledge of potential adverse events is crucial for the clinician in attempt to decrease complications. Title: Anti-Ageing Effect of an Oral Disintegrating Collagen Film Authors: Lee Y, et al. Published: International Journal of Dermatology, June 2021 Keywords: Antiageing, Collagen, Wrinkles Abstract: As the average life expectancy increases, skin ageing and wrinkles due to photoageing has gained attention. Collagen is closely involved in the process of skin ageing. Among the potential methods of drug delivery to the skin, oral disintegrating films show promise for their ability to bypass the loss of active components that is typical of drug absorption via oral administration. This study was conducted to investigate the effect of an oral disintegrating collagen film on skin ageing. A prospective, singlearm study in a cohort of 22 women was carried out to assess the antiageing effect of a oral disintegrating film containing collagen applied daily over a 12-week period. We measured the clinical indicators of skin integrity and performed immunofluorescence and high-performance liquid chromatography analyses of an ex vivo oral mucosa model to compare the absorption rates of collagen films and conventional oral tablets via the mucosa. We found that the oral disintegrating collagen film reduced skin wrinkle depth and significantly increased skin elasticity and density. The novel mode of delivery of collagen via oral disintegrating films has a clinically potential antiageing efficacy and is safe and convenient for daily use.

Title: Analysis of Immediate Use of Sunscreen After Microneedling Authors: Meyer P, et al. Published: Photodermatology, Photoimmunology and Photomedicine, June 2021 Keywords: Collagen, Microneedling, Sunscreen Abstract: Microneedling promotes skin microlesions that lead to an inflammatory process, increase cell proliferation and synthesis of collagen and elastin, therefore restoring skin integrity. This study aims to investigate the differences between the physical and the physicalchemical sunscreen application after microneedling. This was a two-phase study. The first phase investigated the physical and physicalchemical sunscreen penetration mixed with India ink. Sunscreens were applied after the microleakage in vivo on the skin of a volunteer who underwent abdominoplasty 24 hours after the procedure. Histological analyses were carried out using optical and electron microscopy. The second phase analysed the skin reactions of physical sunscreen after different microneedling treatments. 30 volunteers were distributed into three groups: G1 received the ‘roller’ microneedling, G2 received pen micropuncture treatment, and G3 received the fractional radiofrequency treatment. Histological analyses of the first phase indicated that the physical-chemical sunscreen penetrated deeply, and pigment was found among the collagen fibres and dermal fibroblast cytoplasm compared to the physical sunscreen. The second phase results demonstrated that the use of the physical sunscreen after the different microneedling techniques showed no adverse reactions such as itching, pain, or soreness. Title: The Results of the Diode Laser Hair Reduction Treatments After the IPL Hair Reduction Treatments Authors: Atta-Motte M, et al. Published: Journal of Cosmetic and Laser Therapy, June 2021 Keywords: IPL, Diode Laser, Hair Reduction Abstract: Lasers and IPL action are similarly based on the selective photo thermolysis principle, where the melanin acts as chromatophore. There are differences in the way they are built and the light they emit. The goal of this study is to compare the results of epilation treatments by a laser and by an IPL and to rate the effectiveness of a diode laser epilation following a non-coherent light therapy. 45 healthy females, 21-23 year old, skin type II-III took part in the study. 805 nm diode laser and the IPL device with a wavelength of 640-1200 nm was used. The consent for participation and treatment was obtained during a consultation. Participants were randomly divided into three groups of 15: I – one IPL treatment was followed by three diode laser treatments, II – two IPL treatments followed by three diode laser treatments, III – three IPL treatments followed by three diode laser treatments. A percentage average of hair loss among patients treated with a diode laser as a control group is higher which indicates the laser’s effectiveness. The IPL has been shown to negatively impact the effectiveness of a diode laser. This is linked with the way non-coherent light weakens and thins the hair that impedes the absorption of laser light by the melanin and affects the treatment results.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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

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

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

REAL-TIME VISUALISATION

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

1

REFERENCES: 1. www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed September 2019 2. Ulthera release: Ultherapy® décolletage treatment now FDA-cleared. BioSpace website. https://www.biospace.com/ article/releases/ulthera-release-ultherapy-and-0174-d%C3%A9colletage-treatment-now-fda-cleared-/. Accessed January 21, 2020. 3. Fabi SG, Joseph J, Sevi J, Green JB, Peterson JD. Optimizing patient outcomes by customizing treatment with microfocused ultrasound with visualization: gold standard consensus guidelines from an expert panel. J Drugs Dermatol. 2019;18(5):426-432

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

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


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Step 1: Organise your thoughts This may seem like an obvious place to start, yet this initial step can be surprisingly difficult. Years of programming to follow a certain route without deviation can make objectives, such as your personal goals and desires, difficult to consider. From experience, these are the questions you need to be asking yourself if you are debating a career change:

Starting Out in Aesthetics Dr Joanna Hackney shares her ‘step-by-step’ guide to starting a new career in the aesthetics specialty As medical professionals, our career path is often mapped out ahead of us – a series of hurdles and hoops to leap over and through – leading us up the well-established ladder of training and role progression. This treadmill can be a comforting ‘box ticking’ exercise, with relatively little autonomy compared with other occupations. Perhaps this is why a change in my career during my senior training years felt like a giant leap into the unknown. It would appear I was not alone in making the decision to switch careers. In 2018, only 37.7% of Foundation Level 2 doctors continued straight into specialist training programmes,1 sparking a British Medical Journal article to identify ‘why?’2 They received feedback from many junior doctors choosing to leave the NHS and discovered several themes:

lack of value, loss of respect, poor training opportunities in favour of service provision, limited pay, and inflexible rotas. With the strain of the pandemic making working conditions tougher for many, this is a trend which may spiral. Healthcare workers are particularly at risk of ‘burnout’ – a work-related stress syndrome caused by chronic exposure to job stress with approximately one in three physicians experiencing it at any one time.3 Of course, aesthetics is not the only option for those wishing to pursue a different career within medicine, but I believe it to be a great one. This article is intended to provide a possible ‘step-by-step’ guide on how I believe medical professionals can approach this career junction, as well as some tips that I discovered along the way.

Pros

Cons

Practical skills are required

Reduced opportunity for teamwork

Patient facing

‘Patients’ are well and seeking improvements – expectations can be very high

Generally high patient satisfaction with good outcomes

Unregulated industry

Flexible and can allow for good work/life balance

Highly competitive

Limited out-of-hours requirement

Owning a business is a full-time responsibility – you may miss shift work!

Autonomy

Potential conflict between your employees’ desire to increase revenue and your ethical principles

Fast growing industry

Limited guidance and evidence base for new practices

Potential for excellent income

Working as a sole practitioner can be isolating

Figure 1: Table of the possible positives and negatives of working in the aesthetic specialty

• • • • • • •

What are my ultimate career goals? What are my interests? What are my skills and values? What do I want to achieve from my job? What are my constraints? Which work style best suits you? What do I need to change in my current role to achieve this?

Creating a list and ranking your top 10 priorities is a useful way of focusing on these answers. They can then be compared against a selection of potential roles you may be interested in to further direct your decision making. I was extremely well supported by my training deanery when discussing my desire for change and embarked on career guidance provided by Health Education England. Whilst this may not be an option for many, accessing similar resources can be an invaluable tool to assist in your decision. Utilising family and friends during this phase can also be a constructive aid to self-analysis and help you hone-in on your priorities.

Step 2: Establish pros and cons Once you have ascertained that a change is required, you must investigate whether the aesthetic specialty is the correct fit for you. To assist with this, I have compiled a simplified table of some of my personal ‘pros and cons’ of working in aesthetics (Table 1). This list is not exhaustive and is subjective, so do research the industry yourself and come up with your own unique pros and cons list. I would recommend attending an open day for a training academy or an aesthetic conference, such as the CCR conference in October, or the Aesthetics Conference & Exhibition (ACE) in March, where you can speak with industry professionals established in aesthetics. You should also subscribe to a journal to get a real taste for the specialty and get a feel for the community.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Step 3: Attend a foundation training day It came as an astonishing revelation, after years of rigorous training in medicine, that all that was required for me to ‘get started’ in aesthetics was a one-day course and a certificate. In reality, for most, this is just the very first step of a longer journey, yet it is a vital one. Be selective when choosing which training provider to use; consider how you may wish to develop from this point, would you prefer more online or face-to-face contact? Do you feel comfortable practising injecting patients during your first session? Will you be offered support or further training opportunities beyond the initial contact? Many healthcare professionals which attend foundation training days do not go on to progress in an aesthetics career.4 This, of course, could pertain to many, but when speaking with delegates, I have infrequently found the underlying cause to be a lack of interest. More likely, poor follow through can be explained by not completing steps one and two prior to attending a foundation training day, without the required consideration of the bigger picture.

Step 4: Seek insurance and register with a prescriber After attending your foundation training day, now is the time to keep the momentum going and ensure you have the necessary processes in place to begin practicing. Insurance Become indemnified for the treatments you are now certified to undertake. Your usual occupational indemnity is unlikely to cover you for specialist elective aesthetic work, so seek separate insurance or see if you can extend your current plan. There are many companies providing this, some of which include Cosmetic Insure, Enhance Insurance, Hamilton Fraser Cosmetic Insurance. Pharmacy registration Register with a reputable pharmacy or supplier. Some pharmacies that can supply you with your aesthetic products include: Church Pharmacy, Healthxchange, Med-fx and Wigmore Medical. Prescriptions If you are a non-prescribing medical professional such as an aesthetic nurse, or doctor with a provisional GMC registration,

Arranging a mentor or supervisor can be invaluable, and many healthcare professionals within the industry will be happy to offer their guidance

you will need to consider how you will be able to ensure your patients can access prescription-only medicines such as botulinum toxin, emergency drugs such as adrenaline, and those for managing complications, such as hyaluronidase, antibiotics, and steroids. The best option is to gain your independent prescribing license; however, I acknowledge this often is not practical for those just starting out so you will need to work closely with a prescriber. Useful sources for connecting with a prescriber are companies like Aesthetics Associates. Furthermore, the British Association of Cosmetic Nurses (BACN) offer excellent guidance on the legal and regulatory requirements here.5

