JUNE: THE COMPLICATIONS ISSUE

S I C RY ET T H EN ST S N! D AE AR PE O

AW

VOLUME 7/ISSUE 7 - JUNE 2020

CPD: Using Oxygen Therapy Dr Ahmed El Houssieny discusses its use for vascular complication management

News Special: Back to Work Post COVID-19

An overview of the guidance available for returning to practice

Dermal Filler Complication Prevention Mr Dalvi Humzah details the seven ‘Ps’ of prevention

Understanding the Second Victim

Linda Mather explores how complications affect practitioners

Contents • June 2020 06 News The latest product and industry news 18 Advertorial: Evolution of the Elite Brand Exploring the history and future of laser hair removal with Cynosure 19 News Special: Returning to Aesthetic Practice The advice available to maintain safety as clinics begin to reopen their

VASCULAR OCCLUSION EMERGENCY NUMBER

doors following the COVID-19 lockdown

23 Understanding Facial Differences Raising much needed funds for children suffering with facial differences

through the Facing the World charity

24 Join us at CCR An overview of what you can expect at the CCR conference and

exhibition on October 1-2

Spotlight On: Emergency Helpline Page 60

CLINICAL PRACTICE 25 CPD: Using Oxygen Therapy For Vascular Compromise Dr Ahmed El Houssieny discusses hyperbaric oxygen therapy in

vascular compromise management

31 Preventing Dermal Filler Complications Mr Dalvi Humzah explores the seven ‘Ps’ to help practitioners prevent

dermal filler complications

35 Case Study: Necrosis Management Dr Beatriz Molina manages skin necrosis on the nose following

hyaluronic acid filler injection

38 Entering the Aesthetics Awards 2020 Entry to the most prestigious Awards ceremony in the specialty is open!

43 Treating Self-harm Scars Mr Ioannis Goutos explores the impact of scars from self-harming and

the different treatment approaches

47 Case Study: Infection and Nodules Nurse prescriber Alice Henshaw describes how she successfully

treated a complication in the lips

51 Understanding Paradoxical Hair Growth Dr Ingrid Wilson explores the occurrence of paradoxical hair growth as

an adverse event following laser and light treatment

55 Case Study: Vascular Occlusion

Nurse prescriber Lynn Lowery successfully manages a dermal filler complication in the lip

59 Abstracts A roundup and summary of useful clinical papers

IN PRACTICE 60 Spotlight On: ACE Group Emergency Helpline Aesthetics speaks to nurse prescribers Sharon King and Linda Mather

Dr Ahmed El Houssieny is an anaesthetist with a passion for aesthetics, as well as an education provider for cosmetic procedures. He is an associate member of the British College of Aesthetic Medicine.

Mr Dalvi Humzah is a consultant plastic surgeon and delivers his clinical practice through PD Surgery.

He is also director of the award-winning Dalvi Humzah Aesthetic Training and clinical director of Derma-Seal Ltd. Dr Beatriz Molina is the medical director and owner of Medikas clinics, and has more than 12 years’ experience in injectable practice. She is a KOL for Galderma and the founder of IAPCAM. Mr Ioannis Goutos is an academic plastic surgeon specialising in scar management, lasers and body contouring. His practice is based at Barts Health NHS Trust and Harley Street in London.

Alice Henshaw is an aesthetic nurse prescriber and founder of Harley Street Injectables in London. She completed her bachelor’s degree in New Zealand and worked as a cardiac nurse before moving to the UK. Dr Ingrid Wilson became a GP in 1999, is on the specialist register for Public Health Medicine and a Fellow of the Faculty of Public Health. She has a Level 7 BTEC in Laser and Associated Light Therapy and is a director for Crewe Hair & Skin Clinic.

Lynn Lowery is an independent nurse prescriber with more than 10 years’ experience in medical aesthetics. She has been a registered nurse for more than 20 years and remains dual-qualified as a paramedic.

about the world’s first and only emergency helpline for complications

63 Understanding the Second Victim in Complications Aesthetic nurse prescriber Linda Mather identifies the psychological

Clinical Contributors

concerns practitioners may face after causing an aesthetic complication

A E S T H E T I C S AWA R DS E N T RY O P E N !

67 In The Life Of Dr Tijion Esho

Aesthetics learns how Dr Tijion Esho is managing multiple clinics and media commitments in lockdown, while being a full-time dad

68 CCR Exhibitors All the exhibitors you will meet at the CCR conference and exhibition on

October 1-2

NEXT MONTH IN FOCUS: SKIN & TOPICALS • Photoageing and Skincare • Skincare Physiology for Dry and Dehydrated Skin • Introducing Podcasting

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Editor’s letter Here we are in June – still in lockdown, but easing into the ‘new normal’. The past month has seen lots of discussion on when and how aesthetic practitioners should return to clinic, with guidance released by a range of groups and associations. To ensure you’re as Chloé Gronow prepared as possible, we have put together Editor & Content an overview of all the advice available on p.19.

Manager I’m interested to know, how many of you have @chloe_aestheticseditor experienced a complication from a treatment you’ve given? We know that complication rates are likely to be significantly underreported, perhaps because of fear of shame or embarrassment amongst peers, yet while putting together this issue – entirely focused on complication prevention and management – the take-home message from those experienced in this field is most certainly to talk about it.

Professionals say that doing so enables you to identify and learn from any mistake you may have made, while sharing your experience can help others avoid similar situations. Not only that, as nurse prescriber

Linda Mather highlights in her article on p.63, causing a complication can have a significant impact on your mental health. Mather shares her research on the ‘second victim’ in complication cases, detailing how the treating practitioner is affected and the steps they can take to overcome this, with one of the key messages being to open up to peers, friends and family – extremely worthwhile reading.

I would also urge you all to read our Spotlight On the ACE Group Emergency Helpline – this is an amazing service which takes roundthe-clock calls from practitioners faced with a complication. The call handlers all give up their time voluntarily and work hard to support peers in times of crisis. That said, the service needs to be used properly to be able to offer the most effective and timely advice.

Should you need the helpline in future, turn to p.60 to learn more.

Finally, I’m delighted to say that entry to the Aesthetics Awards is now open! I’m particularly excited about the new ‘Results’ categories we’ve added, which give you the chance to be recognised for your excellent aesthetic outcomes. To find out more, turn to p.38 and enter via www.aestheticsawards.com

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

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

Mr Dalvi Humzah, Clinical Lead

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

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

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

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon at the Cadogan Clinic in Chelsea, London. She specialises in cosmetic eyelid surgery and facial aesthetics. Miss Hawkes also leads the emergency eye care service for the Royal Berkshire NHS Foundation Trust.

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

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years.

Recently, he was listed in Tatler’s Top 30 AntiAgeing Experts. Dr Patel is passionate about standards in aesthetic medicine.

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

Dr Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education.

She is the clinical director of Revivify London, an honorary clinical teacher at King’s College London and a visiting associate professor at Shanghai Jiao Tong University.

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine.

She is the founder and medical director of the multi-award winning EUDELO Dermatology & Skin Wellbeing in London. She lectures in the Division of Cosmetic Science and has published more than 100 scientific articles, book chapters and abstracts.

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Pharmaceuticals

Talk #Aesthetics

AbbVie acquires Allergan

Follow us on Twitter @aestheticsgroup and Instagram @aestheticsjournaluk

#Deliveries @macom_medical Big shout out for today’s hero – Irene, our fantastic USP lady who never misses a call and carries the heaviest of macom parcels with THIS smile. Thanks to Irene, even during these unprecedented circumstances, we can continue our mission to care for our customers during their recovery journeys, giving that extra support or simply lifting things up, right where they need it. WE LIFT YOU, IRENE LIFTS US ALL. #Travel @drfirasalniaimi With the world slowly easing the lockdown I am looking forward to my travels and exploring the world again! #Teamwork @bacnurses A #TBT to @ccrlondon with the editor of @aestheticsjournaluk @chloe_aestheticseditor and our membership and marketing manager Gareth! Aesthetics is a media partner of the BACN and we work together on a number of activities and share goals to drive professionalism in the industry, and we couldn’t be more proud to do so! #Reflection @drahsanchaudhry Such beautiful views of London, who would’ve thought this pandemic would shut down all the major cities of the world – sometimes it’s important to remember the good times and keep going – there’s always light at the end of the tunnel. #InternationalNursesDay @sharonbennettskin Proud to be a registered nurse.

A hug to all my colleagues across the world who do amazing working spanning all the specialties. I work with amazing skilled nurses who drive me, educate me, guide me and bring me down to earth. The nurses I know are multiskilled – leaders, KOLs, trainers, professors, businesspeople and entrepreneurs – but most of all caring. Happy Birthday Florence Nightingale. British nurse, statistician and social reformer who was the foundational philosopher of modern nursing and raised the standard and standing of nurses.

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Global biopharmaceutical company AbbVie has completed its acquisition of Allergan plc following regulatory approval of all government authorities. The deal was first announced in June 2019 and aims to significantly expand and diversify AbbVie’s revenue base, providing new growth opportunities in neuroscience with Botox Therapeutics and global aesthetics business with Botox and Juvéderm. The company explains that the portfolio will drive the existing AbbVie growth platform to approximately US $30 billion in revenues in full year 2020, with combined revenues of approximately US $50 billion. Richard Gonzalez, chairman and chief executive officer of AbbVie said, “Our new Allergan colleagues should be commended for all their efforts, along with those of our own employees, to achieve this turning point for our company.

The new AbbVie will be a well-diversified leader in many important therapeutic categories, with both on-market and pipeline assets, and our financial strength will allow us to continue to invest in innovative science and continue to serve unmet medical needs of patients that rely upon us. I am proud of both organisations and look forward to the opportunities ahead.”

Skincare

Exuviance rebrands

UK distributor AestheticSource has announced that Exuviance is being re-branded and split into separate skincare ranges.

The Exuviance brand will now encompass the Exuviance Professional treatment range, the Exuviance Professional home-use range, as well as an exuviance retail range exclusively available online.

AestheticSource confirms that Exuviance Professional and Professional homecare will be exclusive to in-clinic use only and should be administered by trained practitioners. The new Exuviance Professional brand will have new marble packaging and practitioners will receive toolkits designed to help successfully incorporate the brand into their business.

The exuviance retail range is in-line with US branding of rose gold and is a ‘direct to consumer’ range via Skincity UK. Lorna McDonnell Bowes, co-founder and CEO of AestheticSource, said, “This new split of the existing product line is the first step to help Exuviance create exclusive professional products in the future. As you know, the professional has always been at the heart of the Exuviance brand and together we want to develop as your partner and help you grow your businesses. The professional market continues to be an important part of expanding the Exuviance Professional brand worldwide and we value your support during this change.” AestheticSource will soon be hosting an online webinar and other online events to introduce the new Exuviance Professional range to practitioners.

Aesthetics | June 2020

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Vital Statistics

Aesthetics appoints new Clinical Advisory Board member Consultant ophthalmic and oculoplastic surgeon Miss Elizabeth Hawkes has joined the Aesthetics Media Clinical Advisory Board.

In her new role, Miss Hawkes will support the clinical direction of the Aesthetics journal and Aesthetics Awards, as well the ACE and CCR conferences and exhibitions. Miss Hawkes graduated from Imperial College London and has trained at Harvard Medical School in Boston. She undertook postgraduate medical and surgical training at St. Mary’s Hospital in London before embarking on a career in ophthalmic surgery. Miss Hawkes is a specialist in cosmetic eyelid surgery, including upper and lower eyelid blepharoplasty surgery, as well as practising non-surgical aesthetics. She leads the emergency eye care service at the Royal Berkshire Hospital, while practising aesthetics at the Cadogan Clinic in London. Following her appointment, Miss Hawkes said, “I am delighted to sit on the Clinical Advisory Board for Aesthetics. It is a pleasure to work with leaders in the field to maintain high standards in aesthetic practice.” Editor and content manager, Chloé Gronow, added, “We are thrilled that Miss Hawkes is joining our Clinical Advisory Board. She has already written some excellent pieces for the journal, sharing her expert knowledge of eye treatments and anatomy with readers. Miss Hawkes’ experience will only add to our already multidisciplinary Board to further support us in our clinical direction, ensuring all information we share is evidence based and cutting edge.”

52% of British women have changed their beauty essentials since the start of lockdown (No7, 2020)

Nearly 27,000 plastic surgery procedures took place in 2019, a decrease of 7.5% from the previous year (BAAPS, 2020)

28% of 2,000 survey participants said they edit their photos to look as good as possible (Really, 2020)

A global research project of 18,541 women in 40 countries showed that 71% of women are unhappy with their breasts

COVID-19 support

Galderma launches ‘bounce back’ initiative Global pharmaceutical company Galderma has created a new training and support programme to help customers get back on their feet once restrictions lift and clinics can open again. According to the company, the new packages will provide valuable insights, tools and guidance to help customers navigate their way through this challenging period.

Toby Cooper, business unit head of Galderma UK said, “Galderma has been tracking global activities and has a wealth of insights to share with customers. We are looking forward to sharing the insights, expert thirdparty advice, ongoing social media assets and tools that will help clinics bounce back post lockdown.” Later this month aesthetic practitioner and Galderma key opinion leader Dr Kuldeep Minocha will host a webinar on the Med-FX website covering guidance on the latest COVID-19 opening protocols. Galderma says that this will provide advice on deep cleaning and sanitisation, appointment scheduling, managing the flow of people in the clinic, PPE and staff/patient screening. Dr Minocha will also walk through how to use Galderma’s specially-created interactive waiting list template and social media collateral.

Katie Bennett, Restylane brand manager, said, “It could be a long time between getting a spot on the waiting list and getting their appointment in clinic, so we’ll be providing Restylane clinics with the tools they need to keep relationships strong.”

Aesthetics | June 2020

(Body Image, 2020)

Almost 40% of those under 24 have felt less pressured to look a certain way while isolated at home (Skin Proud, 2020)

29% of people would be put off getting an aesthetic procedure out of fear of it going wrong (Cynosure, 2020)

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Events Diary

1 & 2 October, ExCeL www.ccrlondon.com

12 M & A 1R 3 C MH A R1C2H & 2 01231 |/ L 2 O0 N2 D1 O N AESTHETICSCONFERENCE.COM

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Sun protection

New SPF released by ZO Skin Health Skincare company ZO Skin Health has launched a new sunscreen and touch-up powder duo. The ZO Skin Health Sunscreen + Powder SPF 30 is the latest product in the Triple-Spectrum Protection range and has been developed to offer free-radical, blue light and environmental protection, as well as an on-the-go sunscreen touchup. The products are available in three universal shades: the light shade has a cool undertone that aims to neutralise signs of redness and irritation, medium shade aims to produce a natural look or a sheer base, and deep can be used for a warm undertone to contour the face for a more bronzed look.

HA fillers

Training

Teoxane launches digital education Aesthetic manufacturer Teoxane has launched a new digital platform as part of its global medical education programme to enhance the knowledge and clinical skills of aesthetics professionals. The Teoxane Academy Digital Platform has been designed to provide a curriculum of tailored content to injectors at each stage of their career, while complementing and enhancing its global medical education programme. Jordan Sheals, deputy country manager for Teoxane UK, said, “The Teoxane vision has always been to expand the possibilities of a HCP using the Teoxane portfolio of products, and our educational programme is perfectly aligned to this objective – to offer evidence-based clinical education, tailored to the needs of the HCP at that moment in time.” She added, “The launch of Teoxane Academy Digital further supports this vision, by offering an at-home and on-demand learning environment available to all. The platform has been designed, in addition to other Teoxane training programmes, to take the user on a journey from beginner to more advanced modules, allowing for self-assessment and knowledge checks along the way.”

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Restylane Kysse receives FDA approval Hyaluronic acid dermal filler Restylane Kysse has been approved by the US Food and Drug Administration (FDA) for lip augmentation and the correction of upper perioral rhytids. While used widely in the UK, the FDA approval now means the product can be used for these indications in the US when it is launched at an appropriate time following the COVID-19 pandemic. The product uses Galderma’s Optimal Balance Technology and has been demonstrated to last up to a year, with high levels of patient satisfaction. Katie Bennett, brand manager for Galderma UK said, “Kysse is extremely popular in the UK and is linked with nurse Julie Horne’s lip technique, as it integrates smoothly for beautiful results in moving planes.”

Dermatology

Research identifies five common skin issues associated with COVID-19 Five common skin manifestations of COVID-19 have been identified, according to research published in the British Journal of Dermatology.

Images of unexplained skin eruptions in a total of 375 patients with either suspected or confirmed COVID-19 were reviewed by four dermatologists and a consensus was reached.

The five skin manifestations identified were: acral areas of erythema-oedema or pustules (pseudo-chilblain), other vesicular eruptions, urticarial lesions, other maculopapules, and livedo or necrosis.

The study researchers said, “Some of the skin manifestations associated with COVID-19 are common and can have many causes, particularly maculopapules and urticarial lesions.

As such, they may not be particularly helpful as an aide to diagnosis. Livedoid and necrotic lesions, on the other hand, are relatively uncommon, and mostly appeared in elderly and severe patients. However, it is hard to tell if they are directly caused by COVID-19, or simply indicate complications.”

Aesthetics | June 2020

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Skincare

SkinCeuticals releases new products Cosmeceutical company SkinCeuticals has released the Advanced Brightening UV Defense Sunscreen SPF 50 and three new Skincare Concern Kits. According to the company, the Advanced Brightening UV Defense Sunscreen SPF 50 is a duel action, lightweight sunscreen with broad spectrum filters to help protect skin against UVA and UVB rays. It also has a brightening effect, containing 1% tranexamic acid and 2% niacinamide, the company states. The product aims to help with suninduced hyperpigmentation, skin discolouration, dull and rough textured skin, and visible signs of photoageing. The new Skincare Concern Kits aim to provide a prevent, correct and protect regime to address the signs of ageing, blemished or dull, uneven toned skin. The kits include the Age Renewal System, which aims to improve the appearance of fine lines, wrinkles and skin tone; the Clarifying Skin System, which aims to help improve the appearance of blemish-prone skin and enlarged pores; and the Brightening Skin System which, according to the company, targets visible signs of discolouration to deliver brighter, more even skin tone.

B E PART O F THE AE S THE TICS AWARDS The renowned Aesthetics Awards brings together the very best in medical aesthetics – celebrating the achievements, best practice and high standards of professionals working across the specialty

WINNERS SAY… The Aesthetics Awards allows us to pause, reflect and appreciate the good that we and the entire industry can achieve. Our daily focus is striving to better serve our patients, but on this night we turn the spotlight on ourselves, celebrate each other, giving a well-deserved pat on the back – it’s a joy-filled and inspirational evening!

Dr Julia Sevi, Aesthetic Health – Winner of The AesthetiCare Award for Best Clinic North England

JUDGES SAY… I have done the judging for years and it’s always good to see that the winners in the categories I judge are reflective of the scores that I give. There are some fabulous, well-deserving people who win and deserve to be celebrated!

Dr Martyn King, Judge

SPONSORS SAY…

Industry

Allergan Aesthetics hires new marketing director Hania Flannery has been appointed as the new marketing director at Allergan Aesthetics, which was recently acquired

by AbbVie. As part of her new role, Flannery will be managing the marketing for Botox, Juvéderm and CoolSculpting, as well as a pipeline of further innovative aesthetic products. She will be responsible for envisioning and executing marketing programmes to support brand, customer and consumer awareness and needs, whilst abiding by the relevant codes of conduct.

She said, “I am delighted to be joining Allergan Aesthetics at such an exciting time; the business has recently been acquired and is now part of AbbVie. Allergan has long been considered as the world leader in medical aesthetics with a long-standing portfolio of reputable and trusted brands.

I am looking forward to using my experience in beauty and consumer marketing in this next exciting phase of growth.”

We have regularly sponsored categories in the Aesthetics Awards as I believe it is the most important awards ceremony in the industry – it’s a very easy decision to support. At Church Pharmacy we are all about innovation, particularly on the technology side, so we are really honoured to be able to sponsor the category for Product Innovation of the Year. We are super excited for this year to see all the new innovations!

Zain Bhojani, Church Pharmacy – sponsor of The DigitRx Award for Product Innovation of the Year FAST. EFFICIENT. SECURE.

Aesthetics | June 2020

EN TER AN D BO O K TICK ETS TO DAY

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

SAFETY IN PRACTICE GUIDELINES The BACN has produced a set of guidelines to enable you to prepare yourself for reopening your clinics, ensuring the safety of you, your patients and your staff is met. The BACN Board and regional leaders have worked extremely hard on these guidelines and are delighted to be able to share them with you. The Suggested Operational Plan Guidelines for COVID-19 was emailed to members, as well as being available in the members’ resource area of the BACN website.

We have also made our recommendations available to non-members, which can be accessed via the Aesthetics website.

RETURN-TO-WORK DATE We have received enquiries from members as to when you can start practising again. The BACN has been carefully monitoring the Government’s announcements and how they apply to members and aesthetic clinics. It is very important to note that the latest announcements from the Government apply to England, and that the devolved administrations in Scotland, Wales and Northern Ireland may well adopt localised variations.

The BACN has been working to get detailed clarification from the Government. As soon as we have this, it will be posted on our website. It should be stressed that any decision to reopen clinics will be down to individual members.

JOIN US We would like to thank all members who have continued membership/payments and those who have newly joined. We have received some very supportive messages in the past few months and the BACN Facebook group remains active and buzzing with discussions and updates for when we restart clinics. If you would like to become a member of the BACN to meet other aesthetic nurses and gain more access to guidance and support on running an aesthetic practice, email our membership and marketing manager Gareth Lewis via g.lewis@bacn.org.uk This column is written and supported by the BACN

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Coronavirus

Practitioners to launch national COVID-19 testing Aesthetic practitioners Dr Martyn King and Sharon King are launching a national COVID-19 antibody testing service for the general public in collaboration with CST Pharma. The new programme, called MyCovid, is allowing medical clinics to provide COVID-19 antibody testing on mass through a national booking system. It aims to help test individuals who fall outside the Government’s criteria for testing and provide reassurance to those that do not have the virus, or have had the virus without realising. Dr King said the service is a good opportunity for private medical aesthetic clinics to not only help the community, but generate an income during the lockdown period. Dr King said, “MyCovid is committed to helping the country face the challenges of COVID-19 and any positive results will be communicated to the patient’s general practitioner and public health body as SARS-CoV-2 is a notifiable disease. If any medical aesthetic practitioners are interested in becoming a testing centre or would like more information, please complete an enquiry on our website www.mycovid.co.uk, which should be live to accept bookings soon.”

Education

AestheticSource webinars become CPD approved Delegates who have taken part in the online education programme by distributor AestheticSource can now receive 1 CPD point for each webinar they have attended. After viewing a webinar, delegates can complete the company’s Webinar CPD Certification Claim Form, ticking each box for webinars they have joined. Details will then be verified by AestheticSource and, if eligible, a digital CPD attendance certificate will be issued via email in PDF format. Vikki Baker, marketing manager at AestheticSource, commented, “Current COVID-19 lockdown has expedited the development and launch of the AestheticSource online educational platform. The webinar curriculum has enabled us to support our customers when they have required it the most, providing both remote expert training as well as brand refreshers, and therefore we are delighted that this will also enable our customers to accrue CPD for their ongoing development.”

COVID-19

Almost half of aesthetic practitioners return to the NHS Research conducted by Hamilton Fraser Cosmetic Insurance has indicated that 44% of aesthetic practitioners have returned to the NHS during the COVID-19 pandemic. The survey of more than 600 practitioners found that the key reasons for returning were the opportunity to help others and to be able to supplement income lost from clinic closure. Others moved from working part time to full time, with 56% of respondents now working for the NHS full time. Most of those working in the NHS said the biggest concerns they faced were the lack of PPE and the worry of spreading coronavirus to their family. Despite this, one practitioner said, “I have loved feeling part of a work-based family, everyone pulls together in times of crisis and even though many of us are tired from working extra hours we support each other – it’s a job like no other. I love people; be it my colleagues, patients in hospital or aesthetic patients, when this is over I will split my time between nursing and my aesthetics business.”

Aesthetics | June 2020

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Chemical peels

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Research

AlumierMD releases home-based peel kit AlumierMD has launched the @Home Renewal Kit to meet the rising interest in at-home exfoliation protocols to maintain in-clinic results.

The kit includes the Cleanse – HydraBoost, Exfoliate – Bright and Clear Solution, Target – AHA Renewal System and Target – Retinol Eye Gel. Sold exclusively on the AlumierMD e-commerce portal instead of third-party websites, the company explains that the @Home Renewal Kit will allow practitioners who have had to close their clinics to retain the profit margins from online sales.

AlumierMD has also launched a series of e-learning and on-demand webinars for professionals, as well as weekly Instagram Live sessions to help attract patients. Victoria Hiscock, medical communications manager for AlumierMD, said, “Aesthetic professionals are facing a broad array of challenges during this period of lockdown, not least generating an income for their business and maintaining engagement with their patients.

AlumierMD was built upon our commitment to the success of our valued medical partners, who we are seeing optimise our e-commerce platform, on-demand education and consumer driven online events. It’s more important than ever that we stand united and support each other through this uncertain time.” For every @Home Renewal Kit sold, AlumierMD will donate £10 to the NHS in the UK or 10 EUR to the HSE in Ireland.

British research group has tear trough study published in PRS Peer-reviewed medical journal Plastic and Reconstructive Surgery – Global Open has published a study conducted by the Academic Aesthetics Mastermind Group (AAMG) on the safety of tear trough treatment. The AAMG is an aesthetic medicine research group, founded by Dr Zoya Diwan and Dr Sanjay Trikha, and a finalist for The Clinetix Award for Professional Initiative of the Year at the Aesthetics Awards 2019. The study was the first ever published by the group, and looked at the safety, complications and satisfaction for tear trough rejuvenation using hyaluronic acid dermal fillers. The study authors include AAMG chairs and founders Dr Diwan and Dr Trikha, as well as Dr Sepideh Etemad-Shahidi, Dr Zunaid Alli, Dr Christopher Rennie and Dr Amanda Penny. Group chair Dr Diwan said, “The AAMG aims to advance the field of aesthetic medicine through bringing together a community of experts working together on academic research to ultimately contribute to improved patient safety across the globe. We are delighted that we have published our first ever research paper as a group in the high impact Journal of Plastic and Reconstructive Surgery Global Open, focusing on tear trough treatments.

We are working on more research projects to continue to help improve excellence, patient safety and academia within this industry.”

Education

Headaches

Training academy launches online toxin course The London Academy of Aesthetic Medicine has launched The Online Ultimate Toxin Course to allow practitioners to enhance their knowledge on the use and science behind botulinum toxin.

Topics covered include the mechanism of action of toxin, current legislation, available preparations, treatment indications, patient assessment, relevant anatomy, injection points, reconstitution and post-procedure advice. Also detailed will be business aspects of running a clinic, including fee setting, advertising and utilising social media for marketing. The Online Ultimate Toxin Course is led by aesthetic practitioners Dr Wassim Taktouk, a Teoxane UK country expert with more than 11 years’ experience in aesthetics, Dr Sheila Nguyen, an aesthetic practitioner and dentist with more than four years’ experience training practitioners, and Dr Tara Francis, a dentist with five years’ experience in aesthetics and trainer for Stylage dermal fillers. The next dates are scheduled for June 24 and July 29 via Zoom.