Step 5: Keep on top of training A foundation training day will introduce you to the basics of aesthetic injectables, which is a good starting point, but you should be building upon this as your experience progresses. I have found there to be generally two pathways once step five is reached. A ‘learn on the job’ approach, with self-led training and development, or a more didactic approach, seeking further formal training, such as completion of a Level 7 qualification in injectables or Master’s. Personally, I chose to undertake more training at the beginning of my career in aesthetics. If undertaking more training, ensure you choose a reputable company, preferably one that complies with the qualification requirements for delivery of cosmetic procedures. The Joint Council for Cosmetic Practitioners (JCCP) has created an ‘Education and Training Provider Register’ and has established strict standards of entry and premise requirements.6

Arranging a mentor or supervisor at this stage can be invaluable, and you may be surprised to discover that despite the high competition levels, many healthcare professionals within the industry will be happy to offer their guidance. The Cosmetic Practice Standards Authority (CPSA) have created a supervision matrix in their bid to promote practitioner networking, move away from ‘lone practice’ and improve outcomes.7

Step 6: Think about your future Time to organise your thoughts as you decide how you would like to shape your career in aesthetics. Some practitioners choose to set up their own business from the get-go, whereas others prefer to work for someone initially. Either of these options are viable, and are down to individual preference and values, so take your time to consider your predilection. Some considerations to help with this process are: • Are you comfortable in business? A business plan is essential, so if this is not your area of expertise, be prepared to outsource or upskill. • Ensure that if you work for someone else, their principles are aligned with yours. The GMC, GDC and NMC all have guidelines outlining the standards required from their members and it is important that these are not compromised. The GMC have a document offering guidance for doctors specifically offering cosmetic interventions.8 • Consider your marketing plan. Building a patient database can take time, so optimise your chances with appropriate marketing and a professional website.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Be cautious with advertising, and ensure you adhere to the guidelines provided by the Advertising Standards Authority (ASA).9 • Optimise your General Data Protection Regulation (GDPR) compliance10 and organisation with a good patient management system from the beginning. Some examples are Aesthetic Nurse Software, Clever Clinic, Cliniko, iCLINICIAN and iRejuvenation. I would recommend keeping an anonymised ‘logbook’ or portfolio of all the treatments you have performed to demonstrate your competencies when applying for clinic roles.

Step 7: Reflect on your progress At this stage, if you have completed the previous steps, you will have a reasonable impression of whether aesthetics is an expedient career for you. I would urge you to take some time to return to the work you completed as part of ‘step one’ and reflect on whether you are ticking the right boxes. I would also offer advice to compare

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your approach to working within the field of aesthetics to your original medical profession. We must be diligent to remain true to the ethics, codes of conduct, and fundamentals that are so important as healthcare professionals, and alter behaviour which does not stand up to these principles. Do not be disheartened if you find you are not progressing at the rate you had imagined, and try to not compare yourself to others. It takes years of training to become successful in any medical field, and aesthetics is no different.

A worthwhile specialty This guide is intended as exactly that – a guide. In my previous career, a methodical, carefully planned approach suited the specialty and my approach to work, and so I hope that this may prove useful for those in the initial phases of their journey into aesthetics. To paraphrase poet Robert Burns, ‘the best laid plans of mice and men often go awry’, so we must adapt, improvise, and overcome. In my experience, it is worth it.

Dr Jo Hackney graduated from Leeds Medical School and trained in anaesthetics in North Central London, before embarking on a career change after achieving a fellowship at the Royal College of Anaesthetists. She now works as an aesthetic practitioner at STORY clinic in Marylebone and is Clinical Lead at Harley Academy. Qual: MBChB, FRCA

VIEW THE REFERENCES ONLINE! AESTHETICSJOURNAL.COM

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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colleagues and those in the same industry ― their priorities, interests and beliefs may not be aligned with yours. At the heart of any presentation is the goal of taking the audience from their baseline position, impression, belief or understanding (whatever that may be) ― to a new point, where you want them to be. The way you structure and deliver your presentation is what helps create that shift.

Death by PowerPoint

Getting Into Public Speaking PR consultant Julia Kendrick outlines her techniques to get your audience sitting up and paying attention when presenting For many, public speaking and delivering presentations create a feeling of dread akin to the dentists’ chair. However, as with any skill, practice, good techniques and preparation will take you a long way. As live events are slowly resuming post-pandemic, there are many new opportunities to engage as a speaker, presenting to teams, patients, press and the broader industry ― all of which can have strong benefits for growing your profile, enhancing strategic connections, and driving business success. The standard format for most presentations is with PowerPoint decks, but for the sake of brevity we will be focusing mainly on the preparation and style of delivery, rather than slide structure and formatting. Whether you’re new to speaking and presenting, or are in need of a refresher, this article will outline some of the golden rules and key skills to help you deliver a compelling experience for your audience.