Aesthetics | June 2020

Survey suggests toxin protocol not followed A survey has indicated that only 22.5% of practitioners follow the recommended protocol for treating headaches with botulinum toxin. According to the survey conducted by Headache, the journal of head and face pain, 141 respondents said they did not always follow the PREEMPT protocol – the only FDA-approved injection pattern for chronic migraine with use of onabotulinum toxin A. Results found that 70% changed the number of injections, 63% changed the total units injected, 57.7% altered the location of injection sites, 55.5% do not aspirate, 12.1% change the dilution and 2.2% added lidocaine. The main reasons cited for changing treatment approach were to adapt to individual patients’ pain, anatomy and preferences. The authors concluded, “The survey suggests that an advisory protocol containing more evidence and discussion of the reasoning behind the recommendations might be more helpful than the current prescriptive protocol.”

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FINALIST 2019

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Insider News

Coronavirus

Aesthetic Technology launches ventilator for COVID-19 British manufacturer Aesthetic Technology has become the first independent UK company to launch a fully-compliant ventilator in response to the COVID-19 pandemic. According to the award-winning company, which manufactures Dermalux LED, the C-19 Ventilator is based on an existing fully-approved design, for which Aesthetic Technology has been granted a worldwide permissive licence from Medtronic to manufacture for the duration of the pandemic.

The company notes that it is compact, lightweight and portable, Skincare

New home peel released

by Dr Levy Switzerland

providing airway support for both children and adults. Due to its regulatory compliance, the Aesthetic Technology C-19 Ventilator will be available for delivery in countries throughout the world, not just the UK. Huw Anthony, CEO of Aesthetic Technology, said, “In these unprecedented times, as a fully certified manufacturer of medical equipment, we are pleased to be able to play our part and contribute to the COVID-19 cause, not just here in the UK but on a worldwide basis too. Fortunately, we have a very gifted team led by our managing director, Dale Needham, who rose to the challenge. I am very proud of what Dale and his team have achieved and hope that their efforts can play some part in the worldwide fight against this extraordinary pandemic.”

Training

Acquisition Aesthetics introduces Advanced Skin Course After its recent collaboration with skincare company AlumierMD, training provider Acquisition Aesthetics has launched its Advanced Skin Course. The course will train delegates on the use of medical-grade skincare and chemical peeling, while giving them the opportunity to become familiar with the AlumierMD skincare and chemical peeling products.

They will also gain an understanding of how to incorporate medical-grade skin sciences into their aesthetic treatment plans, according to Acquisition Aesthetics. Following the course, delegates will receive an invitation to set up an AlumierMD account and will be able to access account-exclusive benefits.

Dr Bibi Ghalaie, clinical lead for the course, said, “Medical-grade skincare is evidencebased, potent and can produce significant results. Skincare consultations should be an option in every aesthetic practitioner’s treatment portfolio and being trained in one of the top international ranges, like AlumierMD, will help you to excel in the aesthetics field.’’

The Advanced Skin Course launches Saturday September 5 and is open to all healthcare professionals with an active licence to practice.

Sclerotherapy

Skincare brand Dr Levy Switzerland has released the at-home Radical3 Reboot Pro Peel which aims to eliminate dullness and renew cells.

The product features three peeling actions; the first being an exfoliating peel that aims to remove impurities and toxins from the stratum corneum, the second is a 10%+ acid peel containing glycolic and mandelic acid, hibiscus acid, citric acid and black willow bark, while the third is an enzymatic peel which has been shown to stimulate skin oxygenation, helping cell turnover.

According to the company, the Radical3 Reboot Pro Peel can be used on the face, neck, décolletage and hands.

BAS to hold webinar on returning to work The British Association of Sclerotherapists (BAS) will host a three-hour webinar on reopening your clinic post COVID-19 on Saturday June 20. According to the BAS, clinic owners and managers are genuinely concerned about the timing, staff and patient safety, PPE and infection control, cash flow, and how to go about regaining patient confidence and rebuilding a viable business. The webinar will include advice on when it is advisable to open, risk assessment templates, safeguarding and supporting staff, infection control, patient selection and management, how to use marketing to re-establish a patient-base, implementing telemedicine and diversification options to re-build a healthy cash flow.

BAS Chairman Dr Stephen Tristram commented, “Whether, when and how to re-open my practice are the big questions going through my mind at this stage, and I’m certain many others are in the same boat. The BAS 2020 conference has of course been cancelled for the time being, and we are excited to be supporting practitioners by putting together the definitive guide to bringing our clinics out of lockdown and rebuilding a healthy practice. This webinar will be invaluable to all aesthetic, dermatology and vascular practitioners.” The webinar is open to all practitioners, with discounted prices for those who are members of various associations.

Aesthetics | June 2020

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Skincare

Harper Grace gives NHS employees key worker discount UK aesthetic product distributor Harpar Grace International is providing NHS employees with a 30% discount across its iS Clinical, CODAGE Paris and Totally Derma ranges. The online store, which also offers a 30% discount to its partnering clinics, spas and their employees, is accessible with pre-registered details on the Harpar Grace website. To register, NHS employees need to upload a valid work ID as part of the registration process.

Director of Harpar Grace International Alana Marie Chalmers said, “We wanted to ensure that all of our partners and their teams have access to their favourite results-driven skincare. We are delighted to be able to offer a 30% discount to all of our partners on our Staff Benefits Webshop and especially pleased to be able to extend this discount to all NHS employees. It is the least that we can do in these unprecedented times and we are so proud to be able to include an exclusive offer for our NHS Heroes.”

Surgery

Breast implant manufacturer announces lifetime product warranty Silicone breast implant manufacturer GC Aesthetics Ltd has confirmed it will offer a lifetime warranty on all its breast implants. The company previously had a GCA Comfort Guarantee, which provided free-of-charge implant replacements in the event of rupture or capsular contracture. The new GCA Comfort Plus warranty will now also provide free, automatic and retrospective cover for late seroma (swelling which can occur after breast implant surgery) for products implanted since 1 January 2009. In addition, in the case of a late seroma, the company will also provide reimbursement of up to US $3,000 towards the cost of necessary medical scans, as well as surgery to remove the breast implants and associated scar tissue.

Hair

Home hair restoration kit launches Aesthetic manufacturer SkinGen UK has launched the SkinGenuity Hair Restoration Home Kit which aims to stimulate hair growth. Featuring four 5ml bottles that contain 11 growth factors and 0.2mm microfusion applicators, the company notes the product can be used at home to treat pattern baldness. The kit also comes with a brush with hollow needles that aims to deliver more than 30 botanicals to support hair condition. Aileen Cameron, executive director at SkinGen UK, said, “Hair follicle stem cells require specific biosignals from within the skin to grow hair. In an effort to provide the necessary biological signals, growth factors and cytokines that are used to increase hair re-growth need to be added to the scalp. We are pleased to launch the SkinGenuity Hair Restoration Home Kit; a new product utilising growth factors and innovative Inter-Cell Messenger Technology to specifically target the regrowth of hair follicles.”

Aesthetics | June 2020

Insider News

News in Brief Restylane now on Instagram Global pharmaceutical company Galderma has launched an Instagram account for its dermal filler range Restylane using the handle @RestylaneUK. Brand manager Katie Bennett said, “During COVID, a lot of clinics are learning how to schedule social media and building their social media strategy, so we felt this was the perfect time to launch the page, so they could simply follow the page and save the posts they felt suited their clinics goals.” She added that the goal behind the content is to educate patients on dermal fillers, explaining what they are and how they are used.

Aesthetic Nurse Software launches new booking feature Clinic management system Aesthetic Nurse Software has launched a new online feature to allow clinics to take bookings 24 hours, seven days a week, giving patients the flexibility to book an appointment whenever suits them. The feature also allows the clinic to automatically take deposits and send out appointment confirmations and reminders.

Aesthetic Nurse Software includes other functions such as medical questionnaires, consent forms, automatic appointment reminders, marketing tools, and more.

Aesthetic nurse prescriber, Jo Hayward, founder of Aesthetic Nurse Software said, “I created this software because when I entered the world of aesthetics, I just couldn’t find any software that actually met my needs as an aesthetic practitioner. I am proud that we have been able to launch this new online booking feature.”

New injectable textbook published A new book has been published titled Aesthetic Facial Anatomy Essentials for Injections. According to authors, the publication is a detailed and informative guide from international experts on all aspects of facial anatomy; how it changes with age, how it differs in patients, how it is layered, and what danger zones it may contain. The textbook is available in the UK through Archidemia Ltd. Tixel clinical paper wins award A certificate for one of the most read papers in Lasers in Medicine and Surgery has been presented to the authors of an article on thermal fractional skin rejuvenation system Tixel. Written by Ronen Shavit, chief technology officer at Novoxel – the company behind Tixel, and Dr Christine Dierickx, ‘Tixel – A New Method for Percutaneous Drug Delivery by Thermo-Mechanical Fractional Injury’ evaluates the efficacy of pre-treatment with Tixel at low energy settings.

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Manufacturing

Skinade University launches

New cosmeceutical range launches

Health supplement brand Skinade by Bottled Science Ltd has launched a digital training platform called Skinade University, aiming to educate practitioners about nutraceuticals. At present, one live webinar is taking place each day which can be accessed by current stockists or practitioners looking to learn more about Skinade. Skinade partnership managers Agostina Murgia, Daniel Cohel and Alison Leeming are leading the hour-long webinars, which focus on either Skinade Classic, or Targeted Solutions Clear, Cellulite or Derma Defence A&D. After attending seven sessions, practitioners will receive a Skinade ‘diploma’ certificate. Murgia said, “We are delighted to be launching Skinade University. It’s a really good way to train new stockists who have never used Skinade before, as well as give existing clients a re-fresher and to enhance their knowledge on the products.”

Distribution

4T Medical to distribute disinfectant range

Product manufacturer LABthetics has launched a cosmeceutical range in the UK. The company explains that the range comprises nine professional products, including two chemical peels, which have been designed to work in synergy with the home-care system. Featured in the range is a vitamin A renewal cream, which works as a six-step system aiming to introduce retinol to the skin in stages. Also included in the range is a vitamin C 10% l-ascorbic acid with ferulic acid, and a zinc oxide moisturiser that aims to shield the skin from the environment.

Aesthetic nurse Kate Bancroft has been offering the vitamin A product to patients and said, “The easy-to-follow step system is perfect for those new to using vitamin A and works to achieve incredible results in a variety of skin concerns.” Emma Caine, who co-founded LABthetics with her brother Jack Caine, commented, “Our products are British made and we manufacture them ourselves in-house. We use the highest quality ingredients and high potent actives. We have developed the range to be affordable and sustainable using recyclable packaging. Our formulas are not tested on animals, with many of our products being vegan. They are free from palm oils, silicones, microbeads and parabens.” She added, “We understand incorporating a new skincare brand into a clinic can be costly, we have made our home care and clinical packages affordable with no minimum order quantities, we offer local clinic deliveries and always deal with our clinics direct to give the best possible LABthetics experience.”

Advertising

ASA rules against injectable vitamin advert

Aesthetic product supplier 4T Medical has become the exclusive UK distributor for Goodpoint Chemicals, which produces a range of antiseptic and disinfectant products.

The company explains that the range includes both alcoholbased and non-alcohol based disinfectants and cleaning agents, which are suitable for use in hospitals. Julien Tordjmann, managing director of 4T Medical, said, “In view of the current climate this is a welcome addition to our portfolio, which also includes PPE such as type IIR masks, protective full face shields, KN95 masks and gloves.” Goodpoint Chemicals has been awarded certificates: ISO 9001 Quality Control System and ISO 14001 Environment Control System.

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The Advertising Standards Authority (ASA) has upheld a decision to ban a clinic’s marketing materials advertising injectable vitamin D and vitamin B12. A promotional email from an aesthetic clinic in Manchester had the subject line, ‘40% Off! In The Fight Against Viruses!’. Text in the body of the email stated, “It’s Time To Boost Your Immunity! In the fight against viruses! Book in for your vitamin D & B12 shots! Supports your immune system, lung function and aids faster recovery from illness & viruses!”, which was followed by pricing information. The complainant challenged whether the ad breached the Code because it promoted prescription-only medicines (POMs). According to the ASA, all licensed forms of injectable vitamin D and injectable vitamin B12 are classified as POMs, which cannot be advertised to the general public as they are prohibited by the Human Medicines Regulations 2012 (HMRs) and are reflected in CAP Code rule 12.12. The ASA also assessed the specific claims made in the advert. They stated that in the context of a global pandemic, the ad gave the impression that the injections were effective in helping to prevent or treat COVID-19. However, neither the vitamin D or B12 medicinal products are indicated for its prevention or treatment.

Aesthetics | June 2020

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Advertorial Cynosure

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Evolution of the Elite brand

Exploring the history and future of laser hair removal Laser use for hair removal has been used from as far back as the 1960s, albeit fairly unsuccessfully due to the lack of long-term or ‘permanent’ results that were able to be generated. Laser therapy was revolutionised in the 1980s by Dr Rox Anderson and John Parrish, postulating the theory of selective photothermolysis – the use of a specific wavelength to achieve the destruction of a specific target molecule and minimising thermal damage to surrounding tissue.

Perfecting the pulse duration and intensity of laser energy, Dr Anderson and Dr Melanie Grossman laid the foundation of modern hair removal as we know it today, with their group out of the Wellmann Laboratory of Photomedicine, Harvard Medical School in Boston, Massachusetts. They presented work in early 1997 at the American Society for Laser Medicine and Surgery, Phoenix AZ, on the use of the Ruby 695 nm laser for permanent hair removal.

This early work with the Ruby laser, which had its limitations, then led to the adoption of the Alexandrite laser, with its slightly longer 755 nm wavelength, as being more efficient for targeting the stem cells and causing miniaturisation of the terminal hair follicles.

Neither of these wavelengths, however, are still the optimal choice for darker skin types because of their absorption characteristics into melanin. The Neodymium-doped Yttrium Aluminium Garnet, or Nd:YAG, is demonstrated to be safer for the higher melanin content found in the higher Fitzpatrick skin types as its invisible infra-red light, at 1064 nm, has a lower absorption into melanin that bypasses the surface colour of the skin.

These two laser wavelengths, the Alexandrite 755 nm and the Nd:YAG 1064 nm have become the industry standard for hair reduction, each of them optimised for treatment for a different patient population.

Advancements in laser hair removal The first Alexandrite laser model that Cynosure designed was the Apogee 6200, about 20 years ago, and it only had the wavelength of 755 nm. In 2003, the Nd:YAG laser was added and the device was renamed ‘Elite’ and included both wavelengths. The inclusion of the two wavelengths embodied by the Elite provides optimal hair removal across all Fitzpatrick skin types from I to VI. Some years later, in 2009, proprietary technology that sequentially combines wavelengths to combine clinical effects was launched by Cynosure with the Elite MPX. With this device, clinicians had the ability to choose treatment with a single wavelength or a combination (in a sequential mode). Combining synergistic wavelengths in Multiplex modality, allows for a safer treatment profile with lower total fluence. In addition to this, the Elite MPX had an integrated cold air system, making it more compact and additionally, an IPL handpiece for aesthetic treatments.

Thereafter, a new Elite and Apogee with larger spot sizes, up to 18mm 18

Aesthetics | June 2020

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in diameter, started to be used in 2012, under the names of Elite+ and Apogee+.

And then, years later in 2014, Cynosure increased the spot sizes offering larger diameters like 20, 22 and 24mm, allowing deeper penetration of energy into the tissue. This, together with a higher repetition rate, were key advantages for optimising treatments and the Elite+ achieved industry recognition for its efficacy and treatment flexibility when it was shortlisted for Energy Device of the Year at last year’s Aesthetics Awards.

Developments in 2020 The most recent advancement here in 2020 is the Elite iQ, which represents a real revolution in the hair removal market, since this new device incorporates the Skintel, the industry’s only melanin reader, which can give an accurate measurement of the skin melanin content to better guide treatment test spot settings and identify skin colouration changes throughout the course of a patient’s treatments. The Skintel has been an invaluable resource on other hair removal lasers in the Cynosure portfolio for more than 15 years, providing clinic reassurance for the selection of safe and effective treatment parameters for each individual patient’s skin.

The Elite iQ builds on the legacy of our gold standard Elite laser family; it is now faster, more efficacious, and smarter since it has a higher maximum energy for both Alexandrite (+19%) and Nd:YAG (+43%) laser so we can treat patients faster and more effectively and safely.

The Elite iQ is cleared for hair reduction in all Fitzpatrick Skin Types I-VI, and includes the treatment of tanned skin allowing the patients hair removal journey to continue during the summer months. It is also cleared for pseudo folliculitis barbae, and the treatment of vascular lesions, benign pigmented lesions and wrinkles, offering a comprehensive range of clinic treatment options from the one device.

This advertorial was written and supported by

Cynosure UK

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News Special Returning to Practice

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News Special: Returning to Aesthetic Practice Aesthetics explores the advice available to maintain safety as clinics begin to reopen their doors following lockdown As the Government eases lockdown restrictions and implements its COVID-19 recovery strategy, aesthetic clinic owners are preparing to go back to practice.

But where do you start? How do you ensure that your clinic is equipped to manage social distancing and stricter hygiene and infection control

Suggested Operation Plan Guidelines for COVID-19 – Reintegration of Medical Aesthetic Services Source: British Association of Cosmetic Nurses (BACN) Statement: As aesthetic nurses we must continue to review and integrate current evidence and consider how we will adjust our practices to mitigate the spread of COVID-19 in the community. Our goal is to focus on protecting our staff, our patients and ourselves, and deliver appropriate and safe treatments. Each practitioner must carry out a risk assessment for each procedure and their working environment. These guidelines are for practitioners to adapt for their individual practice and use in conjunction with relevant Government guidelines and the individual’s governing professional body.

Sharon Bennett, chair of the BACN, said, “Our goal has been to produce a set of guidelines to enable you to make these adjustments and prepare yourself for reopening your clinics, ensuring the safety of you, your patients and your staff are met. The BACN Board and regional leaders have been working extremely hard on these guidelines and we are delighted and proud to now be able to share them with the aesthetics community.”

Access: The guidance been emailed to all BACN members and is available on the members’ resource page. It has also been made publicly available and can be accessed via the Aesthetics website.1

Mobile working All organisations note that mobile working is not recommended. The BACN states, “There is no risk assessment that can demonstrate fully all the stringent measures required to carry out a cosmetic medical aesthetic treatment in the home. The environment does not lend itself to all that is necessary to ensure adequate

measures than ever before? Thankfully, a number of groups and associations have put together guidance on everything to consider.

While they all stipulate that guidance is not exhaustive and will likely need to adapt with time, familiarising yourself with everything available will likely benefit yourself, your staff and, of course, your patients.

COVID-19 Strategy Source: British College of Aesthetic Medicine (BCAM) Statement: BCAM has published a suite of documents on the process of risk assessment, operation under the COVID-19 Secure strategy and protocols to support practitioners through this early phase of recovery. BCAM has also sought an opinion of counsel from a leading QC in the field of public law in relation to the exact position and has made the full text of the opinion available to its members. This provides clear detail of the legal position, in all four countries of the union, in relation to the legality of operation, compliance with guidance and the requirements to comply with the Government’s new COVID-19 Secure strategy. Dr Uliana Gout, BCAM president, said, “I am delighted the BCAM team has risen to the COVID-19 challenge. There has been a focused and combined effort to obtain independent legal opinion based on the current government guidance, alongside clinical protocols for reopening. I am certain these will be of great benefit to BCAM members as they look to restart their practices.”

Access: The guidance has been emailed to all BCAM members and is available in the members’ area of the BCAM website.

patient and practitioner safety of treating a patient in that setting.”1 The JCCP adds, “Where a practitioner works from several different premises, a risk assessment must be performed for each. However, a risk assessment could not conclude the safety of arrangements where there are multiple practice venues in different geographical locations and again the

Aesthetics | June 2020

JCCP would not support this practice. We would also remind practitioners that where they provide clinical supervision (including prescribing services) for practitioners in wider geographical locations, that they have a duty of care in attending to these patients and therefore this practice cannot be supported by the JCCP.”2

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News Special Returning to Practice

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CAPSCO CAPSCO Infection Control Coronavirus Statement Source: Consortium of Aesthetic Plastic Surgery Clinic Owners (CAPSCO) Statement: CAPSCO is a group of plastic surgeons who own clinics or have positions of responsibility in such clinics or hospitals.

This document has been produced to provide reasoned consensus based on current evidence that has been produced recently. As a group of consultant plastic surgeons, CAPSCO members have safety at the forefront of clinical practice. This document is a guide to reopening of clinics and hospitals owned and run by CAPSCO members. It should be used in conjunction with clinic infection control policies that already exist.

Mr Taimur Shoaib, author of the guidelines and CAPSCO board executive said, “Controlling COVID-19 infection in clinics that perform surgery is of vital importance to protect both staff and patients. Infection transmission can take place at several points in the patient journey. At all these touch points, we should try and limit infection transmission. We have created a pre-screening questionnaire, a consent form relating to the risk of COVID-19, an aftercare leaflet and a cleaning policy to go alongside the infection control policy. We hope they will be helpful to private surgery owners as we begin to go back to practice.”

Access: The guidance is in the process of being issued to CAPSCO members. If any private clinic owners are interested in reading the guidance they can get in touch with Mr Shoaib via taimur@shoaib.co.uk.

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Preparing Your Place of Work: COVID-19 & Return to Practice Source: Joint Council for Cosmetic Practitioners Statement: This guidance document is the outcome of a co-ordinated effort undertaken by the JCCP, with support from sk:n, to ensure, as far as is reasonably possible, best practice is adopted when returning. The core principles have been agreed by independent and expert opinion in the Cosmetic Practice Standards Authority (CPSA). This guidance should be used by competent cosmetic practitioners to ensure that they comply with patient safety and public protection standards required

by Government agencies and by UK statutory professional and voluntary registers. Professor David Sines, chair of the JCCP, said, “It is important to understand that this document is a guidance document, rather than presenting a ‘standard’ against which to benchmark and ‘reset’ your practice. As such we encourage practitioners and staff to continue to explore and to adopt government advice on how to practise lawfully, safely and responsibly. As such the guidelines presented this document should not be regarded in isolation or as alternatives from other definitive advice offered by employers or by Government agencies to inform local decision making.”

Access: The guidance is publicly available via the JCCP website and can also be reached through the Aesthetics website.2

COVID-19 Operational Protocol Source: Save Face Statement: This policy template will not supersede government advice and thus must be reviewed and adapted accordingly. This policy is in addition to routine infection control, health and safety measures and professional standards. It should be made clear to patients and staff that these measures are intended to manage risk and cannot be assumed to completely eliminate any risk of contracting the virus. Ashton Collins, director of Save Face, said, “We are launching a certification programme alongside the protocol. Once we receive clarity from the Government as to when practitioners are able to reopen all of our members will be required to sign a declaration in order to be certified against the standard. We are also drafting patient advice and have surveyed more than 2,000 members of the public to assess what their expectations will be when it is safe to have these treatments again, the results of which have informed all of our policy documents.”

Access: The guidance is publicly available via the Save Face website and can also be accessed via the Aesthetics website.3

COVID-19 Pandemic: Consensus Guidelines for Preferred Practices in an Aesthetic Clinic Source: Dermatologic Therapy Statement: An online meeting of an international group of experts in the field of aesthetic medicine, with experience in administration of an aesthetic clinic, was convened. Consensus guidelines for ‘preferred practices’ were provided for scheduling of patients, patient evaluation and triaging, and for safety precautions about the different procedures. Procedures were categorised into low-risk, moderate risk, and high-risk based on the likelihood

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of transmission of SARS-CoV-2 virus from the patient to the treating physician or therapist. Aesthetic practitioner Dr Nestor Demosthenous, one of the study authors from the UK, said, “These guidelines detailing the infection control measures for aesthetic clinics are of particular importance. While not intended to be complete or exhaustive, these guidelines provide sound infection control measures for aesthetic practices. Since guidelines regarding safety measures and use of PPEs may vary from country to country, the local guidelines should also be followed to prevent COVID-19 infection in aesthetic clinics.”

Access: The guidance has been published in Dermatologic Therapy and can be reached through the Aesthetics website.4

Aesthetics | June 2020

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Aesthetics

Return-to-work date There has been much debate in the specialty surrounding the recommended return-to-work date. The JCCP was the first to advise to aim for July 4, based on the Government’s phased recovery strategy plan that states personal care businesses could be permitted to reopen from this date.2 The organisation has since stated that it is not possible or appropriate for the JCCP to provide definitive guidance on when it is possible for aesthetic practitioners to return to work to provide elective nonmedically related aesthetic treatments and the decision to return to practice should be made by the practitioner themselves.5 Others, however, argue that as a ‘medical service’ they should be able to reopen in May/June. BCAM has supported this notion after seeking guidance from a QC. College secretary Dr Philip Dobson said, “This is a vitally important topic and it is essential that everyone takes the best legal advice when making decisions which affect the safety of patients, staff and the public.” Communications lead Dr John Elder added, “I am proud of everyone at BCAM for pulling out all the stops to obtain this crucial legal opinion. Many of our members running small, private clinics have suffered greatly under the lockdown and we are all itching to get back to seeing our patients again.” Some in the industry have agreed, with aesthetic practitioner and chairman of Healthxchange Group Dr John Curran stating, “BCAM has published Counsel’s opinion confirming it is lawful to start seeing patients again where it is safe to do so and in the context of being medical practitioners. This opinion sets the medically qualified professions apart from beauty therapists and non-medical aestheticians who are not qualified to

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News Special Returning to Practice

provide medical care.” Others, however, have not been so positive.

An anonymous source told Aesthetics that it is not appropriate to class all aesthetic treatments as ‘medical’ and therefore should not be provided immediately. They said, “One could argue that only Care Quality Commission (CQC) registered practices can offer ‘medical’ aesthetic services, but given that only regulated activities fall under this umbrella that could only apply to botulinum toxin injections for hyperhidrosis for example – is this vital during a pandemic?”

In this regard, the JCCP advises that it is important for practitioners to understand that cosmetic procedures being performed by healthcare professionals are not automatically designated as being either ‘medical’ or ‘medically-related’ in nature. The organisation states, ‘There must be a clearly defined, discernible and intended ‘medical’ benefit for the patient’, while outlining suggestions on how to determine whether a treatment can be classed as ‘medically related’.5 Other organisations are awaiting further guidance from the Government before suggesting a reopen date and recommend that practitioners consider localised advice and professional judgement.

The BACN states, “It is important practitioners remember the latest announcements from the UK Government apply to England and the devolved administrations in Scotland, Wales and Northern Ireland can adopt localised variations. It should be stressed that any decision to reopen clinics will be down to individual members,”1 while Save Face says, “Once government has determined services such as ours can resume, the decision to open or remain closed is ultimately one that you must personally take and will be dictated by your own risk and feasibility assessment.”3

Practitioner perspective Surgeon and aesthetic practitioner Miss Mayoni Gooneratne plans to return to practice in early June. She says, “Practitioners need to consider the rate of infection (R) in their area. Currently the R in London is low, whereas it’s higher elsewhere, for example in Sheffield, so that would put be off reopening my practice if I was based there. With my background as a surgeon, I have been preparing to reopen since lockdown by ensuring I have all my safety protocols in place, PPE and staff training over Zoom. I feel confident that we can safely treat patients and will carefully review protocols and guidance as we progress.”