Presenting is all about your AUDIENCE Presenting and speaking is all about connecting authentically with your audience and taking them on a journey with you. This applies whether you are presenting to patients, the public, or

DO

DON’T

• Keep it simple and moving • Have evidence, but keep it topline – save details for a Q&A session at the end • Add some personality (short anecdotes, personal experiences, analogies, metaphors) • Write for your audience (their priorities may not be the same as yours) • Keep reminding your audience of where you’re going (signposting)

• • • • • • • •

Overcomplicate it Over-introduce Repeat yourself Expect people to believe what you are saying just because you say so Make it about you Evade your point Jargonify Wander off topic

Figure 1: Table of the do’s and don’ts of your presentation structure

Remember ― you are creating slides to support a spoken presentation. They should aid your delivery and flow, but not distract from what you are saying. Keeping the deck simple, clean and paced quickly will help hold your audiences’ attention on what you are saying, rather than attempting to read an essay on screen. Consider how you’d feel if a technical glitch meant no slides? This has happened to me on more than one occasion and far from being a disaster, it forces you to really focus on your key messages, rationale and style of delivery, rather than using slides as a crutch.

Step 1: Preparation Before you begin, consider your audience and use these critical questions to help structure and scale what you’re going to say. 1) Who are you presenting to? a. Audience size, demographics (age, background, etc.) and baseline knowledge level? 2) What are the three key points you want your audience to take away from your presentation? a. What end point are you trying to get them to, and ensure you tailor the content to the audience’s needs to get them there b. The magic rule of three: audiences remember fewer messages repeated several times, so keep your three points short, relevant and REPEATED c. If you’re not sure, remember that key messages should tell the audience something they don’t already know and that will help shift them from the current to desired belief/understanding 3) How long do you have to speak? a. VERY important ― allow for approximately one minute per slide to guide presentation length, and cut down or expand your slides to be appropriate for your timeslot (don’t forget to allow Q&A time at the end)

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Top five tips for PowerPoint presentations 1. Don’t. Read. Every. Word. • Use slide notes and rehearse 2. Always face the audience • Don’t turn around to look at your slides – we can’t hear you 3. Don’t use a laser pointer • In my experience, these are distracting and not very effective. It also encourages you to turn around. Verbally redirect the audience or use arrows on the slide 4. Take your time! • Be aware of timings so you neither rush through, nor overrun. Maybe have a buddy in the room to give you a five minute and one minute warning so you can wrap up without rushing 5. Never talk on top of your slides • If you need the audience to look at something ― let them look/read ― then provide comments to broaden and amplify what’s on screen A great tip I once learnt from my presentation trainer years ago was about topping and tailing your talk, to manage audience expectations and keep their attention throughout. They said, “You start by telling them what you’re going to say, then you tell them, then you tell them what you’ve told them.” Sounds simple and a bit silly, but I’ve found it really helps to hold audience attention. In fact, regular ‘signposting’ throughout your presentation (both verbally and using spacer slides) not only helps you keep on track, but it makes the audience more attentive throughout and less likely to ‘drop off’ towards the end. Like a meeting agenda, everyone knows up front the key points for discussion and as you go through each one, you’re reminded of what’s been covered and what’s still to come.

Step 2: Practice and plan By practising and preparing in advance, you can minimise the number of things that might worry you about public speaking ― taking away the unknowns and the fear factor so you can focus on that powerful delivery. Of course, you will likely have prepared your slides but ensure that you verbally rehearse these. Saying things out loud and getting used to the flow can often flag up issues that don’t show up on paper, like running out of breath, finding you’ve repeated yourself or gotten stuck/disconnected. Use a remote clicker and stand up ― present to your mirror, a friend, or a colleague and keep doing it until the flow feels natural and you are not relying so much on those slides to guide what you say, and what comes next. You should have the structure and key points memorised and at the tip of your fingers. If you’re speaking at a workshop, event or congress ― make the stage your comfort

zone! Assess it well ahead of time, perhaps see if you can secure some rehearsal time, get a feel for the space and make friends with the AV support. You may or may not have your own laptop or clicker to use, instead these may be provided to you, so some familiarisation up front helps reduce the performance anxiety. Also consider ― will you be using a lectern or free-standing? If you’re nervous, there is a temptation to use lecterns to ‘hide’ and form a physical barrier between you and the audience. Where possible, I would work on your presenting postures without a lectern as it’s more open and engaging for the audience. If you must use the lectern, ensure you are not always glancing down at the laptop or worse ― behind you ― to read off the screen! It’s disengaging for the audience and often means you can’t be heard clearly. ‘Planting’ is a presenting technique in which you place yourself on the stage in a strong, stable posture, feet slightly apart, shoulders back, hands held gently in an open gesture just under your ribcage. Rather than wandering around the stage, swaying, rocking or fidgeting ― planting helps to keep your audience’s attention focused on what you’re saying ― rather than being distracted by nervous twitching. You can also move slowly and purposefully across the stage at key points to ‘plant’ yourself in a new spot to help emphasise a point and keep things fresh.