Aesthetic practitioner Dr Vincent Wong runs his clinic in London.

He is considering returning to practice from July 4 and has written guidance for other practitioners to consider, published on the Aesthetics website.7 He said, “Although the number of new cases and death rate have gone down, they are still there and still significant – the last thing we need is another lockdown! I’m looking at the current Government advice from the patient’s point of view. Having a medical aesthetic procedure is not on the list, and we must do what we can to ensure that the numbers keep declining and that it is officially safe for us to leave our homes before we reopen.”

REFERENCES 1. Aesthetics, BACN releases guidance for returning to clinic <https://aestheticsjournal.com/news/bacnreleases-guidance-for-returning-to-clinic?authed> 2. Aesthetics, First guidance released on returning to aesthetic practice < https://aestheticsjournal.com/ news/first-guidance-released-on-returning-to-aesthetic-practice> 3. Aesthetics, Save Face share guidance on returning to clinic <https://aestheticsjournal.com/news/ save-face-releases-return-to-clinic-guidance> 4. Aesthetics, New international guidelines released on practice post COVID-19 < https://

Consultant plastic and aesthetic surgeon Mr Dalvi Humzah is planning to reopen his practice from June. He said, “We have everything set up, have changed the layout of the clinic, checked our PPE, and risk assessment considerations. I will be unfurloughing my staff a week before we open to ensure we have sufficient training time to run through protocols and do dummy runs without patients. As we have not been treating patients for a while, many surgeons are implementing a system where they will have a ‘buddy’ for the first surgery they do when they go back. It could be something to consider for injectables, especially those who are less experienced.”

aestheticsjournal.com/news/new-international-guidelines-released-on-practice-post-covid-19> 5. JCCP, JCCP statement on ‘Navigating the Challenges Raised Regarding Returning to Work Safely’ < https://www.jccp.org.uk/NewsEvent/jccp-statement-on-navigating-the-challenges-raised-regardingreturning-to-work-safely> 6. Healthxchange, Statement from Dr John Curran, chairman, Healthxchange Group, in response to the JCCP guidelines for returning to practice. Press release on file.

7. Dr Vincent Wong, Managing a Clinic Post COVID-19, Aesthetics <https://aestheticsjournal.com/hub/ Dr%20Vincent%20Wong>

Aesthetics | June 2020

21

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Charity Facing the World

upper jaw may be underdeveloped. The nose may appear ‘beaked’ and the septum may be deviated. Fingers are short and certain fingers may be fused. There may also be a low hairline.

Syndromes associated with clefts include:

Understanding Facial Differences Raising funds for children through Facing the World Last month we brought you our first article on Facing the World – the charity that supports children born with facial differences. We told you why Aesthetics got involved after learning more from charity ambassador and aesthetic nurse prescriber, Sharon Gilshenan. So what types of facial differences are there and how do they present?

According to Facing the World, of the 54,000 children living with facial differences in Vietnam, many will also suffer from problems associated with their condition. Buchanan et al. explain in Plastic and Reconstructive Surgery that craniofacial syndromes fall into two categories – those involving craniosynostosis and those involving clefts. Each has a different set of potential complications, requiring a unique approach for surgical management.1 They note that craniosynostosis is a congenital disorder in which one or more of the cranial sutures fuses prematurely. The most common syndromes associated with this condition include:2 • Crouzon: sutures in the head are prematurely fused, resulting in abnormal growth of the skull and face. Children with Crouzon syndrome have bulging eyes due to abnormal growth of the midface. They may have a receding upper jaw and protruding lower jaw, as well as dental problems due to abnormal jaw growth.

• Apert: involves abnormal growth of the skull and the face due to early fusion of certain sutures of the skull. Children have protruding eyes that are usually wide-set and tilted down at the sides. They can have problems with teeth alignment due to the underdevelopment of the upper jaw. Some have a cleft palate. Among other anomalies, children with Apert’s can have webbed fingers and toes.

• Pfeiffer: certain sutures are fused prematurely. Children with this condition have a high forehead, and the top of the head may appear pointed. The mid-face appears flattened, the nose is small and has a flattened appearance, eyes are widely spaced, and the upper jaw is underdeveloped, which causes the lower jaw to appear prominent. The thumbs and big toes have a broad appearance and teeth are often crowded.

• Muenke: characterised by the premature closure of the coronal suture of the skull (coronal craniosynostosis) during development.

This affects the shape of the child’s head and face. Other variable features include abnormalities of the hands or feet, hearing loss, wide-set eyes, flattened cheekbones and, in about 30% of cases, some developmental delays.

• Saethre-Chotzen: more than one suture is fused prematurely causing irregular head growth. Eyelids are droopy, while the eyes are widespread and appear bulging and may be crossed. The

• Pierre Robin: a condition in which the lower jaw is abnormally small.

There are also problems with the tongue falling backward toward the throat. A cleft lip and a cleft palate may or may not be present.2 • Treacher Collins: the cheekbones, jawbones and ears are underdeveloped. This diagnosis is given to children who have notching or stretched lower eyelids and partially absent cheekbones. Their ears are frequently abnormal and part of the outer-ear is frequently absent. The lower jaw is also small.2 • Nager: facial characteristics include downward slanting eyelids, absence or underdeveloped cheekbones, a severely underdeveloped lower jaw, malformed outer and middle ears, clefting of the hard or soft palates, absence of lower eyelashes and scalp hair extending on the cheek. Upper limb defects include underdeveloped or missing thumbs and occasional absence of the radial limb.2 • Binder: involves congenital underdevelopment of the maxilla and nasal skeleton. Other features include a hypoplastic or absent anterior nasal spine, a short, flat nose with short columella, an acute nasolabial angle, a convex upper lip and class III malocclusion.3 • Stickler: a genetic disorder that can cause serious vision, hearing and joint problems. Children who have Stickler syndrome usually have prominent eyes, a small nose with a scooped-out facial appearance and a receding chin. They are often born a cleft palate.4 Problems that can arise from facial clefts and palates include difficulty feeding, hearing problems as a result of being more vulnerable to ear infections, tooth decay from an increased risk of teeth development, and speech problems such as unclear or nasal-sounding speech when a child is older.5 In addition, the World Health Organization has indicated that 3.5 million children with more serious facial differences will die each year before they reach the age of five.6 And as well as the physical issues of living with a facial deformity, many children will also suffer from severe mental health issues as a result of their condition. According to Facing the World, most are unable to attend school or become productive members of society.

NEXT MONTH: We look at how facial differences impact the psychology and families of children who are suffering

To donate to this special charity scan the QR Code or visit www.justgiving.com/fundraising/aestheticsmedia REFERENCES 1. NHS, Cleft Lip and Palate <https://www.nhs.uk/conditions/cleft-lip-and-palate/> 2. Buchanan EP et al., Craniofacial Syndromes, Plastic and Reconstructive Surgery <https://www.ncbi. nlm.nih.gov/pubmed/25028828> 3. Children’s Craniofacial Association, Syndromes https://ccakids.org/syndromes.html 4. Drozdowski et al., Binder syndrome: Clinical findings and surgical treatment of 18 patients at the Department of Plastic Surgery in Polanica Zdrój https://www.ncbi.nlm.nih.gov/pubmed/28791817 5. Mayo Clinic, Stickler Syndrome <https://www.mayoclinic.org/diseases-conditions/stickler-syndrome/ symptoms-causes/syc-20354067> 6. Katrin Kandel, Vietnam Training Program, Facing the World < https://facingtheworld.net>

Aesthetics | June 2020

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CCR 2020 Event Overview

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1 + 2 OCTOBER 2020 | EXCEL LONDON

JOIN US AT CCR At Aesthetics we are eagerly anticipating October’s CCR conference and exhibition for some much-needed networking and face time with the who’s who of non-surgical and surgical aesthetics NEW for CCR 2020

• NEW venue: ExCeL London with excellent UK-wide transport links and extensive facilities • NEW CPD-accredited training courses including a one-day video cadaver course with Dr Tapan Patel • NEW Aesthetics Press Conference providing a briefing opportunity for key journalists hosted by Tatler magazine’s Francesca White • NEW educational streams provided by leading brands • Unprecedented number of new product launches due to previous delays throughout the year Be part of the UK’s largest multidisciplinary aesthetic event Once a year, CCR provides the central hub for exhibitors and organisations of both the surgical and non-surgical disciplines. CCR hosts the British Association of Aesthetic Plastic Surgeons (BAAPS) for their Annual International Conference, as well as the International Society of Aesthetic Plastic Surgery (ISAPS) and the British Cosmetic Dermatology Group (BCDG).

In a unique one-off annual event, these organisations, and others, come together to share information with its delegates and inform and address thousands of visitors over the two-day show, now repositioned in ExCeL London.

Make the most of the highest quality education 2020’s CCR will incorporate yet another unparalleled and comprehensive education 24

programme, all of which is CPD accredited.

October’s education highlights include a one-day videoed cadaver training course with industry guru Dr Tapan Patel, of London’s renowned PHI Clinic, along with a much anticipated clinic management focus across all theatres this year, which will provide valuable advice to help get aesthetic businesses back on track post lockdown. For more information or to register your interest for a place visit www.ccrlondon.com.

Meet influential journalists We welcome back our Press Ambassador Francesca White, Beauty Editor At Large and Editor of the Tatler Beauty & Cosmetic Surgery Guide.

NEW for this year, Francesca will take on Aesthetics | June 2020

Highlights include a one-day video cadaver training course with industry guru Dr Tapan Patel

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CCR 2020 Event Overview

an additional role as Master of Ceremonies and compère for the first ever CCR Aesthetics Press Conference.

With an unprecedented amount of media interest at CCR last year, including representatives from BBC Breakfast, Talk Radio, This Morning, The Guardian and BBC Radio to name a few, CCR has developed a more structured press briefing format, open to any registering journalists. We now have a unique closed event for consumer and trade health and beauty journalists to get a concise briefing at the CCR Aesthetics Press Conference. Press can learn about what’s new, while hearing about those procedures and research papers that are making waves in medical aesthetics. With a Q&A session to follow, involving some of the industry’s most recognisable names, CCR is set to provide a completely unique and interactive forum to update and inform key, influential journalists.

Easy to reach from any location CCR is pleased to announce that this year it has moved to a new and more expansive campus, ExCeL London. The change of venue will provide the best exhibitor and visitor experience yet. The huge variety of transport links provide easy access for visitors and exhibitors from all over the UK and internationally and, once arrived, the facilities are extensive, giving little need (if any) to leave the ExCeL campus!

Courtney Baldwin, Event Manager for CCR & Aesthetics, said, “We are committed to facilitating high quality educational content and with the change of venue this year we will provide our best ever exhibitor and visitor experience.

Once again, we have secured the most influential practitioners from around the globe to contribute to our education programme and take the stages for live demonstrations, cutting-edge speaker content and top brand takeovers. This year’s

For your complementary visitor’s pass, please log on to the CCR website

show will provide a much-needed directional change after such a long period of clinic and theatre closures and we at CCR, like all of our visitors I’m sure, are sincerely looking forward to some welloverdue industry face time.”

CCR 2020 brought to you by

www.CCRLondon.com

Aesthetics | June 2020

25

CPD Oxygen Therapy

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Using Oxygen Therapy For Vascular Compromise Dr Ahmed El Houssieny discusses the evidence for hyperbaric oxygen therapy in the management of vascular compromise and when the treatment may be used in practice Since the beginning of the 20th century, the use of hyperbaric oxygen therapy (HBOT) has broadened considerably to encompass a wide range of indications including treatment for decompression sickness, radiation injury, severe anaemia and carbon monoxide poisoning.1,2 To practitioners of aesthetic medicine, HBOT is likely to be associated with the promotion of healing after invasive cosmetic surgery and with skin rejuvenation, as well as possible usage in the treatment of vascular compromise resulting from injection of dermal fillers; which will be the focus of this article.

The rise of HBOT in the management of aesthetic complications Dermal filler use is growing in popularity. Figures from the US show a rise in the number of procedures from 1.5 million in 2007 to 2.6 million in 2018.3,4 Demand for non-invasive procedures using fillers is likewise reported to be growing in the UK.5 As usage increases, the incidence of complications arising from the injection of dermal fillers is reported to increase concurrently.6,7 Further, the move towards larger and deeper injections to achieve volume restoration, as well as increasing numbers of injections administered by non-experts, are also posited as contributing to the number of adverse events (AEs).8 While many AEs associated with dermal filler injection are mild, vascular compromise can lead to serious complications of tissue necrosis, vision impairment or even total vision loss.7,9,10,11 Such complications are rare with an estimated rate of around 0.05% for vascular compromise leading to cutaneous complications.10 The incidence of blindness resulting from vision loss is very rare with exact figures not known.12 HBOT is approved by the Food and Drug Administration (FDA) in the US, which defers to the Hyperbaric Oxygen Therapy Committee on assessment, for necrotising soft tissue infections, hypoxia, central retinal artery occlusion (CRAO) and non-healing wounds.2 The 2016 European Consensus Conference on Hyperbaric Medicine similarly recommends the use of HBOT for these indications, although the authors note the lack of evidence built on more than one randomised controlled trial in any HBOT indications, while broadly recommending that the treatment option should be used.13 The growing interest in HBOT as an option for treating the complication of filler injection may be the result of these approvals, as well as the rising use of dermal fillers and corresponding numbers of AEs.14 Certainly, HBOT is included in many guideline and consensus recommendation documents on the management of vascular complications that have been published within the past few years.7,12,15,16 Within this literature, however, HBOT is largely listed as an additional rather than front-line option, with the suggestion that HBOT may be of value in patients for whom other treatments did not bring about improvement but that further evidence is required to support its use.16,17 It is the role of the practitioner to familiarise themselves with the evidence for HBOT use and the guidance available so they are able 26

to make their own decision about its use in practice in the event of vascular complication arising from dermal filler injection. It should be noted that in the event of visual symptoms after filler treatment, the patient should be referred immediately to an ophthalmologist, who can make a diagnosis and consider what treatment would be appropriate.

HBOT mechanism of action HBOT refers to the administration of 100% oxygen, usually at a pressure of 2 to 3 atmospheres (ATA).18 Breathing 100% oxygen at high atmospheric pressure leads to increased solubility of oxygen in the blood, independently of the red blood cells, which in turn leads to delivery of oxygen to tissue.19,20 Retinal tissue, for example, requires a particularly high level of oxygen in order to function. Normally, there are two blood supplies to the retina through the retinal and choroidal vascular systems.21 HBOT might help to maintain oxygenation of the retina and the vitreous body of the eye through a blood supply via the choroidal system and preserve compromised tissue.21,22 The aim is to support the retina to survive through diffusion until the blood vessel is recanalised.22 In addition to this primary effect, secondary effects of HBOT are due to controlled oxidative stress.23 HBOT produces oxygen and nitrogen species, which are highly reactive and function as signalling molecules in multiple pathways, including those involved in wound healing, particularly vascular and endothelial functions.18,19,23 The mobilisation of stem or progenitor cells from the bone marrow and release of local growth factors lead to neovascularisation and the maturation of collagen.23 Other secondary effects are improved leukocyte function, repair to ischemia-reperfusion injury, the inhibition of bacterial growth, and reduction in tissue oedema.18-20,23 In this way, the delivery of oxygen to tissue appears to both keep tissue viable as well as promoting wound healing.

Contraindications and side effects HBOT is contraindicated in some patients so practitioners must ensure they know the contraindications and check for them in a thorough consultation prior to HBOT use. Absolute contraindications includes those patients with untreated pneumothorax or in those receiving bleomycin, cisplatin, disulfiram, doxorubicin, or sulfamylon.24 It may only be used with care in further groups. These include those with chronic obstructive pulmonary disease (an upper respiratory infection), asthma, a high fever, a pacemaker, claustrophobia, in pregnancy and in individuals who experience seizures.24 HBOT is considered to be a very safe therapy and side effects are self-limiting and generally mild.23 Oxygen toxicity is rare, resolves with withdrawal of oxygen without permanent implications.23 One of the most common side effects is middle ear barotrauma, which can be prevented by teaching patients middle ear clearing techniques and

Aesthetics | June 2020

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using appropriate compression rates.23 Ocular side effects, such as cataracts and myopic fluctuations, should be monitored;22 and the patient referred to an ophthalmologist if necessary. Hyperoxic myopia is one of the most common and is considered reversible.23

Evidence and practice guidance for HBOT in complication management Firstly, it is of vital importance to minimise the risk of vascular compromise that can result from filler injection. The practitioner should be familiar with the methods of doing so, which may include aspiration prior to inserting the needle or cannula into the vessel, low pressure injections and small amounts of filler.9,25 The glabellar, nasal region, nasolabial fold and forehead are all cited as high-risk sites for vascular complications that may result in necrosis or vision impairment or loss.8,9 Although all mechanisms for vascular necrosis are not fully understood, it has been suggested that it may result from both extravascular compression of the vessels by filler as well as intravascular obstruction caused by an injection of filler directly into a blood vessel.9 The practitioner must be familiar with the vascular structure of the face (Figure 1) in order to understand how emboli of injected filler can travel through the arterial network of the face to cause occlusion or compression elsewhere, resulting in blindness or even stroke.8,26 Decisions about treatment, including HBOT, need to be made promptly in the case of vascular complications and practitioners must be able to recognise all symptoms of vascular compromise. Interruption of blood supply to ophthalmic vessels usually results in immediate pain and loss of vision, which should be referred.25 The blanching of the skin associated with vascular compression that is typically seen immediately after injection may be subtle and can go unnoticed and the practitioner should monitor the appearance of any painful, violet patches on the skin.9 In some cases, cutaneous symptoms may be delayed by hours or even days.27

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CPD Oxygen Therapy

reduced mortality; 34% in the â&#x20AC;&#x2DC;standardâ&#x20AC;&#x2122; regimen group vs 11.9% in the group receiving adjunctive HBOT.31 The efficacy and safety of HBOT as an adjunctive therapy in the management of vascular compromise and impending skin necrosis following filler injection is evidenced in a small, but growing, number of case studies.27,32-36 All these case studies, comprising 10 patients in total, show improvement in outcome in cases of severe impending or active necrosis in a range of facial areas following therapeutic regimens that includes HBOT. 27,32-36 These findings support the recommendation of the case study authors, as well as authors offering guidance on the management of vascular compromise due to dermal filler injection, that HBOT should be considered in cases of impending massive necrosis.27,34,36-38 It is important for the practitioner to ensure they are well informed about emerging evidence for HBOT in the management of filler complications as our understanding of HBOT continues to broaden.

For example, one group of authors suggest that HBOT may be of value in treating complications following injection with particulate fillers, such as calcium hydroxylapatite or poly-L-lactic acid, but not hyaluronic acid (HA) fillers.10 There is case study evidence to show the efficacy of HBOT in particulate fillers, whereas as older protocols for HA fillers focus on the use of hyaluronidase.32,39 However, more recent case studies also demonstrate evidence of HBOT efficacy in necrosis following injection with HA fillers as part of a treatment regimen including hyaluronidase. In two cases, HBOT was initiated up to 24 hours after necrotic symptoms appeared and was continued for up to 42 sessions with positive results.33,36 In four further cases, HBOT was used as an adjunctive therapy in delayed-presentation necrosis or was started six or eight days post-injection for necrotic wounds, which had developed despite the use of other therapies.27,35 Improvements in cosmetic outcome resulted in all cases.27,35 One interesting recent development is that of a 2018 case study that reported a case of self-injection at the temples with an HA filler, resulting in immediate blanching, pain and sudden sensorineural hearing loss.40 Immediate treatment with hyaluronidase, topical nitro paste, and warm compresses was given, followed by enoxaparin, aspirin, dexamethasone 10mg IV, piperacillin/tazobactam, and intradermal 1% lidocaine several hours later. Six sessions of adjunctive HBOT were administered over three days, after which the patient showed decreased ischemic discoloration and her hearing returned.40

The evidence for HBOT in vascular compromise and necrosis Despite the growing interest in HBOT as a treatment option for vascular complications after the injection of dermal filler, the evidence for its efficacy is limited.16 It is challenging, of course, to gather evidence from prospective randomised controlled trials (RCTs) in rare events such as these. However, the practitioner can review both the evidence from studies of HBOT in other populations as well as from case studies in patients experiencing vascular compromise resulting from filler injection.

In terms of other patient populations, RCT evidence is available for the efficacy of HBOT in wound care. HBOT use in the treatment of diabetic foot ulcers in particular has demonstrated significant reduction in ulcer size and Supratrochlear increase in the rate and extent of healing.20,28,29 It has artery been suggested that this evidence supports HBOT use in treating dermal filler complications, but it is important to note that the foot and retina are very different tissues Angular artery structurally and metabolically and therefore it is difficult 17 to draw any firm conclusions.

HBOT has also been associated with significant Superior labial artery reductions in morbidity and mortality in multiple case series, prospective and retrospective cohort studies and non-randomised trials in patients with progressive Inferior labial necrotising soft tissue infections.30,31 One retrospective artery analysis of patients (n=42) with necrotising soft tissue infections treated with adjunctive HBOT, for example, Figure 1: Arterial network of the face26 showed the treatment to be safe and effective with Aesthetics | June 2020

Supraorbital artery

Opthalmic artery

Infraorbital artery

Facial artery

27

CPD Oxygen Therapy

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This accords with a Cochrane review of HBOT trials in idiopathic sudden sensorineural hearing loss (ISSHL), which reported significant improvement in hearing following HBOT treatment, which was given in cohort with standard treatment regimens for ISSHL in some patients.41 Study findings from the past decade have demonstrated both that HBOT is more effective in treatment of ISSHL when combined with administration of corticosteroids and when it is initiated as soon as possible.42 In the absence of robust clinical evidence, the practitioner can only make a decision based on the evidence available. Case studies can be of value in supporting the practitionerâ&#x20AC;&#x2122;s judgement, as can recent reviews and consensus guidelines, which draw on evidence in patients with filler complications and in broader populations to support the use of HBOT is as an adjunctive therapy.

Other considerations for HBOT in vascular compromise and necrosis In addition to an assessment of the evidence, there are other factors to be taken into account when considering HBOT for the management of vascular complications. As some authors note, it is imperative to consider the risks, benefits and availability of HBOT before embarking on treatment with any given patient.9,43 Careful patient selection and preparation before complications arise, therefore, are crucial.

When assessing the patientâ&#x20AC;&#x2122;s suitability for HBOT treatment, the practitioner must check the presence of any contraindications as discussed above to reduce risk.8,9,25-27 These should be in the medical history taken at the outset of patient treatment, but any which are not should be checked before HBOT treatment is undertaken. Patients should be forewarned of any side effects and the time these are likely to take to resolve.

It is imperative that practitioners know where the nearest hyperbaric facilities are located, and ideally should have a pre-arranged referral protocol in place. Contact details for facilities should be easily accessible. HBOT should be started as soon as possible after injury has occurred and may go on for an extended period or take place more than once a day.32,33,40 Prompt accessibility to a hyperbaric facility after the onset of symptoms is important as well as subsequent accessibility for the patient. HBOT is an adjunctive measure and should be used as part of a range of measures in addressing vascular compromise and necrosis.7,9,16 Additional recommended management options for immediate and ongoing care include warm compresses and massage followed by hyaluronidase (in the case of HA fillers); sildenafil or similar, aspirin, corticosteroids and nitroglycerin paste and antibiotics.7,9,32,37 Additional management options include low molecular weight heparin.7,16 There is no standardised treatment protocol for HBOT and controversy exists around how much and for how long the treatment should continue. There is no guideline for impending necrosis or wound care related to filler injection.33 Suggested protocols on pressure, frequency and length of treatment set out for necrotising infections and wound care may be used by personnel applying the treatment and adjusted as required.12,29,32 Requirements can vary greatly: one case study patient with impending necrosis following nasolabial fold injection was successfully treated with two 90-minute treatments of HBOT at 2 to 2.4 ATA, one each on day three and four after injection, in order to limit the spread of tissue loss.36 In contrast, a patient with more severe necrosis received an initial session of 2.8 ATA for 135 minutes and then 42 sessions of 2.0 ATA for 110 minutes.33 HBOT in vision impairment The aim of treatment for vision impairment following intravascular filler injection is to decrease intraocular pressure in order to move the 28

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embolus into blood vessels that are more peripheral to circulation around the ocular area and to increase retinal perfusion and deliver oxygen to hypoxic tissues.8 A range of therapies can be used, including corticosteroids, thrombolysis, massage, anticoagulants, anterior chamber paracentesis and HBOT to attempt to achieve these aims.8 However, the evidence suggests that there is no failsafe treatment for retinal embolism.8,10,25 A 2015 study of 98 cases of vision loss resulting from filler injection found that 80.9% of cases of ocular complications following autologous fat injections and 39.1% following HA injections resulted in vision loss, despite treatment with a range of treatment options.8 In this case series, only two of 98 patients were treated with HBOT. One patient did not recover vision after obstruction of the ophthalmic artery following an autologous fat injection.

The second, who had received bovine collagen and polymethyl methacrylate filler resulting in occlusion of the central retinal artery, did retain some faint light perception.8,44,45 As is the case with vascular compromise discussed above, there is a lack of prospective data on the efficacy of HBOT in treating vision loss resulting from filler injection. As with vascular compromise leading to necrosis, the rarity of the condition renders RCTs difficult to carry out.

It is possible, however, to examine HBOT evidence in populations experiencing vascular occlusion due to events or conditions other than as an AE of dermal filler injection.

A meta-analysis of seven RCTs in patients with retinal artery obstruction (RAO) due to a range of causes concluded that HBOT significantly improved visual acuity (p < 0.05).46 These findings endorsed those of a 2012 review of a case series of individuals with central retinal artery occlusion (CRAO) or branch retinal artery occlusion (BRAO) due to a range of causes other than filler injection, which found that 65% (306 of 476) of patients responded to HBOT with some degree of vision recovery.47 A key factor in this outcome is reported to be the prompt initiation of treatment.47 Patients presenting for HBOT after 24 hours of vision loss rarely respond.47 The authors reported that there was not sufficient evidence in individuals with BRAO nor central retinal vein occlusion to support the use of HBOT in these cases.47 However, since this 2012 review, additional evidence has been published. A 2019 non-randomised, monocentric, retrospective study of patients with angiographically confirmed diagnosis of non-arteritic BRAO (n=28), of whom half were treated with HBOT, found that those who had received HBOT had significantly better visual acuity at discharge than those who had not (p=0.0009).22 Further, there are two 2016 case studies in patients with vision loss subsequent to filler injection which show that the presence of the cilioretinal artery, even if occluded, may affect response to HBOT.48,49 Interestingly, the presence of the cilioretinal artery is associated with better outcomes in vision recovery following HBOT.47 This artery is part of the ciliary supply, which supplies the macula region of the retina and is present in approximately 15-30% of individuals.47 In the case study of one individual with central retinal vein occlusion and cilioretinal artery occlusion, the patient responded well to HBOT therapy with 20/20 vision restored after 14 daily HBOT sessions.48 In the second case study, vision loss following occlusion of the posterior ciliary artery responded to HBOT with some but not full vision restored.49 The evidence discussed here suggests that in some cases, vision improvement may be possible with HBOT, depending how promptly treatment is given, on the extent and location of the occlusion as well as the presence of a cilioretinal artery. Clearly, more robust data is required to confirm the effect of HBOT in vision impairment which results from dermal filler injection. In terms of decision making by the

Aesthetics | June 2020

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Aesthetics

aesthetic practitioner, consensus guidelines state that all patients experiencing vision loss after injection with dermal fillers should be referred urgently to an ophthalmologist.7,8

Conclusion Taking steps to prevent the rare complications of dermal filler injection is crucial. However, if vascular compromise does occur, the practitioner is required to administer treatment as soon as symptoms become apparent. With this in mind, it is vital that they have both treatment and referral protocols in place and are ready to respond as quickly as possible.