Step 3: Remain poised During your presentation, try to relax! Be confident in yourself and your expertise – this is why you’ve been invited to speak in the first place. Breathe deeply and take your time to go through your presentation, a brisk pace is great, but flying headlong through slides will not help you get the audience where you

need them to be. Be aware of your body posture, hand movements and facial expressions ― you need to portray confidence and authority so stand comfortably, either ‘planting’ or with the lectern and keep movement to a minimum – no jiggling hands or feet! Hand gestures are great to help make a point ― but don’t overdo it. If you tend to ‘talk with your hands’ try holding onto the lectern (not gripping for dear life) or holding them gently in front of your ribcage.

Not sure where to start? If you’re not yet at the point of running workshops, hosting press events or presenting at congresses, an easy way to increase your experience and comfort with public speaking is to run an Instagram Live or IGTV video on your channel on a topic that would interest your audience. Whilst not directly facing an audience or presenting slides, you still are recording ‘live’ and need to work on your preparation, delivery technique, and confidence. You can also build up your experience at ‘in person’ smaller events – perhaps running an open evening at your clinic for patients and prospects in your local area or speaking at a regional aesthetic event held by an association, or even at local community events about wellness/relevant topics. These skills can apply to internal team training sessions, clinic open days (where you could present on who you are/what you do), all the way up to business presentations and congresses.

Jump into presenting Public speaking and presentation skills are a huge asset to those seeking to build their profile and enhance their business. No matter the scale of the event or size of the audience; effective speaking techniques are highly valuable and can pave the way for bigger and better opportunities. By following the key guidance and best practice techniques in this article, you should be able to structure and deliver a compelling presentation, with or without slides, and set your business up for success. Good luck! Julia Kendrick is an awardwinning PR, communications and business strategy consultant with more than 14 years’ experience. She owns Kendrick PR, which offers both trade and consumer PR for the beauty, wellbeing and aesthetic medicine industries. Kendrick is a seasoned industry speaker, author and trainer, presenting at ACE, CCR and SMART Ideas.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


NEW REVENUE STREAM FOR YOUR CLINIC The new consumer magazine will break down the science to educate consumers on what’s available and how to choose a trustworthy practitioner.

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Define your target audience

Converting Social Media Followers To those newer to social media, marketeer Emily Ruse explains how to turn followers into paying patients The fundamental aim of any business activity on social media is to build brand awareness and drive new leads, but far too often this gets lost in the noise. Many businesses forget that social media is just a tool, and it’s only one small element of a much larger picture. We obsess over our likes, followers, and views, and we miss the critically important concept that having thousands of followers is irrelevant if they aren’t willing to engage with your message and eventually turn into paying customers later down the line. Interestingly, around 25% of social media users follow brands on social media from which they might make a purchase.1 When utilised properly, social media allows a small business to create a significant presence within a very short space of time, and makes it possible for you to reach new audiences and connect with the most prominent figures in your field. It can accelerate the process of gaining credibility and trust – all for very little or no cost. But, to see the best possible results from your social media platforms, they should interface smoothly with your website, blog, email list and even other social media channels to connect with your prospective customers at every single stage of the buyer’s journey and successfully move them through the purchase funnel. So, how do you break through the noise and start taking action that moves the needle in your approach to social media? Ultimately, it all comes down to strategy. Here, I outline some guiding principles to help strengthen your online presence, nurture your followers and have your target audience coming through your door.

Start with social strategy To grow on any social media platform, you need a clear plan with goals that make sense for your business. Perhaps you’d like to build a community of engaged followers, or maybe you’d like your social media accounts to generate more leads and sales. Either way, the goals you set must be realistic, time-driven, and allow you to scale your social media efforts in a way that’s both reasonable and effective. Once you’ve established your social media goals, align them with your most important metrics and KPIs. Rather than on vanity metrics, such as followers and likes, look at data that aligns directly with your goals, such as engagement, click-through, and conversion rates (see Figure 1). By monitoring this data, you will be able to better understand what’s really moving the needle in terms of clicks and revenue.

Once you have a clear picture of your ideal patient, everything else will instantly start to become a lot easier. But understanding who your audience is involves a lot more than just knowing their age, location and gender. Ask yourself: what do they do? What are their interests? What problems are they having? What are the goals they’re seeking? What barriers do they face in reaching their goals? The more detail you can go into, the easier you will find it to form genuine connections with them in your marketing content. The simplest way to gain insight into your target audience is to ask them! Conduct a market research survey of your existing customer database to learn more about their personal characteristics, needs, desires and goals. In my experience, surveys are a good form of qualitative research that ask respondents a short series of open or closed-ended questions, which can be delivered as an on-screen questionnaire or via email. Social listening tools (a software that monitors and analyses online conversations about your brand) can be an excellent way to gather information, too. They give businesses the opportunity to track, analyse and respond to conversations and trends happening in their industry. By tracking and analysing keywords, phrases, and mentions, they can help to identify specific problems that prospective customers of your business are experiencing in the marketplace (pain points) and understand the goals or aspirations that they want to achieve. Don’t forget about your own team in this process! Every day your team talks to real people who are either thinking of using your clinic or are already patients. They have a deep understanding of what your customers are trying to achieve by using your products and services, they know the questions they ask and what their purchasing barriers are. Get to know your followers and customers as real people with real desires and needs, and you will naturally begin to attract them to your business through the social media content you create.