There is growing interest in HBOT as an adjunctive treatment in dermal filler complications. HBOT has been approved by the FDA, by the European Consensus Conference on Hyperbaric Medicine and in other guidelines despite the recognition that more robust evidence is required to demonstrate its efficacy and safety. The practitioner of aesthetic medicine should be aware of the existing evidence for HBOT in both dermal filler complications and in other relevant patient populations that supports the guidelines and to keep up to date with emerging evidence.

Dr Ahmed El Houssieny is a trained anaesthetist with a passion for aesthetics. He is an Honorary Lecturer at the University of Chester and an education provider on cosmetic procedures. Dr El Houssieny is registered with the General Medical Council, as well as being an associate member of the British College of Aesthetic Medicine.

Qual: MBBCH

Aesthetics Clinical Advisory Board Member Miss Elizabeth Hawkes says: “The author gives and interesting overview of hyperbaric oxygen therapy for vascular Consultant compromise following dermal filler injections. ophthalmologist and oculoplastic The jury remains out on the management of this surgeon devastating and rare complication. Aesthetic practitioners must be able to rapidly recognise the symptoms of vascular compromise and refer urgently to an ophthalmologist for assessment and management.”

REFERENCES 1. Krishnamurti C. Historical aspects of hyperbaric physiology and medicine. Intechopen April 2019. <http://dx.doi.org/10.5772/intechopen.85216> 2. Weaver LK. Hyperbaric Oxygen Therapy Indications. The Hyperbaric Oxygen Therapy Committee Report. Thirteenth Edition. 2014. Durham, NC, USA. Undersea and Hyperbaric Medical Society.

3. American Society of Plastic Surgeons. 2000, 2007, 2008 National Plastic Surgery Statistics. ASPS. 2008. <https://www.plasticsurgery.org/documents/News/Statistics/2008/cosmetic-reconstructiveprocedure-trends-2008.pdf > 4. American Society of Plastic Surgeons. 2018 Plastic Surgery Statistics Report. ASPS. 2018. <https:// www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018. pdf > 5. International Medical Travel Journal. UK non-surgical cosmetic treatments could grow to £3BN. 24th Dec 2018. <https://www.imtj.com/news/uk-non-surgical-cosmetic-treatments-could-grow-3bn/> 6. Dayan S, Arkins JP, Mathison CC. Management of impending necrosis associated with soft tissue filler injections. J Drugs Dermatol 2011;10:1007–1012.

7. Urdiales-Galvez, Escoda Delgado N, Figueiredo V et al. Treatment of soft tissue filler complications: expert consensus recommendations. Aesth Plast Surg 2018;42:498–510.

8. Beleznay K, Carruthers JDA, Humphrey S, Jones D. Avoiding and treating blindness from fillers: a review of the world literature. Dermatol Surg 2015 Oct;41(10):1097–1117.

9. Beleznay K et al. Vascular compromise from soft tissue augmentation. experience with 12 cases and recommendations for optimal outcomes. J Clin Aesthet Dermatol 2014 Sep;7(9):37–43.

10. Graivier M, Bass LM, Lorenc ZP, et al. Differentiating nonpermanent injectable fillers: prevention and treatment of filler complications. Aesthet Surg J 2018;38:S29–40.

11. Hawkes, E, Considering Dermal Filler Blindness, Aesthetics journal. <https://aestheticsjournal.com/ feature/considering-dermal-filler-blindness> 12. Walker L, King Y. Visual loss secondary to cosmetic filler injection. J Clin Aesthet Dermatol

aestheticsjournal.com

CPD Oxygen Therapy

2018;11(5):E53–55.

13. Mathieu D, Marroni A, Kot J. Tenth European Consensus Conference on Hyperbaric Medicine: recommendations for accepted and non-accepted clinical indications and practice of hyperbaric oxygen treatment. Diving Hyperb Med 2017 March;47(1):24–32.

14. Hong WT, Kim J, Kim SW. Minimizing tissue damage due to filler injection with systemic hyperbaric oxygen therapy. Arch Craniofac Surg 2019;20(4);246–250.

15. King M, Walker L, Convery C, Davies E. Management of a vascular occlusion associated with cosmetic injections. J Clin Aesthet Dermatol 2020;13(1):E53–58.

16. Signorini M, Liew S, Sundaram H, et al. Global aesthetics consensus group. Global aesthetics consensus: avoidance and management of complications from hyaluronic acid fillers-evidence- and opinion-based review and consensus recommendations. Plast Reconstr Surg 2016;137(6):961e–971e.

17. DeLorenzi C. Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J 2014;34(4):584–600.

18. Thom SR. Hyperbaric oxygen – its mechanisms and efficacy. Plast Reconstr Surg 2011(Jan); 127(Suppl 1):131S–141S. 19. Drenjančevic I, Ed. Hyperbaric oxygen treatment in research and clinical practice. London, Intech Open. 2018.

20. Murad MH, Altayar O, Bennet M, et al. Using GRADE for evaluating the quality of evidence in hyperbaric oxygen therapy clarifies evidence limitations. J Clin Epidemiol 2014;67:65–72.

21. Butler FK, Hagan C, Murphy-Lavoie H. Hyperbaric oxygen therapy and the eye. Undersea Hyperb Med 2008;35(5):327–381.

22. Schmidt I, Walter P, Siekmann U, et al. Development of visual acuity under hyperbaric oxygen treatment (HBO) in non arteritic retinal branch artery occlusion. Graefes Arch Clin Exp Ophthalmol 2020 Feb;258(2):303–310.

23. Heyboer III M, Wojcik S, Grant WD, et al. Middle ear barotrauma in hyperbaric oxygen therapy.

Undersea Hyperb Med 2014;41:359–363.

24. Latham E, Hare M, Neumeister M. Hyperbaric oxygen therapy. 2010. <https://emedicine.medscape. com/article/1464149-overview#a3> 25. Lazzeri D, Agostini T, Figus M, et al. Blindness following cosmetic injections of the face. Plast Reconstr Surg 2012;129:995–1012.

26. Sito G, Manzoni V, Sommariva R. Vascular complications after facial filler injection: a literature review and meta-analysis. J Clin Aesthet Dermatol 2019;12(6):E65–E72.

27. Bravo BSF, Balassiano LKDA, Da Rocha CRM, et al. Delayed-type necrosis after soft-tissue augmentation with hyaluronic acid. J Clin Aesthet Dermatol 2015;8(12):42–47.

28. Abidia A, Laden G, Kuhan G et al. The role of hyperbaric oxygen therapy in ischaemic diabetic lower extremity ulcers: a double-blind randomised-controlled trial. Eur J Vasc Endovasc Surg 2003;25:513– 518.

29. Kalani M, Jorneskog G, Naderi N et al. Hyperbaric oxygen (HBO) therapy in treatment of diabetic foot ulcers. Long-term follow-up. J Diabetes Complications 2002 Mar-Apr;16(2):153–158.

30. Latham E, Hare M, Neumeister M. Hyperbaric oxygen therapy. 2010. <https://emedicine.medscape. com/article/1464149-overview#a3> 31. Escobar SJ, Slade JB, Hunt TK, Cianci P. Adjuvant hyperbaric oxygen therapy (HBO2) for treatment of necrotising fasciitis reduces mortality and amputation rate. Undersea Hyperb Med 2005 NovDec;32(6):437–443.

32. Beer K, Downie J, Beer J. A treatment protocol for vascular occlusion from particulate soft tissue augmentation. J Clin Aesthet Dermatol 2012;5(5):44–47.

33. Hong WT, Kim J, Kim SW. Minimizing tissue damage due to filler injection with systemic hyperbaric oxygen therapy. Arch Craniofac Surg 2019;20(4):246–250.

34. Uittenbogard D, Lansdorp CA, BAuland CG, Boonstra O. Hyperbaric oxygen therapy for dermal ischemia after dermal filler injection with calcium hydroxylapatite: a case report. Undersea Hyperb Med 2019;46(2):207–210.

35. Kruize RGF, Teguh DN, van Hulst RA. Hyperbaric oxygen therapy in hyaluronic acid filler-induced dermal ischemia. Dermatol Surg 2019;00:1–3. Letter.

36. Darling MD, Peterson JD, Fabi SG. Impending necrosis after injection of hyaluronic acid and calcium hydroxylapatite fillers: report of 2 cases treated with hyperbaric oxygen therapy. Dermatol Surg 2014;40(9):1049–1052.

37. Kassir R, Kolluru A, Kassir M. Extensive necrosis after injection of hyaluronic acid filler: case report and review of the literature. J Cosmet Dermatol 2011;10:224–231.

38. Sclafani AP, Fagien S. Treatment of injectable soft tissue filler complications. Dermatol Surg 2009;35(Suppl 2):1672–80.

39. Hirsch RJ, Cohen JL, Carruthers JD. Successful management of an unusual presentation of impending necrosis following a hyaluronic acid injection embolus and a proposed algorithm for management with hyaluronidase. Dermatol Surg 2007;33(3):357–360.

40. Henderson R, Reilly DA, Cooper JS. Hyperbaric oxygen for ischemia due to injection of cosmetic fillers: case report and issues. Plast Reconstr Surg Glob Open 2018;6:e1618.

41. Bennett M, Kertesz T, Perleth M, et al. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus. Cochrane Database Syst Rev 2012;10:CD004739.

42. Bayoumy AB, Ru JA. The use of hyperbaric oxygen therapy in acute hearing loss: a narrative review.

Eur Arch Oto-Rhino-Laryngol 2019;276:1859–1880.

43. Grunebaum LD, Allemann IB, Dayan S, et al. The risk of alar necrosis associated with dermal filler injection. Dermatol Surg. 2009;35:1635–1640.

44. Carle MV, Roe R, Novack R, Boyer DS. Cosmetic facial fillers and severe vision loss. JAMA Ophthalmol 2014;132(5):637–639.

45. Mori K, Ohta K, Nagano S. A case of ophthalmic artery obstruction following autologous fat injection in the glabellar area [in Japanese]. Nihon Ganka Gakkai Zasshi 2007;111:22–25.

46. Wu X, Chen S, Li S, Zhang J, Luan D, Zhao S, et al. (2018) Oxygen therapy in patients with retinal artery occlusion: A meta-analysis. PLoS ONE 13(8): e0202154 47. Murphy-Lavoie H, Butler F, Hagan C. Central retinal artery occlusion treated with oxygen: a literature review and treatment algorithm. Undersea Hyperb Med 2012;39(5):943–953.

48. Hwang K. Hyperbaric oxygen therapy to avoid blindness from filler injection. J Craniofac Surg 2016;27:2154–2155.

49. Hu XZ, Hu JY, Wu PS, et al. Posterior ciliary artery occlusion caused by hyaluronic acid injections into the forehead: a case report. Medicine (Baltimore) 2016 Mar;95(11):e3124.

Aesthetics | June 2020

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Aesthetics

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Preventing Dermal Filler Complications Mr Dalvi Humzah explores his seven ‘Ps’ to help practitioners prevent dermal filler complications Dermal fillers are now firmly established in the non-surgical treatment of facial rejuvenation, providing volumetric and structural manipulation of soft tissues.1 With increasing use, there has been a concomitant increase in dermal filler-associated complications,2 and now, more than ever, with changes in the global situation regarding medical treatment and the pandemic, practitioners need to be aware of all related mitigating factors to deal with direct and indirect complications.3 All practitioners will need to be able to demonstrate the ability to deliver safe practice and care to deal with infection control. Complications may be viewed as occurring temporally – within hours to days following a procedure – or as delayed onset complications.4 In the past few years, specific hypersensitivity-related events seem to appear between one month to a year following an injectable procedure.5,6 In one study involving 400 patients with filler injected into the tear trough area or lips, it was indicated that 4.25% developed prolonged (up to 11 months) and recurrent (average: 3.17 episodes) late (average onset: 8.41 weeks after the injection) inflammatory cutaneous reactions compared to a reported incidence of 0.02% with previous fillers.5 Another study reported five cases of late-onset inflammatory reactions; these were related to different hyaluronic acid products.6 The hypersensitivity-type reaction appears to be related to the technology used in the manufacturing process, and the subsequent differing products of degradation.5,6 The consensus opinion regarding complications appears to relate to several factors – the seven ‘Ps’ – which will be discussed below.

1: Patient selection There is evidence that aesthetic patients in clinics have a higher incidence of body dysmorphic disorder (BDD) than those in the general population.7 It is estimated that the prevalence of BDD in the general population is around 1-2%, while with patients presenting for cosmetic treatments, between 7-15% may exhibit symptoms of BDD when screened.7 Cosmetic medical treatments may result in no change, worsening of concerns or the development of new concerns.8,9 Given these potential issues, screening tools have been developed to identify groups of patients who would not achieve optimum outcomes. The SAGA system is a quick and efficient screening assessment that has been used in aesthetic surgery to ascertain the psychological motivation of patients and aid in patient selection.10 This system assesses the following four parameters in a patient’s journey in seeking cosmetic treatment: episodes of sensitisation, aesthetic self-assessment, peer group comparison, and avoidance behaviours. When used during the consultation it allows surgeons to establish a rapport with the patient, while giving an insight to the patient’s personality and complaint, therefore helping with patient selection for surgical procedures. There are more direct methods of screening for BDD and further information is available regarding different scales direct from the Body Dysmorphic Disorder Foundation.11 Selection of the appropriate patient will benefit the practitioner and reduce risk of unwanted outcomes from the patient’s perspective.

2 & 3: Procedure and product Selection of the appropriate procedure and appropriate product for the specific patient appears to be imperative in avoiding complications.12 The practitioner has to be able to communicate and discuss the relevant procedures and alternative treatment options that may be suitable for the specific patient as part of the consent pathway. One of the main decisions the practitioner has to make is consider the desires of the patient and match this with the available treatment procedures.

It is also clear that the greater the volume of filler, or the use of different fillers simultaneously, appears to increase the risk of adverse events, in particular post-treatment infections. A review of complications by De Boulle and Heydenrych looked at factors which may contribute to dermal filler complications; they concluded that the majority of complications were related Aesthetics | June 2020

Clinical Practice Complication Prevention to sterility of the procedure, placement, volume, and injection technique.13 This is probably related to changes in the soft tissue environment.12,13 With this in mind, practitioners must pay particular attention to selecting patients and assess them in terms of medical comorbidities. An in depth knowledge of regional anatomy with specific knowledge of vascular anatomy and anomalies with the use of injection techniques that place fillers in the appropriate tissue layers will mitigate against adverse events such as vascular compromise or malar oedema.14,15 Using the appropriate technique (needle or cannula) must be considered by the practitioner in placing the appropriate product in the correct layer.

Several studies have shown that needles and cannula deliver products in different patterns.

The needle on the bone technique at 90 degrees results in product being placed in all layers of the facial tissues. Cannulas allow delivery into specific layers and a greater degree of control.15,16 The gauge of cannulas and needles used has also been investigated with regard to arterial wall penetration. It has been demonstrated that a 27 gauge needle has a similar arterial wall penetration to a 27 gauge needle. This study indicates that when using cannulas in the facial region, cannula diameter larger than a 27 gauge is safer and reduces the risk of intra-arterial penetration.17 Selecting patients, performing a comprehensive medical assessment, having knowledge of facial anatomy and the product to be injected, and employing correct, careful, and meticulous injection technique can help decrease the incidence of adverse events.

4 & 5: Preparation and prevention Associated with the factors discussed above, scrupulous cleansing of the skin prior to dermal fillers has been shown to reduce rates of infection.18 One study’s recommendation was based on using 70% isopropyl alcohol, povidone-iodine or a chlorhexidine containing solution.18 Over the last few months, the global COVID-19 pandemic has resulted in a re-evaluation of the skin cleaning protocols.

A review of the disinfection effect of different solutions on inanimate surfaces has shown that surface disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite was effective against coronaviruses within one minute. Other biocidal agents such as 0.05-0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate are less effective.19 These studies, together with recommendations regarding topical skin 31

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cleansing18 will now need to be considered in detail as clinicians re-enter into medical aesthetic practice. Formal guidelines on infection control will be required with appropriate risk assessment of their clinical environment. The recent guidelines from the JCCP/sk:n recommend the use of solutions containing ethyl alcohol, or a hypochlorite solution as skin prep.3

6: Procedural checklists Within the sphere of surgery, the use of checklists has been instituted to reduce adverse events. In a non-surgical setting, such checklists may be of value. The view is that a form of dermal filler checklist or assessment may decrease infective and other adverse events; until recently no such checklist was available. A recent development has been the use of an assessment tool for facial injections – the Assessment Cosmetic Injection Safety Tool (ACIST). This enables practitioners to identify a patient’s potential for adverse events. This tool assess four areas: medical and social history, adverse event risks and eliminators, warning indicators and instructions, and cosmetic plan postponement. In a preliminary study of 100 patients desiring injection of cosmetic fillers, 32% required additional nursing action or further discussion related to their medical and social history and 68% required that the nurse injector consult with the medical director. Of the 68% requiring medical director consultation or intervention, 4% had indications for delaying or avoiding cosmetic treatment injections.

A summative assessment with the cosmetic injection specialist revealed a positive experience with the overall effectiveness of the ACIST. Using such an assessment it was possible to successfully identify factors to reduce or prevent potential dermal filler adverse events.20

7: Photo-documentation The old saying goes, ‘A picture is worth a thousand words’. In facial aesthetics, clinical photography is imperative in recording patient presentation and progression with treatment. It is also very useful in marketing and advertising.21 In recording photographs of patients or videos, a written informed consent is mandatory. This must include information as to what purpose the photographs are being taken, such as for medical notes, presentations, lectures and social media.

It is advisable to prepare the patient prior to photography by arranging the hair away from the face, remove all facial makeup

Aesthetics

aestheticsjournal.com

and jewellery and consider appropriate background and lighting. Specific views, frontal, oblique and lateral views with and without animation should be considered.

Practitioners should ensure consistency between the photography parameters for their before and after images.22 3D photography and analysis is a novel and accurate way of recording patient’s facial and body contours and track changes with time and age. These systems allow analysis, planning and tracking changes following treatments. Several systems are available such as those by Canfield, Crisalix and QuantifiCare. These systems can enable adverse events to be accurately followed and provide accurate discussion of changes in soft tissue contour.23

Reporting adverse events Adverse events will occur in any practice and when it occurs, the practitioner should have all necessary protocols to deal with general and specific problems e.g. vascular compromise or blindness.24,25 Such protocols are important and practitioners should have them set up to institute as soon as these specific complications occur. Note keeping and reporting to appropriate monitoring bodies e.g. the MHRA (Yellow Card) is considered good medical practice and mandatory.25 Ultimately, in order to avoid complications, the practitioner will need to have carefully evaluated the patient, have an in-depth knowledge of anatomy, understand the properties of the specific fillers used and deliver these products appropriately. In the current circumstances, all practitioners will need to have taken a thorough risk assessment of their treatment pathways, as well as safety considerations, for their staff and patients. Specific groups such as the British College of Aesthetic Medicine, the British Association of Cosmetic Nurses and the Joint Council for Cosmetic Practitioners have produced guidance for practitioners to consider instituting for this enhanced infection control policy, which is discussed more on p.19.3,26,27,28 Mr Dalvi Humzah is a consultant plastic surgeon and delivers his clinical practice through PD Surgery in the West Midlands, Gloucester, and The London Welbeck Hospital. He is also director of the award-winning Dalvi Humzah Aesthetic Training and clinical director of Derma-Seal Ltd. He has wide experience in teaching and training nationally and internationally.

Qual: BSc(Hons), MBBS(Hons), AKC, FRCS(Glas), FRCS(Eng), FRCS(Plast), MBA

Aesthetics | June 2020

Clinical Practice Complication Prevention

REFERENCES 1. Dayan SH, Bassichis BA. Facial Dermal Fillers: Selection of Appropriate Products and Techniques. Aesthetic Surg J. 2008.

2. Urdiales-Gálvez F, Delgado NE, Figueiredo V, et al. Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations. Aesthetic Plast Surg. 2018;42(2):498-510.

3. JCCP, Preparing Your Place of Work: COVID-19 & Return to Practice, May 2020. <https://www.cosmeticcourses.co.uk/wpcontent/uploads/2020/05/Preparing-for-return-to-practice.pdf> 4. Snozzi P, van Loghem JAJ. Complication Management following Rejuvenation Procedures with Hyaluronic Acid Fillers—an Algorithm-based Approach. Plast Reconstr Surg - Glob Open.

December 2018:1.

5. Artzi O, Loizides C, Verner I, Landau M. Resistant and recurrent late reaction to hyaluronic acid-based gel. Dermatologic Surg.

2016;42(1):31-37.

6. Bhojani-Lynch T. Late-Onset Inflammatory Response to Hyaluronic Acid Dermal Fillers. Plast Reconstr Surg - Glob Open.

2017;5(12):e1532.

7. Crerand CE, Franklin ME, Sarwer DB. CME Body Dysmorphic Disorder and Cosmetic Surgery www.PRSJournal.com 167e.

Plast Reconstr Surg. 2006;118(7):167e-180e.

8. Phillips KA, Grant J, Siniscalchi J, Albertini RS. Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics. 2001;42(6):504-510.

9. Crerand CE, Phillips KA, Menard W, Fay C. Nonpsychiatric medical treatment of body dysmorphic disorder.

Psychosomatics. 2005;46(6):549-555. doi:10.1176/appi. psy.46.6.549 10. Cohen JL, Biesman BS, Dayan SH, et al. Treatment of hyaluronic acid filler-induced impending necrosiswith hyaluronidase: Consensus recommendations. Aesthetic Surg J. 2015;35(7):844-849.

11. BDD Foundation, Scales Used for BDD. <https://bddfoundation. org/professionals/scales/> 12. Graivier MH, Bass LM, Lorenc ZP, Fitzgerald R, Goldberg DJ, Lemperle G. Differentiating Nonpermanent Injectable Fillers: Prevention and Treatment of Filler Complications. Aesthetic Surg J. 2018;38(suppl_1):S29-S40.

13. De Boulle K, Heydenrych I. Patient factors influencing dermal filler complications: Prevention, assessment, and treatment. Clin Cosmet Investig Dermatol. 2015;8:205-214.

14. Beleznay K, Carruthers JDA, Humphrey S, Carruthers A, Jones D. Update on avoiding and treating blindness from fillers: A recent review of the world literature. Aesthetic Surg J. 2019.

15. van Loghem JAJ, Humzah D, Kerscher M. Cannula Versus Sharp Needle for Placement of Soft Tissue Fillers: An Observational Cadaver Study. Aesthetic Surg J. 2017;38(1):73-88.

16. Pavicic T, Frank K, Erlbacher K, et al. Precision in Dermal Filling: A Comparison Between Needle and Cannula When Using Soft Tissue Fillers. J Drugs Dermatol. 2017;16(9):866 872.

17. Pavicic T, Webb KL, Frank K, Gotkin RH, Tamura B, Cotofana S. Arterial Wall Penetration Forces in Needles versus Cannulas.

Plast Reconstr Surg. 2019;143(3):504e-512e.

18. Ferneini EM, Beauvais D, Aronin SI. An Overview of Infections Associated With Soft Tissue Facial Fillers: Identification, Prevention, and Treatment. J Oral Maxillofac Surg.

2017;75(1):160-166.

19. G. Kampf, D. Todt, S. Pfaender, E. Steinmann, Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents, Journal of Hospital Infection, Volume 104, Issue 3, 2020, 246-251 20. Elmassian GM, Owens SJ, Wood HJ, Gustman SA. Establishing a Standardized Facial Cosmetic Preinjection Safety Tool: The ACIST. Plast Surg Nurs. 2019;39(4):125-135.

21. Khavkin J, Ellis DAF. Standardized Photography for Skin Surface.

Facial Plast Surg Clin North Am. 2011;19(2):241-246.

22. Nair AG, Santhanam A. Clinical photography for periorbital and facial aesthetic practice. J Cutan Aesthet Surg. 2016;9(2):115-121.

23. Lambros V. Facial Aging. Plast Reconstr Surg. 2020;145(4):921928.

24. C D. New High Dose Pulsed Hyaluronidase Protocol for Hyaluronic Acid Filler Vascular Adverse Events. Aesthetic Surg J. 2017;37(7).

25. 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;18(1):71-76.

26. JCCP, Preparing Your Place of Work: COVID-19 & Return to Practice, May 2020. <https://www.cosmeticcourses.co.uk/wpcontent/uploads/2020/05/Preparing-for-return-to-practice.pdf> 27. BACN, Suggested Operational Plan Guidelines for COVID-19, May 2020. <https://aestheticsjournal.com/news/bacn-releasesguidance-for-returning-to-clinic> 28. Aesthetics journal, BCAM releases return-to-clinic advice for members, May 2020. <https://aestheticsjournal.com/news/ bcam-releases-return-to-clinic-advice-for-members>

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Case Study Nose Filler

nose to enhance the patientâ&#x20AC;&#x2122;s comfort at the entry point of the cannula. The patient did not complain of any pain or discomfort during or immediately after this injection. Then, 0.2ml of HA was injected into the dorsum of the nose with no notable abnormalities. Another 0.1ml was added to the right side of the nose and immediately, blanching of the skin was noted. Further injections were stopped straightaway and the cannula was removed. The patient was asked if she was experiencing any pain or discomfort, to which none was reported. At the same time, the patientâ&#x20AC;&#x2122;s skin was being assessed for vascular refill.

Capillary refill time is defined as the time taken for colour to return to an external capillary bed after pressure is applied to cause blanching. As the capillary refill time was dramatically reduced for this patient, it was an indication that the vessel was compromised. There were no other signs to note at this stage.

The patient was informed of the complication and was advised to undergo immediate hyaluronidase treatment. However, despite this advice, the patient refused to have immediate hyaluronidase treatment and wished to wait and see how the complication might progress. She agreed to wait in the clinic reception for 30-60 minutes to re-evaluate.

Dr Beatriz Molina explores the management of After 30 minutes, further skin changes were noted. skin necrosis on the nose following hyaluronic Livedo reticular patterns were noticed on the right acid filler injection side and tip of the nose corresponding to the right angular artery. Discolouration started to extend to Facial fillers are extremely popular as an aesthetic procedure the rest of the nose and the patient reported that tenderness was to temporarily reduce the depth of wrinkles or to contour faces. present on the tip of the nose (Figure 2).