Clarify your messaging Words matter, and the words you use in your marketing communications, on your website, and in emails carry the deeper messages of your brand in many ways. If you’re aiming to attract more highquality patients to your business, the first imperative is to make sure your brand

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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Business objective

Social media goal

Metric(s)

Grow the brand

Awareness (these metrics illuminate your current and potential audience)

Followers, shares

Turn customers into advocates

Engagement (these metrics show how your audience are responding to your content)

Comments, likes, mentions

Drive leads into sales

Conversions (these metrics indicate the effectiveness of your social engagement)

Website clicks, email sign-ups

Improve customer retention

Consumer (these metrics reflect how active customers think and feel about your brand)

Testimonials, social media sentiment, average response time (for customer service/support)

Table 1: A simple social media strategy1

message is clear, relevant, and focused. Your target audience are busy people who are distracted and overwhelmed by the thousands of pieces of content that they consume every day. Stand out from the crowd by creating a consistent brand voice. You can achieve this by crafting a story that’s relatable to your audience. Tell people exactly what you do and how it can help them, so they don’t need to search for the answers. Talk about how your products and services can help them to overcome their problems. It’s important to consider whether the words on your website and within your content communicate that message accurately and well.

Share your stories This may seem simple but infusing your content with stories is a great way to shed light into the behind-the-scenes of your business. Talk about the journeys you or your team are overcoming, past obstacles you’ve faced, something that’s inspired you, or big wins you’ve experienced. Ask your team to talk about their skin journeys and what they’ve learnt along the way. Talk about small everyday things, like what your conversation with your taxi driver taught you this morning. Storytelling is a powerful tool for capturing customer attention and persuasion but keep the stories you tell relatable to your business and your audience, so as to keep the line clear between being a friend and their doctor. When we share our stories and experiences, it shows that you’re a real human being behind the social media account that they can connect with, and not just another business trying to make a sale. Far too many people overthink showing off the human side of their brand on social media. In my experience, business owners worry about what to say or how to look, but your audience want to see the raw, real

and unfiltered pieces of your life. When we focus on showing up with authenticity and intention that’s when we really begin to build meaningful connections with others.

than social media platforms combined.5 It’s very unlikely that someone will check your social media profile every day (and don’t forget that your content is shown to only a small portion of your followers), but 99% of us check our emails daily.5 So, if you have something important to share and want to make sure your audience receives it, an email list is an excellent means of keeping in touch. Once you’ve got people opting in, send them a thank you or a welcome email straight away. This can be set up automatically with most email providers. Use your emails as a tool to allow your audience to know, like, and trust you on a deeper level. The most prominent ways to provide value to your subscribers is to show them how to overcome a problem, save time, or simply add joy to their lives in some way.

Use a lead magnet A lead magnet acts as an incentive to get your followers to hand over their email address and opt into your mailing list. Email marketing should form a significant part of your marketing strategy and your database should be nurtured regularly at least once every two weeks. Ignoring email marketing means you are missing out on potential business opportunities; it has been shown that people who buy products marketed through email spend 138% more than those who do not.3 Driving your followers to an email list is a natural next step for those who aren’t quite ready to book an appointment or purchase your skincare but are highly interested in what you have to offer and want to keep hearing more. As a consumer, it’s much more interesting to get something in exchange for handing over your details. Provide value – something that’s enticing enough to grab the attention of your target audience and offer it in a captivating way that gets them excited to hear more from you. Your lead magnet could be in the format of an e-book, video or checklist, but the key is that it needs to be informative and solve a problem your target audience experiences. Your incentive topic may be something like, ‘Six ways to take charge of acne’ or ‘How to find a reputable practitioner for your aesthetic treatments.’ If someone has subscribed to your email list (remember they must opt in as per the General Data Protection Regulations4), they’re highly engaged with what you have to offer. In fact, email is 40 times more effective at acquiring customers