However, even in the hands of very experienced injectors, there At this stage, the patient agreed to dissolve the HA filler using is always a small possibility of vascular complications such as hyaluronidase. First, 1,500U of hyaluronidase diluted in 1ml of intra-arterial injection of filler substance. This is a case report of a sodium chloride was injected using both cannula and needle to be patient I treated who developed features of vascular obstruction in the sure that the area was covered well. right angular artery, followed by signs of impending skin necrosis after Immediate reperfusion in the remaining areas was noted, as was hyaluronic acid filler injection. improvement of the tenderness in the tip. Following hyaluronidase intervention, the patient was placed under an LED device for 30 Case report minutes. LED phototherapy is based on the principle that living A 30-year-old woman was injected at my private clinic in Bristol cells can absorb, and are influenced, by light. The treatment has for nose reshaping using a hyaluronic acid (HA) filler with a long been recognised for its regenerating and anti-inflammatory concentration of 20mg/ml and lidocaine, using a 25 gauge cannula. properties.1 Firstly, 0.1ml of lidocaine was injected superficially on the tip of the At this point, the pain was gone from the previously affected

Case Study: Necrosis Management

Figure 1: Patient before treatment

Figure 2: Patient 30 minutes post treatment presenting with livedo reticular patterns and discoloration

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Figure 3: Patient 16 hours’ post hyaluronidase

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Figure 4: Patient six weeks’ post procedure

area. There was also persistence of good capillary refill and these parameters were used as the endpoint of the treatment with hyaluronidase. The patient went home and a follow-up appointment was arranged for the next morning. The following day, 16 hours later, the patient came back into clinic and said she was feeling better with no pain to report (Figure 3).

A slight discolouration was still present in the affected area, so the decision was made to treat further with hyaluronidase. Using a 30 gauge needle, 750U were injected superficially into the area of the nose affected. The patient was placed under the LED again for 30 minutes, before being discharged. Another follow-up appointment was made for 24 hours later. The patient rang the clinic 24 hours later and claimed that everything had settled and that there was no pain. Although she was advised that she should still come back to clinic for another assessment, she said she would prefer to contact the clinic if she had any problems and chose not to come back in.

She also asked when she could have her dermal filler treatment done again. She was advised that she could not have it done for at least six weeks to provide enough time for the area to fully heal, so a follow-up was organised for further treatment after this time.

Discussion This case of intravascular filler injection has been presented so that other injectors can learn to recognise the early signs of ischemic skin necrosis, seen in this patient, and start management promptly.

Intra-arterial injection can be identified with blanching, followed by livedo pattern and usually pain.2,3 In most studies, blanching is reported to be transient or lasting for a few seconds,2-5 as it was in this case. However, very often this can be missed by the practitioner if they are not thoroughly and continuously assessing the skin while injecting. On careful examination, poor perfusion of capillary refill, with or without tenderness, can provide an early diagnosis for vascular episode before more obvious livedo reticularis sets in.2-5 Pain is an important identifying feature of intra-arterial filler injection, but may not be appreciated by the patient due to the local anaesthetic used in most fillers these days.

Identifying the possible arterial territory involved helps in treating the whole area with hyaluronidase. In this case, the angular artery was compromised, which resulted in nasal skin changes (Figure 2).

Hyaluronidase is an important modality for management of intravascular HA filler-related cutaneous complications. It is an essential product for every aesthetic practitioner to have if they are practising in injectables.6 The estimated dose of hyaluronidase

Case Study Nose Filler

varies depending on the area involved, as well as the type of filler used.7 A minimum of 750U of hyaluronidase must be used for each vascular territory.2-5,8 There is, however, no unanimity on hyaluronidase dosage in the literature and the interval between two doses.

The optimal timing for treatment of intra-arterial filler injection is as early as the diagnosis is made, and it should not be later than 72 hours to avoid skin necrosis and scarring.4 There are expert consensus reports suggesting to inject hyaluronidase on an hourly basis until the endpoint of treatment showing reperfusion of skin and correction of blanching/livedo, as well as no pain present in the affected area.2-4 The principle is to inject an adequate amount of hyaluronidase at high concentration levels to dissolve the HA material present in that vascular territory.

Summary Complications can occur even with the most experienced injectors.

The involved area was fully recovered from this vascular episode, indicating that complete recovery of the ischemic skin changes, secondary to possible intra-arterial injection or compression, could be achieved using high-dose hyaluronidase. Intra-arterial injection of filler material has the potential to cause significant damage due to blockage of cutaneous vascular supply, which may cause ischemic skin necrosis. Although prevention of vascular complications through detailed understanding of vascular anatomy is extremely important, all injecting practitioners should also be able to recognise the features of such complications quickly for prompt action.

Dr Beatriz Molina is the medical director and owner of Medikas clinics, and has more than 12 years’ experience in injectable practice. She is a KOL for Galderma UK and also an international speaker and a country mentor leader for Galderma Global. Dr Molina is the founder of the International Association for Prevention in Complications in Aesthetic Medicine (IAPCAM).

Qual: LMS Malaga ’93 REFERENCES 1.

Glynis Ablon, Phototherapy with Light Emitting Diodes, J Clin Aesthet Dermatol. 2018 Feb; 11(2): 21–27.

2.

DeLorenzi C. Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J. 2014;34:584–600.

3.

DeLorenzi C. New high dose pulsed hyaluronidase protocol for hyaluronic acid filler vascular adverse events. Aesthetic Surg J. 2017;37:1–12.

4.

Cohen JL, Biesman BS, Dayan SH, et al. Treatment of hyaluronic acid filler-induced impending necrosis with hyaluronidase: consensus recommendations. Aesthet Surg J. 2015;35:844–849.

5.

Hong JY, Seok J, Ahn GR, Jang Y-J, Li K, Kim BJ. Impending skin necrosis after dermal filler injection: A ‘golden time’ for first-aid intervention. Dermatologic Therapy. 2017;30:e12440.

6.

De Boulle K, Heydenrych I. Patient factors influencing dermal filler complications: prevention, assessment, and treatment. Clin Cosmet Investig Dermatol. 2015;8:205–214.

7.

Casabona,G MD, Durability, Behavior, and Tolerability of 5 Hyaluronidase Products.

Dermatologic Surgery: November 2018 - Volume 44 - Issue - p S42–S50 8.

Signorini M, Liew S, Sundaram H, et al. ; Global Aesthetics Consensus Group. Global aesthetics consensus: avoidance and management of complications from hyaluronic acid fillersevidence- and opinion-based review and consensus recommendations. Plast Reconstr Surg.

2016;137:961e–971e.

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Aesthetics Awards Special Focus

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Make 2020 Your Year!

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KEY DATES 1

Get the recognition you deserve at the most prestigious awards ceremony in aesthetics It’s a challenging year for all in the specialty, but we know how much you care for your patients and customers, and believe everything you are doing to continue to support them should be celebrated! If you’re not working at the moment, then many of you may be analysing your business strategy and reflecting on all the fantastic things you’ve achieved in the past year. Why not tell us about them and be rewarded for your efforts in the process?

Winning an Aesthetics Award, or even being shortlisted as a finalist, is a prestigious endorsement of your achievements within the specialism, helping to raise your profile and increase marketing and PR opportunities. It enables you to demonstrate to patients and customers why they should put their trust in you and your brand, and choose you over your competitors.

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ENTRIES OPEN JUNE 1

2 ENTRIES CLOSE JULY 31

3

FINALISTS ANNOUNCED AND VOTING OPENS OCTOBER

4

VOTING AND JUDGING CLOSES DECEMBER

THE CEREMONY The Aesthetics Awards will take place following the second day of the Aesthetics Conference and Exhibition (ACE) 2021 – meaning you can dedicate a whole weekend to learning, networking and celebrating! The glamorous ceremony will host more than 800 guests, providing another remarkable evening full of entertainment, networking opportunities, and acknowledgement of the hardest working companies and individuals in the field. You could be presented with a Commendation, High Commendation or even the Winner’s trophy in front of hundreds of like-minded peers, before dancing the night away in celebration of making it through the most challenging year medical aesthetics is ever likely to see.

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WINNERS ANNOUNCED AT THE AESTHETICS AWARDS MARCH 13

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Aesthetics Awards Special Focus

CATEGORIES PROFESSIONALS AESTHETIC NURSE PRACTITIONER OF THE YEAR

BEST NON-SURGICAL RESULT – NEW FOR 2020!

Aesthetic nurses who continue to deliver exceptional care and clinical expertise will get the recognition they deserve with this esteemed accolade. Finalists selected will demonstrate an outstanding commitment to patient safety, continued professional development and illustrate actions to demonstrate how they are making a difference in the aesthetics specialty. This category is only open to nurses with more than five years’ demonstrable experience of working in the aesthetic specialty. For those with less than five years’ experience, please enter the Rising Star of the Year category.

MEDICAL AESTHETIC PRACTITIONER OF THE YEAR Doctors and dentists are invited to demonstrate their contribution to the profession, as well as how they have been dedicated to providing outstanding care and treatment to their patients in the last 12 months. Applicants must also validate how they have worked hard to continue their professional development as well as display an unprecedented commitment to patient safety. This category is only open to doctors and dentists with more than five years’ demonstrable experience of working in the aesthetic specialty. For those with less than five years’ experience, please enter the Rising Star of the Year category.

RISING STAR OF THE YEAR – NEW FOR 2020!

This award will recognise the doctor, dentist or nurse with less than five years’ experience in aesthetics who is deemed to have contributed most to the profession and/or has provided the most outstanding care and treatment to their patients in the last 12 months. The winner will be judged on their clinical expertise, continuous professional development, commitment to patient safety and the difference they make to their patients and clinic.

They will also be assessed on what they are beginning to do to improve the profession as a whole. Only those with less than five years’ experience are eligible to enter this category.

Do you have an aesthetic result that your exceptionally proud of? Showcase it to your peers in this new category for 2020. You may have utilised any type of non-surgical treatment, individually or in combination with others, to create the result and it may have been achieved over a number of sessions. As well as providing photographic evidence of an excellent aesthetic result, you should demonstrate excellent patient care and patient satisfaction with the outcome. Treatment must have been given after January 1 2019.

BEST SURGICAL RESULT – NEW FOR 2020!

This award will recognise the consultant plastic surgeon who has created the best surgical facial aesthetic result for a patient. The practitioner may have utilised non-surgical treatments to complement the result. As well as providing photographic evidence of an excellent aesthetic result, the entry should demonstrate excellent patient care and patient satisfaction with the outcome. Treatment must have been given after January 1 2019.

OUTSTANDING ACHIEVEMENT IN MEDICAL AESTHETICS This prestigious trophy will be awarded to an individual with a distinguished career in aesthetics who has made a significant contribution to the profession. There will be no finalists for this category and the winner will be selected from within the profession

by Aesthetics Media. Readers are invited to share their suggestions by emailing contact@aestheticsjournal.com.

CONSULTANT SURGEON OF THE YEAR – NEW FOR 2020!

This award will recognise the consultant surgeon who is deemed to have contributed most to the profession and/or has provided the most outstanding care and treatment to their patients in the last 12 months. The winner will be judged on their clinical expertise, continuous professional development, commitment to patient safety and the difference they make to their patients, clinic and the profession as a whole. Entrants must be practising in surgery and non-surgical aesthetics.

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Aesthetics Awards Special Focus

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CLINICS

BEST NEW CLINIC, UK & IRELAND Did you open your very own clinic after January 1 2019? Show your current and potential patients that your new clinic is something to be proud to be associated with. Finalists should demonstrate initiatives designed to promote growth, commitment to customer service, patient care and safety, as well as good feedback from patients.

This category is not opened to existing clinic brands that have opened a new site – instead you are encouraged to enter clinic in your regional category.

CLINIC RECEPTION TEAM OF THE YEAR The reception staff are the face of your business, and it’s time your fabulous team members were recognised for their hard work. If you can provide evidence of outstanding customer service, a continuous training programme, strong practitioner support and effective teamwork, then you need to enter your team into this category.

REGIONAL CLINIC AWARDS Clinic finalists in each region across the UK will be recognised for their commitment to excellence in patient care and safety, customer service and evidence of good feedback from their patients.

Enter now to put your mark on the map! ⊲ ⊲ ⊲ ⊲ ⊲ ⊲

Best Clinic North England Best Clinic South England Best Clinic Midlands & Wales Best Clinic Scotland Best Clinic Ireland Best Clinic London

PRODUCTS

THE DIGITRX AWARD FOR PRODUCT INNOVATION OF THE YEAR The Aesthetics Awards will celebrate the products that have truly revolutionised the market in 2019. The judges will look for widely-used products displaying genuine innovation leading to treatment for new indications, quicker or more straightforward results and enhanced patient safety, all backed by sound evidence. Products must have launched into the UK market after 1 January 2019. Products must not have been entered into the Aesthetics Awards in previous years.

FAST. EFFICIENT. SECURE.

ENERGY DEVICE OF THE YEAR If you are a supplier or manufacturer of an energy device, now is the chance to prove why yours is the best in the UK. Your device must demonstrate a wide range of indications, optimum duration and tangible benefits over similar treatments on the market and, most importantly, evidence of good safety and efficacy.

INJECTABLE PRODUCT OF THE YEAR Manufacturers or UK distributors of injectable products for the UK aesthetics market are invited to enter this category. Highlight why your product stands out from the crowd by showcasing evidence of good safety and efficacy, optimum duration and tangible benefits over similar products on the market.

TOPICAL SKIN PRODUCT/RANGE OF THE YEAR With an abundance of topical skincare on the market, it can be challenging for practitioners to select which ones to adopt in their clinic. This award will be given to the manufacturer or exclusive UK distributor who can demonstrate that their topical skin product/range is effective, safe and easy to use.

SURGICAL PRODUCT OF THE YEAR – NEW FOR 2020!

A new category for 2020, this award will recognise the surgical product that supports a specific indication and can show evidence of good safety and efficacy, optimum results, with benefits over other similar products on the market.

OPEN TO ALL PROFESSIONAL INITIATIVE OF THE YEAR Have you, your company or association launched a patient-focused and professional campaign within the last year or made significant developments to an existing initiative? The judges will look for evidence of activity designed to benefit the industry as a whole, along with tangible outcomes, rewarding the promotion of consumer education and patient safety.

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Aesthetics Awards Special Focus

TRAINING PROVIDERS

INDEPENDENT TRAINING PROVIDER OF THE YEAR Judges will look for the independent training provider who offers a programme with engaging methods of delivery, a high-quality continued development strategy and achievement of measurable outcomes.

SUPPLIER TRAINING PROVIDER OF THE YEAR Do you offer excellent training events or programmes to clients who stock your products or services? This award will look for engaging methods of delivery, a high-quality, relevant programme and achievement of measurable outcomes.

COMPANIES PRODUCT/PHARMACY DISTRIBUTOR OF THE YEAR If you work for a distributor of aesthetic or pharmaceutical products then enter your company today. This award acknowledges the vital role played by distributors who bring new, international products and treatments to the UK market. Finalists will be selected on the basis of their product representation, customer service and ongoing support to practitioners.

MANUFACTURER OF THE YEAR Are you a product manufacturer that offers excellent customer support and the latest range of products? Prove to your clients that your product developments and support for practitioners is superior by entering this category.

ENTER TODAY! HOW TO ENTER All entries must be made via aestheticsawards.com. You can enter as many categories as you wish, but you may only enter yourself, a company you work for, an employee who works for your company or a product made that is distributed by your company. Entries made on behalf of a third party will not be accepted. You may only enter each category once. All entries must be accompanied by the supporting evidence requested in the entry form.

SALES REPRESENTATIVE OF THE YEAR What do you do to offer unsurpassed levels of customer service to your clients? Those chosen as finalists will be able to show outstanding levels of support for their customers, a strong commitment to their industry and a proven ability to assist clinics in supporting patients and growing sales of their product and/or services.

BEST CLINIC SUPPORT PARTNER Does your company offer outstanding support to medical aesthetic clinics in the specialty? Those who enter will offer business services tailored to the aesthetics market such as CRM, clinic software, PR, advertising, marketing, financial support, legal advice and insurance.

YOUR ENTRY You are encouraged to keep your entry concise and clear; use bullet points and take advantage of formatting options such as bold, underlines and italics to ensure your entry is easy to digest for judges. Please note that formatting cannot be copied and pasted from Word documents, so you should only add these when submitting your entry on the website. A strict word limit is enforced for each question and you must not exceed this; however, your entry does not have to meet it.

THE JUDGING PROCESS After the entry closing date of July 31, a list of finalists will be selected in each category, which will be published in the Aesthetics journal and on the website. Users registered on the Aesthetics website are able to vote for a winner in the designated categories, which will also be evaluated by an expert judging panel. Other categories will be assessed solely by the judging panel, which will be carefully selected to avoid conflicts of interest.

OUR TOP TIP! What makes you stand out from the crowd?! Your entry should not only be supported by evidence, but judges will be looking for new and exciting developments, so be sure to highlight what makes you different from the rest!

Aesthetics | June 2020

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the NEW depigmenting solution by mesoesteticÂŽ

NEW from the world leader in depigmentation treatments now you can correct pigmentation imperfections and improve the quality, turgor and appearance of the intimate area in a single clinical session.

This is the latest innovation in pigmentation treatment brought to you by mesoesteticÂŽ through over 35 years of research and development.

Developed in collaboration with specialised gynaecologists.

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Clinical Focus Scars school adolescents in 2002 indicated that only 12.6% reported their injuries to a hospital/medical professional.8 Although self-mutilating behaviour was considered by some early clinicians as a form of suicidality, accounts since have suggested that this type of behaviour is not strongly associated with a high risk of suicide.5 A UK mortality follow-up study published in 2004, involving 11,583 individuals over an average of 11.4 years, identified that the overall mortality by suicide in the cohort was 2.6%.9 Further studies are eagerly awaited to delineate the most recent epidemiological trends.

Clinical presentation

Managing Self-harm Scars Mr Ioannis Goutos explores the impact of scars from self-harming and the different management approaches Self-harm injury represents a challenging presentation in clinical practice, which is frequently associated with a socially stigmatising pattern of scars. Patients may present to a variety of healthcare professionals in the reconstructive as well as the aesthetic arena with a quest to ameliorate the appearance of scars by means of either surgical revision or resurfacing procedures. This article aims to explore the literature pertinent to the topic and presents the basic tenets of holistic patient management.

Background and epidemiology of self-harm Self-harm injury has been traditionally regarded as a presentation accompanying various mental disorders like psychosis, depression, post-traumatic stress, as well as personality disorders.1 The European Society for Dermatology and Psychiatry classifies self-harm under impulsive, non-hidden, non-denied behavioural pattern for skin modifications.2 This impulsive behaviour consists of isolated or recurrent acts directed towards the self, most commonly without an obsessive component, rendering rapid but short relief from a variety of ‘intolerable internal states’.3 The epidemiology of self-mutilation in the past decades has changed towards younger individuals without a defined psychiatric condition e.g. depression, anxiety or personality disorders, with such behaviour often occurring within a high achieving academic/ professional background.4 Self-harm is increasingly being used as a coping strategy among teens and young adults to decrease emotional distress, dissociation and posttraumatic symptoms.5 It has been postulated that the ‘contagion factor’ may contribute to the increase in self harm activity by virtue of curiosity, peer pressure and risk-taking behaviour promoted in popular media.4 This coping strategy pattern has become a major health concern and many individuals are expected to seek treatment in the near future.4-6 A number of literature reports have suggested that self-harm affects 4% of the general population, with equal prevalence among males and females.5,7 It is important to note that the true incidence of self-harm is very challenging to accurately define, given that it occurs in a number of diverse settings and is thought to be underreported.4 One study among Aesthetics | June 2020

The clinical presentation of patients with self-harm scars varies widely in terms of the underlying mechanism, time lapse following injury, as well as the individual scar characteristics. The upper limb (especially non-dominant) is most frequently involved, followed by the lower limb and trunk in order of prevalence.10 In my experience, scars tend to be multiple, parallel in pattern, most frequently hypopigmented (i.e. lighter in colour compared to neighbouring skin) and atrophic in quality (i.e. containing decreased amount of collagen). Bridges of intact skin in-between the individual scars is a frequent finding, which contributes to a characteristic stigmatising pattern.

A definite proportion of my patients presenting with recent scarring have erythematous and hypertrophic (i.e. bulky) scars. I have found that the majority of individuals resort to concealing behavioural patterns in daily activities; these include avoiding exposure/covering involved bodily parts with clothing in an attempt to avoid challenging situations in everyday encounters.

Most individuals present to my clinic with complaints regarding the stigmatising pattern of their scars and report feeling trapped in long-standing shame, regret and guilt, resulting in significant body image disturbance.

Management principles Patients with self-harm scars need to be approached with sensitivity and openness within a multidisciplinary setting familiar with the holistic needs of this subgroup of individuals. The managing team should ideally encompass professionals of plastic surgery/dermatology background, as well as 43

Clinical Focus Scars psychologists/psychodynamic therapists and other allied health professionals.

It is vital that as part of the consultation, clarity is obtained that the individual is determined to commit to internal processes needed to refrain from self-harm; it is also important that there is a supporting network of interpersonal/social relationships and stable employment in place before any consideration for intervention.

It is good practice to refer all patients to a psychology or psychotherapy practitioner before commencing any scar management.

This allows patients to deal with any remaining internal conflicts pertinent to the original motives behind self-harm and, most importantly, have support for any difficult emotions that may arise during physical scar management.5,11 Reluctance in treating self-harm scars is intense in the clinical literature on the basis of potential medicolegal implications and an interval of at least two years following injury before any consideration for reconstruction has been proposed.12 I believe this notion is best challenged within the context of individual circumstances relevant to each patient and the specialist skillset of the responsible medical practitioner.

Scar management options Symptomatic treatment For a small proportion of patients with painful, itchy hypertrophic scars, steroidbased strategies using tape, injections or laser-assisted techniques can be very successful.13,14 Camouflage approaches Makeup products are a valid option for patients wishing to conceal areas of scarring and avoid invasive options, with the main drawback being the need for repeat applications. Tattooing can be either of decorative nature or medical grade and can contribute to a better colour match with the surrounding skin.15 Follicular transfer (hair transplant) is another option that has been described in a single literature case report and is appropriate for hair-bearing areas of the body.16 Resurfacing techniques These options can address concerns regarding the surface characteristic of scars e.g. colour, texture and contour and hence ameliorate the stigmatising self-harm pattern.

Mechanical removal of the epidermis through dermabrasion has traditionally been used 44

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Patients with self-harm scars need to be approached with sensitivity and openness within a multidisciplinary setting familiar with the holistic needs of this subgroup of individuals

as a resurfacing modality, either alone or in combination with other adjuncts.17 In my experience, its popularity has decreased over the last decade given new emerging technologies in scar management.

Percutaneous collagen induction or microneedling is one such technology. It relies on the creation of a non-confluent and non-ablative pattern of skin punctures with the resultant preferential release of transforming growth factor beta-3 (TGF-β3) rendering a remodelling effect.18 My personal experience would support the use of long needles (2.5-3mm long) in order to stimulate the maximum collagen regenerative response and this frequently necessitates the use of regional anaesthetic or sedation techniques to ensure patient comfort during the procedure.

Non-ablative fractional laser has also been described as a treatment option; it relies on the creation of a pattern of micro-thermal damage zones (MTZs) leaving intact surrounding tissue able to stimulate a healing response and scar remodelling. This modality is less invasive than ablative ones (e.g. carbon dioxide) and carries less risk of unwanted side effects, including dyspigmentation.19 In a single study involving 16 patients undergoing three sessions of 1565 nm Erbium glass laser at four-week intervals, highly significant changes in objective scar measurements, as well as clinical evaluation parameters, were reported.20 The carbon dioxide fractional laser resurfacing approach has also been utilised Aesthetics | June 2020

in the literature. A retrospective review in a South Korean centre involving 11 patients employed one to six sessions spaced four to eight weeks apart. Pre and post treatment photographs at three months after the last treatment, using a quartile grading scale, indicated that 82% patients showed significant improvement (between 51% to>75%) and a mean overall improvement score of 2.82 (range from unsatisfied -1 to very satisfied -4). In terms of complications, some post-inflammatory hyperpigmentation was seen.21 Surgical scar revision techniques These techniques aim to alter the shape/outline and reduce the overall number of scars. Direct excision can be a good option for markedly wide scars; most frequently multiple/serial staged excisions are necessary if scarring is present over a large surface area.22 Dermal templates (artificial skin) can also be used. One of the most popular templates consists of an outer layer of silicone and an inner layer of bovine collagen crosslinked with glycosaminoglycan matrix (chondroitin-6-sulphate). It is applied to the wound following block scar excision to act as a neo-dermis with epidermal cover, achieved using a split skin graft. Two case series in the literature have reported satisfactory results, with socially and cosmetically acceptable scar appearance and increased selfconfidence. Complications included graft loss in one patient necessitating a further re-grafting procedure and variable levels of

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hyperpigmentation.22,23 Tissue expansion is another option and involves the insertion of an inflatable prosthesis near the scar field and its gradual expansion in the outpatient setting. Eventual block scar excision and re-draping of the extra skin generated eventually produces a single scar. Such an approach can remove the multiple scar pattern frequently seen in affected individuals; nevertheless, it represents a long reconstructive journey with associated risks of expander infection/extrusion. Split skin graft techniques have been described in the literature, with most resurfacing the scarred area using skin from remote donor sites (e.g. thigh/buttock).24,17 More modern techniques avoid the creation of extra scars by harvesting skin grafts from the index scar field.25,26 Combined skin graft and scar excision techniques can also be useful. Isotopic split skin grafting involves graft harvest from the scarred area, excision and direct closure of the widest scars, and the final replacement of the skin graft onto the original site.27 A combination of surgery and laser resurfacing techniques have also been described. A single study involving 26 anatomical sites of 16 patients has detailed a combined approach involving trimming of hypertrophic scars down to intact skin level, intralesional steroid injection, carbon dioxide laser resurfacing and the application of a thin split skin graft under general anaesthetic. Encouraging results were reported with scars assuming a socially acceptable appearance similar to a burn scar; complications included one case of partial graft loss and one of hyperpigmentation and inclusion cysts in the early postoperative period.1 An increasingly popular combination in my

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practice is the use of non-ablative fractional laser (NAFL) following direct excision and closure. A recent systematic review has provided promising preliminary data on the ability of early laser intervention to reduce scar formation and improve overall outcomes following surgery.28

A holistic approach Self-harm scarring is a challenging clinical presentation. Patients presenting for scar resurfacing and revision are best managed by a multidisciplinary team incorporating allied health professionals experienced in supporting their needs in a holistic manner.

Mr Ioannis Goutos is an academic plastic surgeon specialising in scar management, lasers and body contouring. His practice is based at Barts Health NHS Trust and Harley Street in London.

Qual: BSc(Hons), MBBS(Hons), FRCSEd(Plast), MSc Burn Care REFERENCES 1. Acikel C, Ergun O, Ulkur E, Servet E, Celikoz B. Camouflage of self-inflicted razor blade incision scars with carbon dioxide laser resurfacing and thin skin grafting. PRS 2005 116: 798-804.

2. Gieler U, Consoli SG, Tomas-Aragones LT. Self-inflicted lesions in dermatology: terminology and classification- A position paper from the European Society for Dermatology and Psychiatry.

Acta Derm Venereal 2013; 93:4-12.

3. Cumming S, Covic T, Murrell E. Deliberate self-harm: have we scratched the surface? Behavior Change 2006;23: 186-99.

4. Derouin A, Bravender T. Living on the edge: the current phenomenon of self-mutilation in adolescents. MCN Am J Matern Child Nurs. 2004 Jan-Feb;29(1):12-8; quiz 19-20.

5. Briere J, Gil E. Self-mutilation in clinical and general population samples: prevalence, correlates and functions. American Journal of Orthopsychiatry 1998 68(4):609-20.

6. Favazza AR. The coming age of self-mutilation. J Nerv ment Dis 186: 259, 1998 7. Zlotnick C, Shea MT, Pearlstein T, Simpson E, Costello E, Begin A. The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse and self-mutilation. Comprehensive Psychiatry 37(1) 1996: 12-6.

8. Hawton K, Rodham K, Evans E, Wetherall R. Deliberate self harm in adolescents: self report survey in schools in England. BMJ 2002;325 (7374): 1207-11.

9. Zahl DL, Hawton K. Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11583 patients. British Journal of psychiatry 2004, 185: 70-75.

Clinical Focus Scars

10. Agris J, Simmons CW. Factitious (self-inflicted) skin wounds. PRS 1978 62(5): 686-92.

11. Welch JD, Meriwether KRC, Trautman R. Stigmata: part I. Shame, Guilt and Anger. PRS 1999 104(1): 65-71 12. Levekron S. Stigmata: Part I (Letter). PRS 2000;105(3):1240-1.

13. Ali FR, Al-Niaimi F. Laser-assisted drug delivery in dermatology: from animal models to clinical practice. Lasers Med Sci 2016 31: 373-81.

14. Goutos I and Ogawa R. Steroid tape: A promising adjunct to scar management. Scars, Burns & Healing 2017; DOI: 10.1177/205951311769.

15. Guyuron B, Vaughan C. Medical-grade tattooing to camouflage depigmented scars. PRP, 1995; 95(3).

16. Gozu A, Ozsoy Z, Solmaz M. Microfollicular hair transplantation may be a simple solution to camouflage self-inflicted wound scars on dorsal forearm. Annals Plastic Surgery 2006 56(2): 224-5.

17. Baytekin C, Menderes A, Mola F, Fidaner H, Barutcu A. Treatment of self inflicted scars with overgrafting: Destigmatisation The Internet Journal of Plastic Surgery 2005; 2(2): 1-6.

18. Aust M, Bahte S, Fernandes D. â&#x20AC;&#x2DC;Applications Scars from cut injuriesâ&#x20AC;&#x2122; in Illustrated guide to percutaneous collagen induction

by Quintessence Publishing UK, 2013.

19. Verhaeghe E, Ongenae K, Bostoen J, lambert J. Nonablative fractional laser resurfacing for the treatment of hypertrophic scars: a randomized controlled trial Dermatol Surg 2012, 39:3: 416-34 20. Guertler A, Reinholz M, Poetschke, Steckmeier, Schwaiger H, Gauglitz GG. Objective evaluation of a non-ablative fractional 1565nm laser for the treatment of deliberate self-harm scars.

Lasers Med Sci 2018 33:241-50.

21. Lee SJ, No YA, Kang JM, Chung WS, Kim YK, Seo SJ, Park KY. Treatment of hesitation marks by the pinhole method. Lasers Med Sci 2016 31: 1339-42.

22. Todd J, Ud-Din S, Bayat A, Extensive self-harm scarring: Successful treatment with simultaneous use of a single layer skin substitute and split-thickness skin graft. ePlasty 2012; 12: 219-30.

23. Ismail A, Jarvi K, Canal ACE. Successful resurfacing of scars from previous deliberate self-harm using Integra dermal matrix substitute. JPRAS 2008 61, 839-41.

24. Binns JH, Alperstein DN. Disguising the slashed wrist (letter) PRS 1983; 72: 420).

25. Papanastasiou S. Treatment for self-inflicted lacerations cars, PRS 1995; 96: 1745 26. Chou C-Y, Chang HA, Chiao H-Y et al. Interchangable skin grafting to camouflage self-inflicted wound scars on the dorsal and volar forearm: A case report. Ostomy wound management 2014;60(4):50-52.

27. Goutos I, Ogawa R. Isotopic split skin graft for resurfacing of deliberate self harm scars. Plast Reconstr Surg Glob Open 2018;6:e1801; doi: 10.1097/GOX.0000000000001801.

28. Karmisholt KE, Haerskjold A, Karlsmark T, Waibel J, Paasch U, Haedersdal M. Early laser intervention to reduce scar formation-a systematic review. JEADV 2018, doi: 10.1111/jdv.14856.

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Case Study Infection and Nodules

Time and adverse reactions

Case Study: Lip Filler Infection and Nodules

The patient provided a timeline during the consultation, which guided the diagnosis as some adverse events occur immediately after filler injections, while others do not.

The types of complications that could occur following filler treatment, according to time of onset, are illustrated in Figure 2.1 Initial observations showed the patient had a severe lip infection. After careful manipulation of the upper and lower lips it was possible to palpate and view uneven surfaces through the swelling, which were painful to the touch. The pain and swelling had come weeks later than the injection, so I then needed to assess whether the lumps were filler nodules, granuloma or delayed hypersensitivity. Descriptions of how they present are detailed in Figure 3.2

Step one: control the infection

As with any procedure that penetrates Nurse prescriber Alice Henshaw describes how she the skin, soft-tissue filler injections can be associated with infection.3 Because chronic identified and successfully treated a complication inflammation or infection leading to the in the lips formation of a granuloma can interfere with the wound healing process, infection control A 45-year-old female patient sought help after suffering a is essential.4 Moreover, wound infections are often associated with negative reaction from dermal filler injection to her upper and aesthetically and functionally unfavourable scarring.5 Erythematous lower lips for aesthetic purposes from an overseas clinic. nodules, multiple red and tender lumps that persist beyond the first During the initial consultation we discussed the background to her few days of treatment, may be signs of inflammation.6-8 Additionally, lip filler procedure. This had been the patient’s first cosmetic dermal there is a risk for infection with swelling following filler injection and filler injection. Wary of overly inflated lips, the patient researched resultant abscess, however this is beyond the scope of this article as it clinics and chose an established company in California with certified did not occur with this patient. dermatologists. She paid at the higher end of the procedure scale of As a first-line treatment, a course of amoxicillin/clavulanic acid was prices in the belief she would receive the best product administered prescribed for 14 days. Whether the infection was secondary to by a skilled practitioner. the filler nodules or the primary cause of possible granulomas, it The patient’s consultation provided neither a detailed explanation was necessary to reduce the pain and swelling before an informed as to the type of filler used nor adequate post-treatment care and decision on how to treat the lumps could be made. advice. The patient contacted the clinic one hour post procedure A secondary reasoning behind prescribing antibiotics ahead of to ask why she had uneven and painful lips and was advised it was treatment of the lumps was due to the likelihood of the lumps being because she had not massaged her lips. filler nodules. Confirmation from the original clinic that a hyaluronic Three months’ post treatment, back in the UK, the patient was acid (HA) based filler has been used allowed for treatment by experiencing difficulty with her speech, and had painful lumps and hyaluronidase. Hyaluronidase should be used with caution if swelling at night time. The patient went to visit a local beautician infection is also suspected since this may lead to the infection who attempted to squeeze the lumps out through incisions to the spreading further along the tissue plane.9 It was for this reason, upper and lower lips. The only result was increased swelling, pain and infection. The patient presented to Harley Street Injectables a Early complication Late complication month following her visit to Erythema Granuloma the beautician (four months Oedema, swelling Migration post treatment) with painful, swollen lips which affected Ecchymosis, bruising Hypertrophic scar her day-to-day activities, Lump, nodule Telangiectasia including work and socialising.

Blanching, discolouration Skin defect She was staying at home with Skin necrosis Infection increasing anxiety and felt she Infection, biofilm Figure 1: Patient’s lips upon presentation, could not leave the house due four months’ post treatment. Lips were swollen and painful. to embarrassment (Figure 1).

Figure 2: Table demonstrating types of complications according to time of onset1 Aesthetics | June 2020

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Case Study Infection and Nodules

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Granuloma

Presentation and symptoms

Causes

Onset

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Filler nodule

Aesthetics

Delayed hypersensitivity

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Infection

Cystic, nodular, bluish, indurated plaques with congested capillaries that are bigger than the injected volume of filler and develop simultaneously at different sites.

Evenly sized, whiter in colour and harder than granulomatous nodules.

Erythema, oedema, indurated papule, nodule with or without itching.

Erythema, swelling, oedema, induration and/or tenderness.

Filler dependent: type and volume of filler used.

Injector dependent: poor injection technique (overcorrection or too superficial injection), lack of massage.

Filler dependent: HA or bovine type collagen.

Subject dependent: bacterial, viral, fungal, parasitic infections.

Subject dependent: infection and biofilm.

Injector dependent: attention to skin cleanliness and patient selection.

Subject dependent: lack of massage (poly-l-lactic).

Delayed by months or years after filler injection.

Early – up to two weeks after filler injection.

Injector dependent: poor patient selection, poor skin cleansing.

One month after filler injection with spontaneous resolution after one year.

Early or delayed.

Figure 3: Table describing presentation, cause and onset of various filler-related complications2

and the health of the patient, that resolving the infection before treatment was pursued. When the patient presented for her second appointment two weeks later, the infection had been treated, the patient’s lips had reduced to a normal size and the suspected filler nodules were much more evident (Figure 4).

Step two: identify the lumps During the two-week follow up, it was evident the swelling and some of the tenderness had resolved but the lumps remained.

I therefore needed to identify the cause of the lumps before proceeding to treatment. The potential causes reviewed were granuloma, delayed sensitivity and filler nodules.

injections are frequent, including pain, bruising, and transient oedema. These tend to disappear in a few days and usually require no treatment.18 It has been suggested that the reason HA fillers cause more swelling and bruising than collagen fillers is the anticoagulant effect of HA, which has a structural similarity to heparin.19,20 Immediately after injection, skin erythema is usually transient and normal. If erythema lasts for more than several days, it is likely to be a hypersensitivity reaction.21 However, erythema should be differentiated from infection. Delayed hypersensitivity was considered as the patient did not have a dermal filler history; however, as the nodules were even in size and white in colour, it was more likely they were filler nodules.

Delayed sensitivity When hyaluronic acid replaced bovine collagen in dermal filler treatments, very few adverse reactions secondary to injections remain.17 However, nonallergic local side effects at the sites of

Filler nodules Lumps or nodules usually appear as cystic, oedematous or sclerosing types shortly after treatment in the form of well-confined palpable lesions, which can result from injection in areas of thin soft-tissue coverage (e.g. eyelids, nasojugal region, and lip), injection of too much material, clumping of the filler, or dislocation by movement of the muscles.21-24 The lips are an area of high mobility with thin mucosa. Measures to avoid visibility of the implanted material include firm massage and meticulous placement of filler in the deep supraperiosteal plane.25,26 If HA filler is injected too superficially, or if there is an uneven distribution of the injected product, visible, pale nodules in the skin may result.27 This was observed in the patient. The original clinic had told the patient to massage the lumps in her lips post treatment, providing a strong indication that the lumps were a result of an incorrect dermal filler injection technique. In my practice, I advise patients not to touch the area injected with filler because of

Figure 4: Patient’s lips two weeks after a course of antibiotics. Suspected filler nodules more evident.

Figure 5: Patient’s lips two weeks after treatment with hyaluronidase. No inflammation, pain or nodules remained.

Granuloma Granulomas are relatively rare complications with a frequency of occurrence reported as 0.02-0.4% after HA use for dermal filler in the dermis.10 Granuloma, which is a chronic inflammatory reaction with various aetiologies, can be defined as a tumour composed of a collection of immune cells, mainly macrophages.11 In the case of foreign body granulomas, macrophages are activated and fused into multinucleated giant cells12,13 via non-allergic reactions that occur six to 24 months after filler injections.14-16 Given the lumps were early complications for this patient, coupled with the relative rarity of occurrence, the diagnosis of cystic granuloma was excluded.

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risk of infection so therefore do not advise them to massage. I personally massage the area after injecting the filler as I know the right pressure and technique. The uneven lumps had occurred immediately after treatment, their visual appearance and the probability of an HA-related granuloma being so low, it was reasonable to explore treatment as HA-based filler nodules.

The patient went to visit a local beautician who attempted to squeeze the lumps out through incisions to the upper and lower lips

Step three: action taken 1500 units of hyaluronidase was reconstituted with 10ml of bacteriostatic saline. A patch test was administered to the patient’s arm using 10 units of solution with no adverse reaction.

Then, 2ml of the dilution was injected into the nodules via 10 unit bolus injections using a 25 gauge insulin syringe into the upper and lower lip, massaging at the same time. After one hour the patient felt more movement in her lips and the nodules had decreased in size. She was advised to return in two weeks’ time for a follow up.

The two-week follow-up consultation concluded the successful treatment of the incorrect filler procedure and associated infection. The patient did not present inflammation or pain to her lips. Her lips were even and soft to touch. The patient’s desired result of undoing the filler revision was fulfilled and as a result she felt healthy and confident in herself (Figure 5).

Summary This paper has concentrated on the differential diagnosis of nodules consequent from dermal filler injection. Although neither dermal filler granulomas nor delayed hypersensitivity were present with this patient, it is important that the aesthetic injector is fastidious in minimising the conditions that predispose their formation.

Dermal filler-related granulomas may be prevented by meticulous cleansing and disinfecting of the skin, sterile injection technique (avoiding injection through any nasal or oral mucosa), prophylactic antibiotics, as well as using smaller gauge needles to minimise trauma and access for bacteria.28 Patients should be advised to avoid makeup immediately before and after injection. For more information on the risk of infection from makeup, you can read

aestheticsjournal.com

Case Study Infection and Nodules

‘Special Feature: Make-up Post Procedure’ on the Aesthetics website.29 Overcorrection with dermal filler, injecting too large a volume of the wrong type of filler for the tissue type, and lack of even redistribution of the filler due to lack of massage, should be avoided. Correct injection technique with placement of needle at the appropriate depth before injecting and discontinuing injecting before retraction of the needle is recommended.28 Counselling the patient and adopting preventative measures such as appropriate filler choice and prevention of infection should be an integral part of any treatment using dermal filler injections.

Patient consent, education and adequate follow-up support should be fundamental throughout the entire consultation process.

Alice Henshaw is an aesthetic nurse prescriber and founder of Harley Street Injectables in London. She completed her bachelor’s degree in Auckland New Zealand and worked as a cardiac nurse before moving to the UK. Henshaw then completed her master’s in London and worked at numerous cosmetic clinics, before opening her own practice on Harley Street.

Qual: BHSc, PGcert, RN REFERENCES 1. Pavicic, T. and Funt, D., 2013. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clinical, Cosmetic and Investigational Dermatology, (6), pp.295-316. <https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3865975/>.

2. Cybulska, B. (2016) ‘Granuloma Management’. Aesthetics Journal, 3 (4) pp. 32-25.

3. Lee, JM., and Kim, YJ. (2015) ‘Foreign Body Granulomas after the use of dermal fillers: pathophysiology, clinical appearance, histologic features, and treatment’. Archives of Plastic Surgery, 42, pp.232-239.

4. Kang, BS., Na, YC., and Jin, YW. (2012) ‘Comparison of the wound healing effect of cellulose and gelatin: an in vivo study’. Archives of Plastic Surgery, 39, pp.317–321.

5. Mioton, LM., Jordan SW., Hanwright, PJ., Bilimoria, KY., Kim, JY. (2013) ‘The relationship between preoperative wound classification and postoperative infection: a multi-institutional analysis of 15,289 patients’. Archives of Plastic Surgery, 40, pp.522–529.

6. De Boulle, K. (2004) ‘Management of Complications After Implantation of Fillers’. Journal of Cosmetic Dermatology, 3:2, pp.15.

7. Lemperle, G., and Duffy, DM. (2006) ‘Treatment Options for Dermal Filler Complications’. Aesthetic Surgery Journal, 26, pp.356–364.

8. Sclafani, AP., Fagien, S. (2009) ‘Treatment of Injectable Soft Tissue Filler Complications’. Dermatology Surgery. 35, pp.1672–1680.

9. DeLOrenzi, C. (2013) ‘Complications of Injectable Fillers’. Aesthetics Surgery Journal, 1(35), pp. 575.

10. Lee ,JM., Kim, YJ. (2015) ‘Foreign body granulomas after the use of dermal fillers: pathophysiology, clinical appearance, histologic features, and treatment’. Archives of Plastic Surgery. 42, pp. 232–239.

11. Boros, DL., and Truden, JL. (1985) ‘Collagenase, elastase, and nonspecific protease production by vigorous or immunomodulated liver granulomas and granuloma macrophages/eosinophils of S mansoni-infected mice. <https://www.ncbi.nlm.nih.gov/pubmed/2996360> 12. Murphy, KM., Travers, P., and Walport, M. (2008) ‘Janeway’s immunobiology’. New York: Garland Science.

13. Farber, JL, and Rubin, E. (1999) ‘Pathology and Review of Pathology’. Philadelphia: LippincottRaven.

14. Gauthier-Hazan, N., Lemperle, G., Wolters, M, et al. (1863) ‘Foreign body granulomas after all injectable dermal fillers: part 1. Possible causes’. Plastic Reconstructive Surgery. 123, pp.1842–1863.

15. Williams, GT, and Williams, WJ. (1983) ‘Granulomatous inflammation: a review’. Journal of Clinical Pathology. 36,pp.723–733.

16. Gauthier-Hazan, N and Lemperle, G. (2009) ‘Foreign body granulomas after all injectable dermal fillers: part 2. Treatment options’. Plastic Reconstructive Surgery. 123 pp.1864–1873.

17. Cerroni, L, Christensen, L, Kutzner, H, Requena, L, Requena C, and Zimmermann, U,. (2011) ‘Adverse reactions to injectable soft tissue fillers’. Journal of the American Academy of Dermatology. 1, pp.34.

18. Pollack, SV. (1999) ‘Some new injectable dermal filler materials: Hylaform, Restylane and Artecoll’.

Journal of Cutaneous Medical Surgery. 4, pp.527-32.

19. Barbucci, R., Lamponi, S., Magnani, A., and Renier, D. (1998) ‘The influence of molecular weight on the biological activity of heparin like sulphated hyaluronic acids’. Biomaterials. 19, pp.801-6.

20. Hedner, U, and Pandolfi, M. (1994) ‘The effect of sodium hyaluronate and sodium chondroitin sulphate on the coagulation system in vitro’. Ophthalmology, 91, pp.864-6.

21. Ahn, D., Jeong, H., Kim, J and Suh, I. (2014) ‘Treatment Algorithm of Complications after Filler Injection: Based on Wound Healing Process’. Journal of Korean Medical Science. 29:3. ppS176–S182.

22. Bhatia, AC and Cohen, JL. (2009) ‘The role of topical vitamin K oxide gel in the resolution of postprocedural purpura’. Journal of Drugs and Dermatology. 8, pp.1020–1024.

23. Gauthier-Hazan, N., Lemperle, G and Rullan, PP. (2006) ‘Avoiding and treating dermal filler complications’. Plastic Reconstructive Surgery. 118, pp.92s–107s.

24. Duffy, DM, and Lemperle, G. (2006) ‘Treatment options for dermal filler complications’. Aesthetic Surgery Journal. 26, pp.356–364.

25. Fagien, S and Sclafani, AP. (2009) ‘Treatment of injectable soft tissue filler complications’.

Dermatologic Surgery. 35, pp.1672–1680.

26. Alam, M, and Dover, JS. (2017) ‘Management of complications and sequelae with temporary injectable fillers’. Plastic Reconstructive Surgery. 120, pp.98s–105s.

27. Cheng LY, Sun XM, Tang MY, Jin R, Cui WG, Zhang YG. An update review on recent skin fillers. Plast Aesthet Res 2016;3:92-99. http://dx.doi.org/10.20517/2347-9264.2015.124 28. Cybulska, B. (2016) ‘Granuloma Management’. Aesthetics, 3 (4) pp. 32-25.

29. Kilgariff S, (2019) ‘Special Feature: Make-up Post Procedure ‘, Aesthetics <https://aestheticsjournal. com/feature/makeup-post-procedure>

Aesthetics | June 2020

49

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Understanding Paradoxical Hair Growth Dr Ingrid Wilson explores the occurrence of paradoxical hair growth as an adverse event following laser and light treatment The use of energy-based devices such as lasers and intense pulsed light (IPL) has become increasingly popular for the treatment of unwanted body hair. However, as the use of these devices for hair removal have become more widely used, spontaneous reports of the perception of increased hair growth at sites around previous hair removal has been noted. This rare but notable adverse effect is known as paradoxical hypertrichosis. It was first described in the literature in 2002 following IPL therapy1 and can cause great distress to patients.2,3

Clinical Focus Hair Growth at 10-12 week intervals over a course of seven treatments. After 10 years, the area of paradoxical hair growth was sparser compared to immediately post treatment, however it remained denser compared to pre-treatment.6 Hypertrichosis is reportedly less common in African-American patients (skin type VI) due to their tendency to have coarse (non-vellus) facial hair.9 A retrospective study published in 2005 to review the prevalence and features of the paradoxical effect included all patients who underwent laser hair removal with a long-pulsed alexandrite laser (755 nm) at a certain practice in the US during a four-year period.10 Patients with post-laser hypertrichosis (p=489) were compared with 50 randomly selected patients who had undergone laser hair removal. Of the 489 patients, three (0.6%, 95% confidence interval: 0.01-1.9%) reported increased hair after laser hair epilation. There was a trend for this adverse effect to occur in darker skin phototypes (IV) and with black hair as compared with the unaffected comparison group (n=50). However, due to the small number of cases (n=3) researchers could not adequately test factors such as age, sex, treatment settings, and number of treatments statistically.10 Hypertrichosis has also been recognised with IPL use.11 A study of 991 hirsute women treated with a multifunctional laser and IPL system found that paradoxical hypertrichosis and terminal hair changes were detected after a few sessions of IPL therapy among 51 patients.12 In another study, 1,000 patients were treated with one IPL system, in which paradoxical hypertrichosis was recorded in 12 cases. In the same study using a different IPL system, 1,541 patients were treated and hypertrichosis was recorded in 79 cases.13

Why does it happen?

Definitions and occurrence Hypertrichosis is a condition in which the hair is longer and denser than what is considered normal for an individual based on their age, sex, ethnicity and location of the body and can be classified based on its distribution (generalised vs. localised), age of onset (congenital vs. acquired) and type of hair (lanugo or vellus vs. terminal).4 While the incidence of paradoxical hypertrichosis ranges from 0.6% to 5.1%,5 its exact prevalence is unknown and it is believed to be underreported.6 It appears to occur with low fluences and has been noted in all laser types, such as diode, Nd:YAG and alexandrite lasers, as well as IPLs. According to the literature, alexandrite laser (755 nm) and IPL (590-1200 nm) devices have the highest incidence.1,7,8 Paradoxical hypertrichosis most commonly occurs on the face and the neck2,5 and it has been suggested that individuals with darker skin types (III-V) with dark, thick hair and underlying hormonal conditions may be at increased risk of experiencing the condition.5 Although, one case has been reported in the literature of a Fitzpatrick skin type II male aged 21. He was treated with an Alexandrite 755 nm laser set between 20 and 22J/cm2 Aesthetics | June 2020

The exact mechanism of action remains unknown, but it is speculated that low fluences can stimulate the transformation of vellus hairs into darker terminal hairs. In many studies, the explanation for increased hair growth with laser ablation is that suboptimal thermal energy is delivered to nearby follicles which results in induction of the hair follicle cycle.14,15 It does make sense that hypertrichosis can occur after laser or IPL hair removal because low level laser therapy (LLLT) is used in treating hair loss. Red or near infrared laser light can promote tissue repair and regeneration,16 and LLLT 51

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stimulates cellular activity. Home-use LLLT devices that emit low power coherent monochromatic red light have been developed for various skin conditions, including hair growth,17 particularly androgenetic alopecia. The majority of studies covered in a 2015 systematic review found an overall improvement in hair regrowth, thickness, and patient satisfaction following LLLT therapy.18 A group of researchers observed the transformation of small vellus hairs into larger terminal hairs upon low fluence diode laser treatment and named this phenomenon ‘terminalisation’ of vellus hair follicles.7,19 Another group of researchers suggested that although

Individuals with darker skin types (III-V) with dark, thick hair and underlying hormonal conditions may be at increased risk of experiencing the condition

the heat produced by laser or IPL is less than the temperature necessary for thermolysis of the hair follicle, this heat may be sufficient to induce follicular stem cell proliferation and differentiation by increasing the level of heat shock proteins (HSPs) such as HSP27, which plays a role in regulation of cell growth and differentiation.20 Sub-therapeutic injury caused by the laser or IPL could also result in the release of certain factors which could potentially induce follicular angiogenesis and affect the cell cycling.21 Sunlight has also been identified as having a tendency to induce hypertrichosis, and agents such as psoralens and porphyrins have been reported to potentiate it, so it would be prudent to avoid.5

How can paradoxical hypertrichosis be avoided?

If treatment is going ahead, the best advice is to warn patients, particularly with skin phototypes III-V of their increased risk and include it in your consent forms. However, the only real way to completely avoid the potential occurrence of paradoxical hypertrichosis is not to treat with laser or IPL devices, especially using low fluences in skin types III-V, or to suggest alternative treatments.

Traditional hair removal techniques such as shaving, waxing and chemical depilation might be good options. Electrolysis is an option for those who are high risk and seeking permanent hair removal. For those wanting permanent hair reduction, the use of higher fluence lasers in correctly selected patients might be an option to consider. Another consideration is eflornithine 13.9% cream, sold under the brand name Vaniqa. It is a topical treatment

aestheticsjournal.com

Clinical Focus Hair Growth

that acts to reduce the rate of hair growth and appears to be effective for unwanted facial hair on the moustache and chin area.22,23 It does not remove the hairs, but there have been good results when used in combination with other treatments such as lasers and IPL to give the patient the best chance for successful hair removal.22,23

Summary Paradoxical hypertrichosis is a rare, but notable adverse effect that can occur following laser or IPL treatments. Careful selection of patients is required for avoidance, particularly skin types III-V with low fluence devices. Practitioners should consider alternative treatment approaches if they believe their patient might be high risk and carefully consult their patients on this potential eventuality.

Dr Ingrid Wilson became a GP in 1999, is on the specialist register for Public Health Medicine and is a Fellow of the Faculty of Public Health. She has a Level 7 BTEC in Laser and Associated Light Therapy and is qualified in electrolysis for hair removal with VTCT and Sterex. Dr Wilson is the director for Crewe Hair & Skin Clinic.

Qual: MB ChB, BSc(Hons) MPH FFPH REFERENCES 1. Moreno Arias G, Castelo Branco C, Ferrando J. Paradoxical effect after IPL photoepilation. Dermatol Surg 2002; 28(11):1013–1016.

2. Alajlan A, Shapiro J, Rivers JK, et al. Paradoxical hypertrichosis after laser epilation. J Am Acad Dermatol 2005;53:85–8.

3. Hirsch RJ, Farinelli WA, Laughlin SA, et al. Hair removal induced by laser hair removal. Lasers Surg Med 2003;32 (Suppl 15):63.