Engage with your followers Social media can be a very powerful tool when it comes to attracting new leads to your business. Begin by outlining your goals and getting to know your target audience so that you can create content that engages and speaks directly to the people you’d like to attract. Ensure you’re talking about how your services will change their lives, provide call-to-actions, create an integrated follower-to-customer journey, share stories with your followers and encourage them to participate in conversations. Once they feel connected to your brand, they will readily turn into customers, as well as refer you to their family and friends. Emily Ruse is the founder of Bloom & Beyond Studio and has several years of experience working in the aesthetics industry. She specialises in helping aesthetics, beauty and wellness brands refine their marketing strategy and reach their target customers. Ruse holds a Level 6 Diploma in Digital Marketing from the Institute of Data and Marketing (IDM). REFERENCES 1. Edward Stockwell, 2019, Do your social media followers actually buy <https://www.envision-creative.com/blog/doyour-social-media-followers-actually-buy/> 2. Christina Newberry, 2020, How to create a social media strategy in 8 easy steps. <https://blog.hootsuite.com/how-tocreate-a-social-media-marketing-plan/> 3. Nora Aufreiter, Julien Boudet, and Vivian Weng, 2014, Why Markets Should Keep Sending You e-mails. <https://www.mckinsey.com/business-functions/ marketing-and-sales/our-insights/why-marketersshould-keep-sending-you-emails#> 4. General Data Protection Regulation, 2020, <https://gdpr-info. eu/> 5. Allison Hott, 2021, Email marketing statistics. <https:// optinmonster.com/email-marketing-statistics/>

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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In The Life Of: Dr Sophie Shotter The clinic owner and complications advisor gives us an insight into her daily life emails, and go to bed. If I have the energy, I’ll read a book but I really try to prioritise my sleep during the week, so I would rather have less unwinding time and make sure I’m asleep by 10:30pm at the latest.

Exercise kick-starts my day... I usually get up at around 6am and have a black coffee to help wake me up. Then, I’ll do some form of exercise – either by myself or with a personal trainer. I absolutely love working out and I’m a bit of a fitness freak, so I tend to only have one rest day per week. Since the end of the first lockdown I’ve had a really great routine, and I think part of that is having an exercise bike at home. Not having to get up at 5am and go to the gym has really helped my mornings and given me some extra sleep! Sometimes I’ll meditate in the morning if I have time, but most commonly I’ll do it at night because mornings can often be quite a rush. I usually leave for work by 8am at the very latest, but it really depends which clinic I’m in. Every Tuesday I work in London at the Cosmetic Skin Clinic where I have a 9am start, and it takes me roughly two hours to get there from my home in Kent.

Helping with complications… Once or twice a week will involve aesthetic complications. I am part of the Allergan Aesthetics complications help group, meaning that anyone who buys filler from Allergan and feels they need help, advice or medical input on something can get referred to me by their product specialist. The cases are given to me remotely by Allergan so that I can have a phone call with the practitioner and tell them exactly what I would do in their position, which they can then replicate. Every now and then I’ll have to see someone face-to-face if it’s a tricky case.

My day is full of patients… When I get to my own clinic, Illuminate Skin Clinic in Kent, I’m seeing patients back-toback until the moment I leave – I rarely have time for a lunch break. This differs slightly when I’m in London as I use most of my morning to speak to and see the press, so this helps break up my week a bit! I do a lot of work with key journalists to raise consumer awareness about safe aesthetic treatments. That often means meeting with the media and sometimes treating them, giving them an opportunity to ask questions or interview me, and sometimes treating them. Typically, I see about 20 patients a day, and the most common treatment I’ll perform is facial fillers or botulinum toxin. I always tend to do a full-face approach when treating, and I very rarely will have someone in to do just their lips or just their cheeks. The ones who I treat more holistically are much more satisfying! The reason I enjoy doing them so much is because of the immediacy of the results, and I think it’s how we can make the most impact non-surgically. Before the patient leaves the clinic, they can see the difference you’ve made to their face and their smiles are what gets me through the day! I’ll finish work any time between 8:3010pm. Once I get in, I make myself a quick and healthy dinner, check over all my

On the weekends… My weekends are full of self-care, and I have a strict rule of no alarm clocks. On a Saturday I have a personal trainer in the morning and then make time for pampering – getting my hair and nails done is a must, as well as a lovely hot bath.

What I would change… Not much now, but I used to find it very hard to get a good work/ life balance. It’s important for practitioners to try and make some more time for themselves!

What’s exciting me at the moment… The Profound radiofrequency microneedling device by Candela! Even though it’s not super new to the UK it hasn’t been talked about that much, and I’m just so happy with the results I’ve been getting from it.

Having support like this is something that I think is integral in our industry, because when we work in the NHS we’re so used to working in multidisciplinary teams and we lose this sort of support in aesthetics because we’re often working alone. Being a complications advisor means I can give practitioners another port of call for second opinions and stop them from feeling alone.

My most memorable day… I first trained in aesthetics in 2012 while I was working in anaesthetics and intensive care, and during the next two years I fell in love with the specialty completely. So, my most memorable day has to be when I started doing aesthetics as my full-time career! I remember it specifically as being the first Wednesday in August 2014, because this would usually be the day in the NHS that I would be assigned my new jobs. Instead, I got to wake up and think ‘this is the start of my new adventure!’ At that point I had set up my first clinic as part of the Illuminate brand, and now every first Wednesday of August I think about that day and remember that feeling. I really do love my job, and even though it seems like I have a really busy schedule I’m so lucky that for almost seven years I’ve been able to do what I’m passionate about every single day.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021


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The Last Word Dr Steven Land argues why the responsibility of complication management resides with the treating practitioner All aesthetic practitioners will experience some kind of complication during their career and, in spite of a lack of empirical data, anecdotally the number of complications is increasing.1,2 This would be in keeping with the growth of the sector as a whole – even if the complication rate remained steady, we would expect a greater number if more procedures were being done. As we see more and more inexperienced, unregulated, non-medical injectors enter the market it would seem only logical that this rate is actually on the increase,3 and that certainly appears to be the case to those of us who regularly pick up the pieces. So, who is responsible for these problems? Who should be accountable and who is it that actually ends up shouldering the responsibility? Here I discuss these questions and propose what we can do about it.