4. Michalik D; Whittington C; Bednarek R; Marks K. Localized hypertrichosis of intermammary cleft in monozygotic twins. Pediatric Dermatology. 35(3):e178-e179, 2018 May. 5. Desai S. Mahmoud BH. Bhatia AC. Hamzavi IH. Paradoxical hypertrichosis after laser therapy: a review. Dermatologic Surgery. 36(3):291-8, 2010 Mar. 6. Honeybrook A; Crossing T; Bernstein E; Bloom J; Woodward J. Long-term outcome of a patient with paradoxical hypertrichosis after laser epilation. Journal of Cosmetic & Laser Therapy. 20(3):179-183, 2018 Jun. 7. Bouzari N, Firooz AR. Lasers may induce terminal hair growth. Dermatol Surg 2006; 32(3):460.

8. Sophia Rangwala AB, Rashid M Rashid MD PhD, Alopecia: A review of laser and light therapies, Dermatology Online Journal 18 (2): 32012.

9. Ethnic Dermatology Principles and Practice. Edited by Opheliz Dadzie, Antoine Petit and Andrew F Alexis. Chapter 18. Lasers and the ethnic patient . Heather Woolery-Lloyd and Kristian Figueras p269 10. Alajlan A, Shapiro J, Rivers JK, MacDonald N, Wiggin J, Lui H.Paradoxical hypertrichosis after laser epilation. J Am Acad Dermatol. 2005 Jul;53(1):85-8.

11. Vlachos SP, Kontoes PP. Development of terminal hair following skin lesion treatments with an intense pulsed light source. Aesth Plast Surg 2002;26:303–7.

12. Radmanesh M. Paradoxical hypertrichosis and terminal hair change after intense pulsed light hair removal therapy. Journal of Dermatological Treatment. 20(1):52-4, 2009.

13. Radmanesh M; Azar-Beig M; Abtahian A; Naderi AH. Burning, paradoxical hypertrichosis, leukotrichia and folliculitis are four major complications of intense pulsed light hair removal therapy. Journal of Dermatological Treatment. 19(6):360-3, 2008.

14. Bukhari IA. Pili bigemini and terminal hair growth induced by low-fluence alexandrite laser hair removal. J Cutan Med Surg 2006;10:96-8.

15. Lolis MS, Marmur ES. Paradoxical effects of hair removal systems: A review. J Cosmet Dermatol 2006;5:274-6.

16. Schindl A, Schindl M, Pernerstorfer Schon H, Schindl L. Low intensity laser therapy: A review. J Investig Med 2000; 48(5):312–326.

17. Metelitsa AI, Green JB. Home use laser and light devices for the skin: An update. Semin Cutan Med Surg 2011; 30(3):144–147.

18. Wouter P,. Kluijfhout MSc ,Joaquin J. Jimenez MD. Low level laser therapy as a treatment for androgenetic alopeciaLasers in Surgery and . Medicine. 49:27–39, 2017.

19. Bernstein EF. Hair growth induced by diode laser treatment. Dermatol Surg 2005; 31(5):584–586.

20. Wikramanayake TC, Rodriguez R, Choudhary S, Mauro LM, Nouri K, Schachner LA, Jimenez JJ. Effects of the Lexington LaserComb on hair regrowth in the C3H/HeJ mouse model of alopecia areata. Lasers Med Sci 2012; 27(2):431–436.

21. Bouzari N, Firooz AR. Lasers may induce terminal hair growth. Dermatol Surg 2006; 32(3):460.

22. Zahoor H; Noor SM; Paracha MM. Combination of Intense Pulse Light and Topical Eflornithine Therapy versus Intense Pulse Light Therapy al Adjuvant eflornithine to maintain IPL-induced hair reduction in women with facial hirsutism: a randomized controlled trial.one in the Treatment of Idiopathic Facial Hirsutism: A Randomized Controlled Trial.- Journal of the Pakistan Medical Association. 69(7):930-933, 2019 Jul. 23. Vissing, A C; Taudorf, E H; Haak, C S; Philipsen, P A; Haedersdal, M. Using Eflornithine is useful for maintaining results of IPL hair removal Journal of the European Academy of Dermatology & Venereology. 30(2):314-9, 2016 Feb.

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Case Study: Lip Filler Vascular Occlusion Nurse prescriber Lynn Lowery explores the management of a vascular occlusion As an independent nurse prescriber, I have been treating aesthetic patients since 2008. In December 2017, over the Christmas period, I was contacted by a local nurse practitioner who had several years’ experience in injectables. The practitioner had treated a patient’s lips with a hyaluronic acid (HA) filler 24 hours’ prior and needed help managing a vascular occlusion.

Patient history This was the 44-year-old female patient’s first lip filler treatment. Following aspiration, she was injected with 1ml in total, using a linear thread technique with a needle. At the time of the injection, the patient developed a bruise to the lip, but the practitioner stated that it didn’t appear to have any signs of vascular compromise, such as pain, discolouration or reduced capillary refill time.1 The practitioner was confident that all was fine and discharged the patient.

Three hours post injection on December 23, the patient contacted the practitioner to say she had developed a discolouration to the skin above her lip. The patient was advised that she may have a complication and to come straight back into the clinic so that the practitioner could review the patient. As well as the discolouration, the practitioner noted reduced capillary refill time and increased pain to the area, so concluded that the patient had a vascular occlusion and that the filler needed to be urgently removed.2 The treating practitioner used hyaluronidase at a dilution of 1500 units reconstituted with 10ml saline and administered approximately 450 units to the area. The patient was then discharged, and advised to take aspirin 75mg daily. The following morning, on December 24, the patient came back for a review. The vascular occlusion was still evident, so the treatment was repeated using the same dose of hyaluronidase, which had been stored overnight in the fridge.

Patient presentation to my clinic On the same day, the treating practitioner called me to assist as the patient was still not showing signs of improvement. I reviewed the patient at 1pm on the same day, accompanied by the treating practitioner. The patient presented with bruising and discolouration to the skin (Figure 1) and described her pain as a dull ache to the left side of the face, including the eye and radiating to the ear. Her capillary refill time at the area of injection and the surrounding tissue, including the nose tip, was five to six seconds. After a through consultation and consent with myself and the treating practitioner, it was felt by both of us that the vascular occlusion was not successfully managed. The patient was still suffering from the common symptoms of occlusion, and had also developed livedo reticularis.1 This arises from altered blood flow in the skin’s microcirculation; the dermal filler reduces the flow of fresh arterial blood, causing a collection of venous blood which appears as a purple discolouration.3

Figure 1: Patient 24 hours after HA injection to the lip presenting with livedo reticularis4

Figure 2: Patient 48 hours after HA injection, following hyaluronidase treatment in my clinic

Case Study Lip VO

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The patient was happy to go ahead with hyaluronidase treatment to the vascular occlusion under my care.

Complication management The patient was administered a stat dose of aspirin 300mg to manage any coagulation around the occlusion.1 A treatment protocol of 1500 units hyaluronidase diluted in 2.5ml of normal saline was then used.1,5-7 A TSK 25 gauge 38mm cannula was inserted into the entry point at the oral commissure and the occlusion was approached from 1cm superior to the nasolabial fold. I used 1.5ml of the solution via the cannula to the deep subcutaneous tissue, then injected the remaining 1ml via needle to the lip and over the superior labial artery. The patient was advised to undergo warm compressions and massage to the occluded areas for the next six hours whilst at home.1 She was given a prescription for lansoprazole 15mg daily, aspirin 75mg daily and ciprofloxacin 500mg twice a day for seven days.1 Despite it being Christmas, a review was planned for the following day.8 Unfortunately, on December 25, the patient was still suffering from discomfort and tenderness to the whole left side of her face, including an ache to the gums, teeth and eye, and was having difficult eating and drinking (Figure 2). The capillary refill was still delayed, so the protocol was repeated from the previous day – 1500 units in 2.5ml via needle and cannula. I was still not confident that the occlusion was clearing, and a review was planned for the following day (December 26), where the patient again presented with the same symptoms (Figure 3). Again, the same protocol was repeated for a third time – 1500 units in 2.5ml was flooded throughout the occlusion with particular attention to the upper gingival tissue within the oral cavity.

At this stage, I added a prescription for Aciclovir 200mgs five times a day for five days as the patient regularly suffers from

Figure 3: Three days after initial filler treatment. Patient displaying with discolouration and skin breakdown due to cellular tissue death

Aesthetics | June 2020

Figure 4: Patient four days after original filler treatment, showing improved tissue reperfusion

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Case Study Lip VO

Summary

Figure 5: Patient five days after original filler treatment showing tissue repulsed and healing evident of the tissue breakdown

Figure 6: Patient after hyaluronidase treatments and hyperbaric oxygen chamber session seven days after original filler treatment

herpes and she could feel it developing.1,9 Later that day, the patient contacted stating that the ache to the face was beginning to subside. I booked another review for the next day on December 27, and when she arrived she was beginning to feel the improvement.

The pain and aching had reduced, the tissue reperfusion was markedly improved and she felt able to drink better (Figure 4). The following day, on December 28, the patient sent over her own picture for me to review, which showed further improvement in the tissue perfusion and healing (Figure 5). I arranged for the patient to have a one hour 30-minute session in the local hyperbaric oxygen chamber on December 28 and the result can be seen in Figure 6. Note that ideally this treatment would have been arranged earlier, if not for the Christmas holidays. The patient was able to make a full recovery, with reversal of the occlusion and successful tissue repercussion after six days.

The effect of the treatment to the surrounding tissue took many weeks to fully improve.

• Hyaluronidase storage and stock: the treating practitioner only had 1500 units of hyaluronidase on site, and with it being a difficult time of year to get stock, it could be why they chose to use a lower dilution and dose, as well as store the solution overnight and use the next day. Guidelines advise that hyaluronidase should be discarded if it is not used as it may impact the effectiveness of the drug, so should be avoided.7,10,11 Practitioners should also bear in mind that more than 1500 hyaluronidase is often needed in an emergency situation, so should consider stocking more on site.

• Treatment before holidays: treatment during big holidays, such as the Christmas period, can make it more difficult to manage a complication – pharmacies are closed, patients don’t want to hang around in clinic and everyone is harder to get hold of if you need advice. The hyperbaric oxygen chamber was closed during this time, causing a delay in this treatment.

Practitioners should consider whether they want to treat before an event such as Christmas, or if they need to have backup stock in clinic. I know of some practitioners who stop treating two weeks before Christmas, so perhaps this could be considered.

• Patient trust: as the patient needed to be seen by another practitioner to manage the complication, the patient lost trust in that practitioner, not returning to them again for further treatment. In my experience, being able to appropriately manage the patient at this time can actually increase their trust, rather than lose it as they feel confident in your clinical care.

• Know best practice guidelines: have an awareness of practice guidelines from groups such as the Aesthetic Complications Expert (ACE) Group5 as well as the latest clinical studies in this area.

Discussion Dealing with a complication is one of the most difficult experiences we face as practitioners and all should undergo training in recognising complications and their management. This particular case study highlights several learning points and considerations: • Hyaluronidase dilution: a dilution of 1500 units reconstituted with 2.5ml of saline is recommended to be used in emergency situations, so the first treatment that used 10ml of saline was very likely to be too diluted to have an effect.1,5,6,7 This would likely have contributed to the need for so many repeated hyaluronidase treatments in this case.

• Hyaluronidase dosage: it is recommended that high doses should be used in emergency vascular events.1,5 However, lower doses were first used in this case, which may also have prolonged the complication.

Aesthetics | June 2020

Practitioners need to be responsible for their own education and develop a programme for themselves to continue to learn within the aesthetics field so they are prepared for emergency events. This may include attending conferences, training events and reading industry publications. Always be connected to colleagues and industry associations who can assist you should you need additional support. It is important to have a structured plan in place so that you know what you need to do in the event of a vascular occlusion. Always listen to your patient in regards to the symptoms they feel during the complication, especially pain and discomfort as these are the greatest indication that things are improving.

For more information on the evidence behind hyperbaric oxygen therapy and to earn a CPD point, turn to p.25.

Lynn Lowery is an independent nurse prescriber with more than 10 years’ experience in medical aesthetics. She has been a registered nurse for more than 20 years and remains dual-qualified as a paramedic. Lowery has been an Allergan and Merz trainer and is currently a mentor for Northumbria University.

Qual: NIP, paramedic, Pg Cert in Aesthetics REFERENCES 1. King M et al, Management of a Vascular Occlusion Associated with Cosmetic Injections, J Clin Aesthet Dermatol. 2020 Jan; 13(1): E53–E58. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7028373/> 2. Chang, S.H. (2016) ‘External Compression Versus Intravascular Injection: A Mechanistic Animal 3. Gaafar Ragab et al., Three patterns of cutaneous involvement in Granulomatosis with polyangiitis, Journal of Advanced Research ( IF 5.045 ) Pub Date : 2020-05-07.

4. Thomas von Arx et al., The Face – A Vascular Perspective, Swiss Dental Journal SSO 128: 382–392 (2018). <https://www. swissdentaljournal.org/fileadmin/upload_sso/2_Zahnaerzte/2_ SDJ/SDJ_2018/SDJ_5_2018/SDJ_2018-05_research.pdf> 5. ACE Group, Guidelines. <http://acegroup.online/guidelines/> 6. De Lorenzi, C. (2017) ‘New High Dose Pulsed Hyaluronidase Protocol for Hyaluronic Acid Filler Vascular Adverse Events’, Aesthetic Surgery Journal, pp 1-12.

7. King M, Convery C, Davies E. This month’s guideline: the use of hyaluronidase in aesthetic Practice (v2.4). J Clin Aesthet Dermatol. 2018;11(6):E61–E68.

8. DeLorenzi, C. (2014) ‘Complications of Injectable Fillers, Part 2: Vascular Complications’, 9. King, M, This month’s guideline: Management of Necrosis, J Clin Aesthet Dermatol. 2018 Jul; 11(7): E53–E57.

10. Hyalase 1500 I.U. Powder for Solution for Injection/Infusion or Hyaluronidase 1500 I.U. Powder for Solution for Injection/ Infusion. <https://www.medicines.org.uk/emc/product/1505/ smpc> 11. PACKAGE LEAFLET: INFORMATION FOR THE USER Hyaluronidase 1500 I.U. Powder for Solution for Injection/ Infusion. <https://www.medicines.org.uk/emc/files/pil.1505.pdf>

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Clinical Papers Abstracts

A summary of the latest clinical studies Title: COVID-19 Pandemic: Consensus Guidelines for Preferred Practices in an Aesthetic Clinic Authors: KM Kapoor, et al.

Published: Dermatologic Therapy, May 2020 Keywords: COVID-19, Coronavirus, infection control, aesthetic clinic Abstract: Strict infection control measures in response to the current COVID‐19 pandemic are expected to remain for an extended period. In aesthetic clinics, most procedures are provided on a one-to-one basis by the physician or therapist. In such a scenario, guidelines detailing the infection control measures for aesthetic clinics are of particular importance. An online meeting of an international group of experts in the field of aesthetic medicine, with experience in administration of an aesthetic clinic, was convened. The meeting aimed to provide a set of consensus guidelines to protect clinic staff and patients from SARS‐CoV‐2 infection. Consensus guidelines for ‘preferred practices’ were provided for scheduling of patients, patient evaluation and triaging, and for safety precautions about the different procedures. Procedures were categorized into low‐risk, moderate risk, and high‐risk based on the likelihood of transmission of SARS‐CoV‐2 virus from the patient to the treating physician or therapist. While not intended to be complete or exhaustive, these guidelines provide sound infection control measures for aesthetic practices. Since guidelines regarding safety measures and use of PPE may vary from country to country, the local guidelines should also be followed to prevent COVID‐19 infection in aesthetic clinics.

Title: Mitigation of Postsurgical Scars Using Lasers: A Review Authors: Artzi, Ofir et al.

Published: Plastic and Reconstructive Surgery - Global Open, April 2020 Keywords: Scars, post-surgery, lasers, wounds Abstract: Most postsurgical scars are considered esthetically and functionally acceptable. Currently, there is no definite consensus treatment for postsurgical scarring. The purpose of this review is to shed some light on the value of scar mitigation and the efficacy of different lasers employed on postsurgical wounds. A systematic literature review and computational analysis were conducted to identify relevant clinical articles that pertained to the use of lasers for mitigating postsurgical scars. Articles included the National Institutes of Health–National Center for Biotechnology Information–PubMed search and sources cited from relevant studies after 1995. Trials that attributed pre- and posttreatment scores of scar severity based on a verified scar evaluation scale were chosen. To adequately assess the efficacy of the modalities, the final scaled scar appearance scores were realigned and normalized to a standard scale for unbiased comparison. After filtering through a total of 124 studies, 14 relevant studies were isolated and thus included in the review. Studied lasers were as follows: Pulsed dye laser (PDL), carbon dioxide, diode, potassium titanyl phosphate (KTP), and erbium glass (Er-Glass) lasers. Treatment with lasers in the postsurgical wound healing phase is safe, effective, and advised in mitigation of pathologic scar formation.

Title: A Prospective Study on Safety, Complications and Satisfaction Analysis for Tear Trough Rejuvenation Using Hyaluronic Acid Dermal Fillers Authors: Diwan, Zoya et al.

Published: Plastic and Reconstructive Surgery - Global Open, April 2020 Keywords: Dermal filler, tear trough, periorbital Abstract: Tear trough (TT) treatment with hyaluronic acid soft tissue fillers is an increasingly popular aesthetic procedure. The traditional needle technique is cited many times in the literature with no studies looking at the results, complications and satisfaction rate with the use of the cannula device instead. The aims of this study are to describe the experience of 4 aesthetic doctors in the treatment of TT deformity and assess complications and side effects, overall satisfaction and improvement. Twenty-four patients were included (48 TTs) that fulfilled the inclusion and exclusion criteria and they were assessed over a 4-week period, looking at the complications, side effects, satisfaction rate, and others with the cannula technique for the medial TT. Twenty-two women and 2 men each had the medial TT filler supra-periosteally using a cannula device. They were all reviewed at the 2-week stage +/− the 4-week stage. 100% of patients noted an overall improvement to the TTs and 75% were satisfied with their results with the other 25% requiring further filler to be satisfied. There were no major complications and only a small number of minor side effects like mild bruising and swelling that lasted up to 4 weeks. TT treatment, if performed using a cannula with a maximum of 1ml used in one sitting between both eyes, according to this study, is a safe treatment with a very low pain rating and with no major complications and high patient satisfaction.

Title: The M.A.STE.R.S algorithm for acute visual loss management after facial filler injection Authors: Graue, G et al.

Published: Journal of Cosmetic Dermatology, April 2020 Keywords: Dermal fillers, vision loss, complications Abstract: Algorithm of treatment includes ocular physical Maneuvers, hyAluronidase administration, intravenous STEroids, intraocular pressure Reduction, and Supplemental Oxygen (M.A.STE .R.S) based on previous acute management reports. Special consideration for algorithm buildup was made for ophthalmic diseases that share physiopathological features such as central retinal artery occlusion, systemic vasculitis affecting vision, and acute glaucoma.

Finally, a systematic cross-review of the reported cases with visual loss was done to identify the level of evidence and grant a recommendation grade. A search through PubMed and Medscape databases for English-written scientific papers using the terms facial filler, retinal artery occlusion, management, treatment, complications, and adverse events quoted a total of 46 papers (190 cases) which were then analyzed. The proposed algorithm provides an initial guideline based on prior literature reports and physiopathology involving facial filler injection complications. Analysis identified 22 successfully treated cases with vision recovery (11.57%). Ocular physical maneuvers had the best evidence-based level and grade recommendation (A) for the management of acute vision loss secondary to facial filler injections.

Aesthetics | June 2020

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Spotlight On Emergency Helpline

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Spotlight On: ACE Group Emergency Helpline Aesthetics speaks to nurse prescribers Sharon King and Linda Mather about the world’s first and only emergency helpline for aesthetic complications

A need for help The Emergency Helpline was born out of need, King says, which was clearly identified after she performed an audit of the Group’s Facebook Forum. “We noticed a huge number of practitioners requesting help for dermal filler complications – at the time of audit we had 389 filler-related complications, with 207 relating solely to the lips alone and many of these were potential vascular occlusions.3 Although our forum is great for practitioners getting 60

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Patients also need to be consulted on the risks and how you will manage them appropriately, Mather says, noting, “As a call handler I have found that many patients have no idea what’s going on during their complication because they haven’t been consulted properly. This is really important not only for consent purposes, but so they understand the risks associated with treatment and how a complication will need to be handled if it arises.”

VASCULAR OCCLUSION EMERGENCY NUMBER

If you were to occlude a vessel while injecting your patient tomorrow, how would you deal with it? You need to be able to quickly diagnose the problem, have the necessary emergency equipment to hand, and undergo the step-by-step process for management. But would you know who to turn to for guidance if you needed a second opinion or assistance of any kind? At the end of 2018, the Aesthetic Complications Expert (ACE) Group set up the world’s first and only helpline dedicated to assisting practitioners who need immediate expert assistance to manage emergency complications.1,2 In this article, Aesthetics speaks to ACE Group co-founder and aesthetic nurse prescriber Sharon King, and ACE Group board member and aesthetic nurse prescriber Linda Mather, to learn more about the unique ACE Group Emergency Helpline, how it works and how practitioners can make the most of the service for optimum patient outcomes.

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together, sharing ideas and debating, it’s not ideal for what could be an emergency situation. A lot of people really needed to speak to somebody, and fast, and hence the helpline was born,” King explains.

Now, in a normal week, its call handlers receive around four to five emergency calls from its 4,000 plus members. Most calls are regarding suspected vascular occlusions following dermal filler injection, as well as delayed onset nodules and infections.

When should you call?

According to Mather, a vascular occlusion following dermal filler injection is the main emergency practitioners should be using the service for. However, she adds that many practitioners struggle with diagnosing a vascular occlusion. Mather says, “Of the calls we have had regarding suspected vascular occlusions, 25% have turned out to be bruising, while around 75% have been a confirmed occlusion. For anaphylaxis or visual impairment, practitioners should be dialling 999 and seeking urgent referral, not calling the helpline. Delayed onset nodules and infections are not normally ‘emergencies’, however, there are lot of really distressed and frightened practitioners out there who don’t know who else to call for help, so may call us. At the end of the day, because we are ultimately talking about patient safety, we will always be happy to support that practitioner so the patient can get the best treatment

Before you treat Mather and King first advise that before performing any aesthetic treatment, practitioners should be knowledgeable in diagnosing and managing Re-enacted examples of inappropriate images sent to the ACE Group call complications. handlers. Practitioners must remember the importance of clinical hygiene Mather highlights, and professionalism during these stressful situations.

“Before you go near a patient you should have complications outcome.” Therefore, King and Mather training and have a rehearsed plan set say practitioners should use their clinical out. Always have an emergency kit on the judgement on when it is appropriate to call. premises, and this should be stocked and King notes that in many cases, particularly ready.” King adds, “It’s amazing how many those that are not time sensitive, practitioners people don’t have a plan – when you are should refer to the ACE Group Guidelines working in a hospital environment you have before dialling the helpline.4 She says, “If plans for everything so you should do the it’s a delayed onset nodule or infection, for same in private practice. Your staff should example, that’s not absolutely time sensitive, also be trained and prepared to know what then you can refer to the guidelines – they to do if you need to start your complication should be easily accessible in the clinic. I process. Tell them where your emergency kit recommend putting them in the same place is and what they need to do to assist you.” as your emergency kit.”

Aesthetics | June 2020

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ACE Group Emergency Helpline call handlers5

Sharon King, aesthetic nurse prescriber

Linda Mather, aesthetic nurse prescriber

Dr Martyn King, aesthetic practitioner

Dr Lee Walker, aesthetic practitioner

Spotlight On Emergency Helpline of the complication and the state of the practitioner. Mather has written an article on p.63 about the psychological impact of causing a serious complication on the practitioner, as well as a dissertation for her Master’s. She says often practitioners will need support through this time, which she is happy to give. King and Mather encourage members to contact their call handler again should they need any further assistance.

“Sometimes the practitioner just needs to call back for advice on the best antibiotics to use in that circumstance, or skincare recommendations afterwards,” says King.

Things to bear in mind Dr Cormac Convery, aesthetic practitioner

Gillian Murray, prescribing pharmacist

Calling the helpline Practitioners need to be ACE Group members in order to access the helpline.

There is one number that will call through to seven call handlers, each with significant experience in managing aesthetic complications. Mather says, “One call handler will pick up the call and will usually hear a panicked practitioner at the end of the line saying they need help. We will firstly ask them to remain calm and take a breath because we need a concise and clear story of what’s happened. It can be really traumatic for the practitioner when something like this happens, but staying calm is really important.” Mather says that the call handler will then ask the practitioner to give their name and their phone number in case the call is cut off.

The practitioner should then go through what has happened in as much detail as possible. The call handler might ask when the procedure was carried out, the product used, how much, the injection technique and entry points, what concerns the patient is presenting with, what you saw and how the patient was feeling. For suspected vascular events, the call handler will also ask what the capillary refill time was before you started injecting and what it is now. Mather notes, “Don’t forget your hygiene standards in a vascular emergency. Wear gloves when you are pressing for capillary refill – I have seen numerous practitioners pressing on a patient’s newly injected lips with dirty finger nails!” King adds, “Following this, we will then ask to look at the patient via a video call through something like FaceTime or WhatsApp. The practitioner can show us

Emma Davies, aesthetic nurse prescriber

what is going on and we might ask them to send us photographs if the video quality isn’t very good. We will also ask for the patient’s name and use that while addressing them so that we can make them feel as comfortable as possible through this process.” King and Mather advise practitioners to consider image and video quality, taking note of the lighting and angles, as well as your internet connection. “Really think about the call handler trying to interpret what you are looking at to help them provide the best advice to you,” Mather says, adding, “Again, always stick to strict hygiene practices; I actually had one person take a picture of a patient sitting on the toilet, which is not ok.”

The call handler will then provide advice on what the practitioner should do to manage the situation. King highlights that the advice given is always related to evidence-based medicine and the ACE Guidelines that have been collated and published,4 as well as the call handler’s own experience. “At this time, we will either leave the call and let the practitioner implement our advice, or perhaps we might stay on the call and consult with them for the whole treatment, watching while they inject the hyaluronidase, for example,” King says, adding, “Sometimes it’s a matter of advising them to refer on to a specialist, such as an ophthalmologist for visual impairment or a plastic surgeon for wound management, as has happened in one particular case, or perhaps it’s just a bruise; in which case, we are no longer needed.”

Following the call

King and Mather encourage practitioners to ring during normal business hours if possible; however, they acknowledge that they have taken calls outside of this for genuine emergencies. Callers should be respectful of the call handler, and know that any breaches of professional standards could result in the call handler reporting them to the practitioner’s professional body. Patient consent must be obtained before sharing the patient’s information with the ACE Group. For example, Mather says, “My paperwork says that the patient consents to having their photos taken and stored safely, as well as that I may need to share the photos in the case of an emergency with a third party, so it should be in writing before the complication occurs.” Data sent electronically must also adhere to GDPR.2

Complication education King and Mather both say that if practitioners are treating patients, it’s not a matter of ‘if’ they will cause a complication one day, but ‘when’ and they need to be ready and prepared for this possible eventuality. In the ideal world, they say that practitioners would be so educated and prepared that there would be no need for the Emergency Helpline. However, even the best practitioners may seek guidance from their peers and the helpline is there to help direct practitioners to use the appropriate pathways.