The medical practitioner’s responsibility It’s commonly argued that complications should ultimately come down to the person that does the treatment – if you caused the problem, you should fix it. But we know it’s not actually that simple as fixing the adverse event may require resources outside of what you have available personally. Alongside this, many training providers do not go into much depth when it comes to complication recognition and management in a short foundation course. No one expects every practitioner to be able to fix every single potential complication and side effect from aesthetic treatments. However, I would expect every medical practitioner to make an appropriate differential diagnosis of the problem based on their history and examination and refer the patient on appropriately. Ultimately, the responsibility still resides with the original treating practitioner to ensure they have access to the resources needed and seek additional training to correctly diagnose, and manage, the complications that their treatment may cause. The individual practitioner’s role in complication management has many facets. Primary amongst these is education –

knowing how to avoid complications and how to manage them requires constant updating of knowledge and skills as new research and new modalities become available – such as ultrasound.3 This leads onto self-awareness: good practitioners know what they know, but also know what they don’t know and the gaps in their knowledge and skills. Known as the Dunning-Kruger effect (a hypothetical cognitive bias stating that people with low ability at a task overestimate their ability)4 practitioners need to be able to recognise gaps in their own knowledge or skills and what can help them plug these gaps. Support networks can be vital in avoiding and dealing with complications. They can be a way of learning from others ‘mistakes’ (thus avoiding or lessening certain stages of the Dunning-Kruger effect) and they can be a source of help in the event of a complication. All practitioners should strive to develop a support network of some sort – this may be local practitioners they can call on for help and advice, a regional online support group, industry associations such as the BACN or BCAM, or one of the well-established complications groups such as ACE Group World or the CMAC. I feel all practitioners should strive to make contacts within secondary care organisations too, for example, those in plastic surgery, maxilla-facial surgery and/or ophthalmology. These colleagues can provide vital input in the event of serious complications – dermal filler-related necrosis or blindness, significant abscess or infection. Armed with all of these weapons – education, complications management skills, self-awareness and a support network – most practitioners should be able to deal with almost anything the field of aesthetic medicine can throw at them.

Regulatory considerations and the NHS As we know, there is no regulation of who can carry out aesthetic procedures, no benchmark for the standards they should be achieving, or even a legal framework for the level of education they should have attained before putting needle to skin. How do you

Last Word

Aesthetics aestheticsjournal.com Complication Management

know your training and complications course actually equip you to avoid or deal with a problem when it occurs? Furthermore, aesthetic complications are medical conditions requiring medical intervention, which makes it difficult for non-medical injectors to take proper ownership of their complications. What we should all be certain about is that these problems should not default to the NHS. Time and again across internet forums we see the default option ‘send them to see their GP/A&E’ and I see this from both medics as well as non-medics. There is a very minimal role for the NHS in dealing with the majority of aesthetic medicine complications as they do not usually have the skills, knowledge and training in specific aesthetic complications – read more on p.20. Certainly, there is the odd, incredibly rare complication that will require NHS input – blindness, abscesses requiring formal surgical drainage – but this pathway should be the absolute exception, not the norm. C

Complications are a priority We move this forward by getting our own house in order. Every practitioner should come to terms with the fact that they are responsible for the outcome of their treatment. They should have up-to-date knowledge of aesthetic complications – how to avoid and deal with them – from a reputable training provider. Every practitioner should endeavour to cultivate a support network to help out should the worst happen; and every practitioner needs to be pushing for regulation to remove the cowboys (both training and practicing) and create a safer specialty. Dr Steven Land qualified in 2001 and has trained in medicine, surgery, plastic surgery, and emergency medicine on his journey to be an A&E doctor at the regional MTC and an aesthetics doctor. He has a special interest in dermal filler complications. He is the clinical director of award-winning clinic Novellus Aesthetics in Newcastle and is due to launch his own training academy later this year. Qual: MBBS, MRCEM REFERENCES 1. Save Face, Complaints Report. 2019. <https://www.saveface. co.uk/complaints-report/> 2. Kilgariff, S, News Special: Aesthetic Complications, Aesthetics journal, 2019. <https://aestheticsjournal.com/feature/aestheticcomplications> 3. Kilgariff, S, Utilising Ultrasound in Aesthetics, Aesthetics journal, 2020, <https://aestheticsjournal.com/feature/utilising-ultrasoundin-aesthetics> 4. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated selfassessments. J Pers Soc Psychol. 1999 Dec;77(6):1121-34.

Reproduced from Aesthetics | Volume 8/Issue 8 - July 2021

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JULY 2021: The Complications Issue  

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