REFERENCES 1. Aesthetics journal, ACE Group launches emergency helpline, December 2018. <https://aestheticsjournal.com/news/ ace-group-launches-emergency-helpline> 2. ACE Group Emergency Helpline Policy. <https://acegroup. online/policies/emergency-helpline-policy/> 3. News Special: Lip Filler Complications, Aesthetics January 2019, News Special: Lip Filler Complications <https://aestheticsjournal. com/feature/news-special-lip-filler-complications> 4. ACE Group Publications <https://aestheticsjournal.com/feature/ news-special-lip-filler-complications> 5. ACE Group board member profiles <https://acegroup.online/ about/>

Usually the call handler will follow up with the practitioner, depending on the severity Aesthetics | June 2020

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Understanding the Second Victim in Complications Aesthetic nurse prescriber Linda Mather explores the psychological concerns practitioners may face after causing an aesthetic complication and provides recommendations for overcoming them Adverse events (AE) occur within all healthcare settings. When an AE occurs, it can have a negative impact on the physical, psychological and the social wellbeing of the practitioner responsible, resulting in the healthcare practitioner (HCP) becoming the second victim (SV); the affected patient being the first victim. The term second victim was first established in a paper by Wu in 2000,1 but it was in subsequent work by Wu and other authors where detailed definitions of this phenomena began to appear.2-5 Scott (2009) described SVs as ‘healthcare providers who are involved in unanticipated adverse patient events such as medical error and/or patientrelated injury where the provider of care becomes traumatised by the event’.5 It is common knowledge that there is a rise in patients requesting and receiving nonsurgical cosmetic interventions and, subsequently, a rise in the number of adverse events.

Despite this rise there remains a paucity of published work that considers Second Victim Phenomenology (SVP). This I did not find surprising as there is little done to support SVs in other healthcare settings, despite the healthcare setting becoming the third victim when an AE occurs.6 Aesthetic procedures such as dermal fillers carry risks to patients. Although most practitioners may be extremely skilled and appropriately trained, they may still experience adverse events that can occur during or following a treatment episode.

This article aims to provide reference to the current literature, as well as to consider a small study undertaken for dissertation work in an attempt to better understand ‘second victimhood’ (SVH) and determine whether it exists within aesthetic practice. This may serve to forewarn and forearm future practitioners should they be faced with adversity in the form of a dermal filler related AE.

Adverse events and second victim in healthcare A review of the literature demonstrated the existence of SVH within healthcare settings, but no published material pertaining specifically to SVH within the context of aesthetics.

According to one paper by Conway et al. AEs occur daily within healthcare.7 Daniels and McCorkle discuss that despite the complexity of SVH, little is done to prepare HCPs on Aesthetics | June 2020

Mental Health Complication Management how to deal with it.6 Other safety critical disciplines such as pilots, fire fighters and the police however, receive education pertaining to the expected stressors of SVH. The complex feelings associated with SVH can cause the second victim to survive, thrive or drop out.2 Most of the literature that discusses AEs and SVH does not include direct quotes from participants, but rather, such as one study by Seyes et al., includes tabled results, demonstrating that feelings of guilt, psychological distress, fear and irritation scored highly in the aftermath of an AE.8 My interest in SVH evolved when I began supporting practitioners whom had experienced AEs. I noticed similarities in their emotional responses and felt that these responses required further investigation.

Therefore, I conducted a qualitative phenomenological study with ethics approval that aimed to answer the question, ‘What is the lived experience of an aesthetic practitioner following a dermal filler adverse event?’ A convenience sample was selected of eight experienced aesthetic practitioners, all of whom were female nurses, with the age range of late 20s to 60s. They had all experienced a significant AE whilst treating a patient, for example vascular occlusion (VO).

Scott et al. discussed that every SV has their own way of coping, but described a general six-stage recovery trajectory for SVs.5 These were used as parallels to my own findings from the eight aesthetic practitioners and are as follows: 1. Chaos and accident response. Here the participants within my study panicked and almost lost the ability to respond to the incident, before rallying themselves to deal with the incident in an appropriate manor.

2. Intrusive reflection characterised by ‘what if’ questions. Participants without exception questioned themselves as nurses and in fact as people.

3. Restoring personal integrity by looking for support to tell their experience or understand the impact on them personally and professionally.

Participants began to make sense of what had happened and the associated feelings that they were dealing with, and therefore sought out support and the means to reflect.

4. Enduring the inquisition from others and 63

Mental Health Complication Management wondering about the impact of their mistake. There were heart-breaking comments from the participants within this study who felt that they had lost credibility not only in the eyes of other practitioners but also from their families.

5. Obtaining emotional ‘first aid’.

Unanimously the participants looked for someone who understood what they were experiencing and could guide them forward.

6. Moving on or dropping out, surviving or thriving. All the participants, despite strongly wanting to drop out, managed to find a way through their trauma and not only survive, but they thrived and developed better practice because of it.

Second victim in aesthetics After collating the data from my eight participants, themes were drawn from the transcribed interviews. A very brief synopsis of the themes are outlined below.

1. Physical symptoms of the patient Physical symptoms of the patient became one of the first themes to emerge due to its importance to the participants. All participants discussed the presenting factors of the VO that they and their patient had experienced.

Participants described the visual signs of VO. One participant said, “It was going blacker before my eyes”, another described it as, “Oh my goodness, her lip is blue”, and a third said, “Her lip; it turned white”. Although I had not anticipated this theme, I believe it’s important to recognise it because although these three complications were VOs, they all described different presenting factors which may be confusing to new or inexperienced practitioners as they may not understand that the symptoms of a VO can present very differently. This in turn could result in to misdiagnosis, leading to inappropriate treatments and less than satisfactory patient outcomes.

2. Visceral feelings The participants were graphic in describing and recalling their initial feelings when they experienced a serious AE; these feelings had also ranked as high importance within the literature. One participant described it as, “One of the worst feelings of my entire life; I wanted to be sick”, while another said, “I actually felt like I had run somebody over.

That’s how bad I felt”, and another stated 64

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All of the participants discussed the impact of events as so overwhelming that they wanted to give up their aesthetic careers feeling, “Absolutely terrified – I was in a blind panic”. One participant went as far as describing feeling so panicked they felt as though they wanted to, “Throw themselves off a bridge”.

All the initial reactions described by the participants to a serious AE were strong visceral reactions. In highlighting this it may help to prepare practitioners for these negative and unsettling emotions that are experienced in the initial stages of experiencing an AE. Without exception, the participants all described a feeling of denial and this was documented as a sub theme, as was justification. Within this sub theme, many of participants attempted to justify what had happened by using words such as, “I was so busy, I was running from room to room,” or “I had used that product before and it had always been fine”.

3. Longer-term feelings Despite the participants experiencing negative emotions, going into denial and attempting to justify their actions, they each managed to take control of the situation and ensured that the patients made a full recovery. However, despite this, the participants described a subsequent wave of emotions that affected them in the longer term. They began to experience feelings of fear, blame, shame and guilt and these were unanimous within the study. These feelings sat alongside empathy for the patient that had suffered the AE. Each participant discussed negative feelings relating to delivering a treatment that should have enhanced the patient’s life in some way, but had ultimately led to harm.

4. Intellectualising The participants demonstrated resilience and emotional recovery unanimously.

Recovery occurred when they were allowed time to reflect. It was not addressed how much time was needed for this recovery. A paper by Chan et al. discussed two major coping strategies that could be employed Aesthetics | June 2020

in the aftermath of an AE. The first was problem-focused strategy, which involved developing constructive attitudes and behavioural changes, while the second was emotion-focused strategy.9 Emotionfocused strategy was employed by the participants wherein they managed their personal distress by accepting responsibility and implementing positive changes to their practice to reduce future error. They used problem-focused strategy wherein they constructed new ideas about their practice and adopted behavioural changes.

5. Lessons learnt Each participant had a plan of varying degree as to what they would do in the event of a significant AE. These plans ranged from ‘phone a friend’ to being fully rehearsed and ready; most of them having the Aesthetic Complications Expert (ACE) Group guidelines to hand and having read through these guidelines.11 Wu and Steckleberg discussed that the disclosure of adverse events is necessary if practitioners are to learn from mistakes and improve patient safety.4 Participants described not only feeling better after disclosure but also discussed changes they made to their practice following their experience. Without exception, the participants changed their consultation process. They also described tightening up on their documentation and ensuring full disclosure of potential risks and side effects to the patients. However, no matter how prepared they were, none of them felt prepared for the shock of feelings that they experienced.

6. Help and support Harrison et al. suggests that supporting clinicians in the aftermath of an AE may prevent future errors and SV burnout.10 In a web-based survey of 5,300 faculty members (898 surveys completed and returned) by Scott et al., it was found that organisational respite was the most frequent type of support desired by their participants.2

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They needed ‘time away’ to compose themselves and make sense of what had happened. However, participants within my study were unable to have any time out as they were lone workers with the pressure of appointments and had all of the financial issues associated with running a business.

This was considered an extra pressure by some of the participants.

It is unlikely that organisational respite within aesthetics would be possible as the majority of practitioners are dependent upon their earnings to support their lifestyle.

Participants discussed family and friends as being important for help and support, but conversely the participants were confounded by embarrassment at having to admit that they had ‘done something wrong’.

All but one of the participants discussed the ACE Group guidelines as a source of invaluable support,11 alongside having a knowledgeable and experienced colleague that they could access for counselling and help. I found it surprising that despite the current culture for practitioners to access support by social media, only one of the participants mentioned this, which demonstrated that the participants had access to direct support.

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numbness, detachment, depersonalisation, confusion, grief anxiety and depression.4 Aesthetic practitioners should always consider every aspect of the patient journey in an attempt to avoid an AE. The patient should be fully consented in line with governing body principles and practitioners should only carry out procedures that are within their sphere of competence using products that have excellent safety profiles based on clinical studies. Despite this though, AEs can still happen.

6. Going back to practice All of the participants discussed the impact of events as so overwhelming that they wanted to give up their aesthetic careers. Scott et al. demonstrated that 30% of their participants suffered anxiety and depression, questioned their own skills and wished to leave medicine.2 It was generally support from others that helped them through this stage of their experiences. Wu and Steckelberg discussed that interactions with other medical colleagues can be critical to the coping process and without this the practitioner may feel isolated.4 Participants in my study said that they had given prior consideration to what they would do in the event of a VO occurring and had rehearsed this circumstance. However, they went on to state that this did not prepare them for the shock that they experienced.

They agreed it would have been far worse without this preparation and felt that it was the support of others that enabled them to return to their practice and carry on.

• By accepting that things can and do go wrong, practitioners may be better prepared physically and mentally should an AE occur. Having a watertight plan of what to do and rehearsing can also go a long way to helping practitioners to look after their patient in this scenario.

• It can help to recognise that in the event of an AE you may feel shocked, upset and likely have a visceral reaction such as shaking and feeling faint. Accept that this is normal; forewarned is forearmed.

Some of the participants discussed having trained colleagues, whom they worked with, who could help in the case of an emergency. However, most practitioners work in isolation; if this is the case then make sure you have a colleague you can call, and have a backup number. Ensure your phone is to hand and always fully charged.

• Building relationships and accessing support was seen as paramount within this study. It helped the participants, in their time as SVs, to survive and thrive as opposed to dropping out.

• Develop a plan of care for YOU. We often fail to look after each other and ourselves, especially in the aftermath of an AE where we are likely to be crushed with blame, shame, guilt and self-doubt. Access clinical supervision whether you have suffered an AE or not. We have an obligation morally and professionally to ensure that we are mentally and physically fit for practice.

Although there is a paucity of published work considering clinical supervision within the specialism of aesthetic practice, we must remain aware of the importance of clinical supervision as aesthetic practitioners usually work in isolation.12

Discussion and recommendations

Summary

This small study suggests that SVH does exist within aesthetics and may be very similar to SVH within other healthcare disciplines, causing individuals to feel initial

There is very little data to demonstrate the number of AEs within aesthetics and certainly further data collection is required, as is further investigation into second Aesthetics | June 2020

Mental Health Complication Management victimhood within aesthetics. This study highlights that the physical presenting symptoms in the case of a VO are often different, and may occur in other types of AEs. It may also help to prepare practitioners for the very strong, very negative emotions that are experienced in the initial stages of an adverse event and how they can develop resilience.

Linda Mather is a registered general nurse and independent prescriber with more than 30 years’ experience within the NHS. Mather opened Chamonix clinic in 2008 and her second clinic a few years later.

In 2012 she developed the Northern Cosmetic Nurses Forum, which then became the regional branch of the BACN. Mather also runs her own aesthetic training company and is currently a board member of the ACE Group.

She also has an MSC in aesthetics.

Qual: RN, NIP, DIP HE, PG cert Ed, MSc aesthetics.

REFERENCES 1. Wu, AW. (2000) Medical error: the second victim. The doctor who makes the mistake needs help too. British Medical Journal. 320(7237) pp 726–727.

2. Scott, S., Hirschinger, L.E., Cox, K., McGoig,M.,Hahn-Cover,K.,Epperly,K.M., Phillips, R.N., Hall,L. (2010). Caring for Our Own: Deploying a Systemwide Second Victim Rapid Response Team. The Joint Commission of Quality and Patient Safety. Vol 36 No 5 pp. 233-240 3. Wu, A.W., Folkman, S., McPhee, S.J. (2003) Do House Officers learn from their mistakes? Qual Safe Health Care; 12 pp 221-227 4. Wu, A.W., & Steckelberg, R. Medical error, incident investigation and the second victim: doing better but feeling worse? British Medical Journal Qual Saf (2012). Vol 12 No 4 pp. 267-268.

5. Scott et al. The natural history of recovery for the health care provider “second Victim” after adverse patient events”. Qual Saf Health Care (2009) 18: pp 325-330.

6. Daniels,G., & McCorkle, R. (2016) Design of an Evidence-Based “Second Victim” Curriculum for Nurse Anetheticts. American Association of Nuse Anesthetists. Vol 84 No 2 pp107-113.

7. Conway, J., & Weingart, S (2009) cited in Wu. A.W., & Steckleberg, R. (2012). Leadership: Assuring respect and compassion to clinicians involved in medical error. Swiss Medical weekly.

139:3 8. Sayes, D., Wu, A.W., Van Gerven, E.,Vleugals, A., Euwema, M., Panella, M., Scott. S.D.,Conway. J., Sermeus, W., Vanhaecht, K. (2012). Health Care Professionals as Second Victims after Adverse Events: A Systematic Review. Evaluation & the Health Professionals. 36(2) pp.135-162 9. Chan S.T. Khong P.C.B., Wang.W. Psychological responses, coping and supporting needs of healthcare professionals as second victims. International Nursing Review (2016) 64 pp 242-262.

10. Harrison, R., Lawton, R., Perlo, J., Gardner, P., Armitage, G., Shapiro. (2015). Emotion and Coping in the Aftermath of Medical Error: A Cross-Country Exploration. Journal of Patient Safety.

Vol 11 No 1 pp. 28-34 11. ACE Group. (2019). <http://www.acegroup.online> 12. Greveson. K. (2018) Obtaining Support in Aesthetics. Aesthetics Journal. Vol 5 No 11 pp 64-65.

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1 + 2 OCTOBER 2020 | EXCEL LONDON, UK

The UK’s largest gathering of medical aesthetic practitioners

+120 Faculty 12 Brand Takeovers 15% Visitor Increase 23 Press Attendance

“

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5,873 Attendees

CCR is the largest conference in terms of medical education, corporate responsibility. There’s a lot of innovation happening here.

Nancy Ghattas, Associate Vice President Country Manager, Allergan

“

It’s so encouraging to see so much press interest at the show this year, not only their interest in aesthetic innovations but also in the general elevation and betterment of the industry as a whole in terms of safety and ethics too.

“

Dr Marwa Ali, Harrods Wellness Centre

Book your stand now www.ccrlondon.com

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In The Life Of Dr Tijion Esho

In The Life Of Dr Tijion Esho

Managing multiple clinics and media commitments in lockdown, while being a full-time dad My mornings start early…

I typically get up around 4:30am to join video conference calls with my team in Dubai. We opened the clinic in 2018 after I travelled to the country to see my partner, who was working there at the time. I learnt more about Dubai’s aesthetic market, which is fascinating and different to the UK, with treatments for dark tear troughs being very popular. I now spend a week every quarter seeing patients there. With COVID-19, I’m managing two time lapses of how the situation is developing in both Dubai and the UK. Then, about 6:30am my 18-month-old son Roman wakes. I sort breakfast and get him ready for the day, before making a start on my emails. One of my main focuses is speaking to the patients who were booked for treatment as part of the Esho Initiative. I set this up to offer corrective treatment free of charge to those who have congenital deformities, severe scarring or disfigurement from a life-changing incident. At the moment, some of these patients are particularly vulnerable as treatment has had to be put on hold.

After breakfast…

By 8am, it’s time for media calls. For example, after speaking to Aesthetics today, I have a call with my literacy agent to discuss the book I’m writing. Then it’s time to catch up with the TV producers; I’m currently the resident aesthetic doctor in the Channel 4 show Body Fixers, which I love, and we’re working on a spin-off show that follows me around my clinics.

We’d just started filming before lockdown was enforced, so we’re currently trying to figure out if it’s possible to maintain clinical standards, social distancing and filming when we reopen!

Next up will be a call with my podcast hosts; three doctors who also work in the media. We launched Steths, Drugs & Rock ‘n’ Roll to decipher fact from fiction when it comes to health, discuss the latest medical advancements and aim to entertain listeners with stories from our work.

A lot of work goes into planning topics, writing draft scripts and, of course, juggling everyone’s time to come together. I’m really

Afternoons consist of…

If I wasn’t a doctor…

I’d be a graphic designer! I’ve always loved art and design but my traditional Nigerian dad only had five careers in mind for me – medicine, dentistry, law, accounting or engineering. I’m glad I listened to him though – he saw my potential and your parents always know you best!

My hobby outside of medicine is…

Property investment and renovation.

I love the creative aspect of how you transform a home – one of my favourite TV programmes is The World’s Most Extraordinary Homes! proud of what we’ve achieved so far!

Being in the public eye means there is an expectation on you to ‘do good’ and you can be open to scrutiny. I’ve never seen this as a challenge as I’ve had that goal throughout my life. I grew up in a deprived area of North London and my parents, who moved to the UK from Nigeria, sacrificed a lot to help me get to where I am today.

Being a black person from an area where there were little career prospects made me recognise that it’s important not to waste any opportunities that come my way. I’m proud that I can use my media platforms to promote safe aesthetic practice and highlight the good work that is being done by many medically-qualified clinicians in the specialty.

Aesthetics | June 2020

Virtual consultations! I was lucky when lockdown hit as I am very used to doing virtual consults with my patients in Dubai, so I already had a system in place. Now I’m working with my UK clinic teams to get everything ready for reopening and using this time to figure out ways to improve processes and patient experiences.

Normally, I spend most of my time working from my London clinics in Harley Street and Wimbledon, with a long weekend in Newcastle once month, as well as of course my quarterly Dubai visits. I was doing a lot more travelling before my son was born, but when he came along I knew I needed to scale back as being a hands-on dad is really important to me.

Thankfully, I have a great team who could support with this. Clinic life for me involves seeing a lot of complications. I used to see one every three to four months, but now they make up a third of my list every day. Of course a lot of that comes from being known for corrective work through my media presence, however I believe that the growth of the industry and increasing regulation problems also have a big impact. In terms of preventing complications, I always say to practitioners don’t think you won’t experience them – you will. Just ensure you’re not taking any shortcuts with the treatments you offer; don’t compromise on the quality of products you use or the environment you practice in. It’s also helpful to be part of a peer group. Some practitioners want to hide away from complications they have experienced in fear of judgement from peers, however it’s important to understand that it’s okay to make mistakes, get the correct help and share what you’ve learnt in a safe environment.

My evenings are spent…

Checking the Government’s daily updates to see what applies to the clinics, before taking Roman for a walk and chilling out with my partner to find out how her day has been.

She’s a director at Price Waterhouse Cooper so is also very busy and passionate about her work – I love that about her and am proud of how we manage to integrate our lives, especially with a toddler!

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Update your clinic and discover the latest products from over 200 brands at CCR

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With many launches having been delayed this year, companies exhibiting at CCR will be showcasing the very latest never-before-seen aesthetic products on the market, including the newest treatments and cutting-edge aesthetic technologies.

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October, so that you can take advantage of the CCR show deals to replenish your much-needed supplies and to ensure your clinic is up-to-date for the Autumn/Winter season and leading into a successful 2021.

Below is a list of the companies you can meet at CCR on 1 & 2 October 2020 at ExCeL, London.

3D AESTHETICS B20 Launched in 2012, aesthetic device manufacturer 3D-lipo Ltd supply advanced, non-surgical systems to the aesthetics market. They specialise in multi-technology devices targeting fat loss, cellulite reduction, skin tightening, facial indications, vaginal rejuvenation, laser hair removal and tattoo removal. 3D-lipo is currently available in over 800 clinics in the UK. 3d-lipo.co.uk 4T MEDICAL LTD G12 supplies carefully selected cosmeceutical and medical aesthetic products that meet the highest manufacturing standards. The company, which is located near Cambridge, has built a solid reputation for providing competitively priced products and outstanding customer service. Training is available for all products. 4tmedical.com

3D Dermology Combines pulsed variable vacuum and skin rolling for the effective treatment of cellulite.

What the experts say...

‘As a Clinician I need to know that the treatments we offer are safe, effective, scientifically based and fit in with our ethos of holistic care for our clients.

Before

After

3D-Lipo has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd (Milton Keynes)

For further information or a demonstration call: 01788 550 440

www.3d-lipo.com www.3d-skintech.com

ABC LASERS F12, leaders in aesthetic/medical equipment and surgical systems, are sole distributors for Alma Lasers. ABC’s technological innovations, clinical expertise and in-depth understanding of practitioners’ needs led to the development of the multitechnology Harmony PRO platform, Soprano PLATINUM – the genuine pain-free hair removal laser – and Accent Prime Platform. abclasers.co.uk ADVANCED ESTHETIC SOLUTIONS D10 An award-winning company distributing face, body and laser platforms for the medical, cosmetic and beauty industry with realistic and affordable opportunities for results driven treatments. AES is derived from being at the forefront of cutting-edge excellence in medical and aesthetic technologies. The company is also sole UK distributor for innovative platforms and products Quanta System Lasers, Pollogen, Lipofirm Brand, NOON Aesthetics and Ready Medical. www.advancedestheticssolutions.co.uk AESTHETICSOURCE E10 provides world renowned clinically proven brands promoting Skin FitnessTM focusing on NeoStrata®, SkinTech®, RRS®, Exuviance® & XXtralash, with more to come. Our passion is for great customer service; supported by bespoke marketing materials, strong PR, thorough training and friendly, helpful knowledgeable staff. We are here to support your business. aestheticsource.com

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AGNES MEDICAL C32 AGNES MEDICAL was founded by Dr Ahn Gun Young with his 20 years of his knowledge and know-how of dermatology theory. We develop our device base on anatomical knowledge and provide our own protocols with a systematic training programme. agnesmedical.com ALFA MEDICAL H35 We, Alfa Medical, are a supplier of medical devices and beauty products. Our product range includes PDO / PLLA / P(LA/CL) threads with a needle, cannula and meso needles, HA Filler and cosmetics. We have CE, GMP, ISO and CPNP certifications. www.alfamedical.co.kr

TM

ALLERGAN E30 is a global pharmaceutical company that develops and manufactures branded pharmaceuticals, primarily focused on four key therapeutic areas: medical aesthetics, eye care, central nervous system and gastroenterology. Its medical aesthetics portfolio includes the Juvéderm range of facial fillers, botulinum toxin A and CoolSculpting for body contouring. allergan.co.uk

ALLIANCE PHARMACEUTICALS LTD G40A, together with KELO-COTE®, is delighted to support ACE 2020. The KELO-COTE® patented range of products includes a gel, spray and UV gel, which are used for the treatment and prevention of keloid and hypertrophic scars. alliancepharmaceuticals.com

BALDAN GROUP MEDICAL DIVISION B18 The Baldan Group boasts over 35 years of experience, brands that have been established on the market for more than 54 years and strong roots in marketing and innovative technologies, offering a digitally advanced product range. The Group’s experience has resulted in a new initiative geared towards the medical sector. www.baldangroupmedicaldivision.it/en/ medical-division/ BAPTT GROUP H41 Baptt Group is a dynamic team providing a design consultancy, manufacturing and shopfitting service covering the UK and Ireland. Established for over 35 years, we can demonstrate many reference sites specialising in the aesthetic clinic sector, pharmacy and specialised retail environments. www.baptt-group.com BEAUTY EXPERT KOREA D19 Beauty Expert Korea is one of the leading companies in the field of aesthetic science. Through the high performance of our R&D and investment, we bring new innovations onto the market with new demands. With all the effort we make on our working hours, our customers and partners now and in the future will be satisfied with great results. www.beautyexpertk.com BELLE (ADVANTECH SURGICAL LTD) E25 Advantech Surgical & Belle strives to deliver the most innovative products to the UK plastic surgery and aesthetic markets. We represent MicroAire Aesthetics, NewMedical Technology, Aerolase Lightpod Lasers, Indiba Deep Care, V Lift Pro PDO Threads, EnerJet, Regenyal Laboratories, Kerastem Advanced Hair Therapy, and Tulip Medical. www.belle.org.uk BIO ID H42 Advances in medicine have shown that the use of bioidentical hormones can ease the symptoms of menopause, and counteract the effects of ageing and disease in both men and women. Bioidentical hormone treatment aims to replace these depleted hormones and restore the body to its optimum function. www.bioidhormones.com BLINK MEDICAL LTD D50 BTL AESTHETICS D18 is a leader in the aesthetics industry with cutting edge technology supported by a comprehensive library of peerreviewed publications. It is a market leader in skin tightening and body contouring applications and in line with industry trends leading the way in feminine health. The BTL Exilis Ultrafemme 360 radiofrequency system is targeted for vaginal health and the BTL Emsella for high frequency focused electromagnetic applications for pelvic floor rehabilitation. btlaesthetics.com/uk CAMBRIDGE STRATUM H36 is a distributor of world-class aesthetic and medical equipment. Our goal at Cambridge Stratum is to provide tried and trusted products, at more affordable prices, without loss of product quality or support. We ensure all equipment is fully approved and undergoes long-term evaluation and testing (in our award-winning associated Cambridge clinic), before it is released for sale. cambridgestratum.com CANDELA F10 Candela – a leading global aesthetic device company, whose technology enables physicians to provide solutions for a range of aesthetic applications including hair removal, wrinkle reduction, tattoo removal, women’s health, resurfacing, scar treatments, body contouring, treatment of benign vascular and pigmented lesions, acne, leg veins and cellulite. www.candelamedical.com/uk

CELLUMA BY BIOPHOTAS INC E28, the award-winning Celluma is a 3-in-1 LED device FDA-cleared to treat acne, wrinkles and pain. Can be used clinically as a powerful stand-alone modality or as a treatment add-on. Celluma is CE-certified for dermal wound healing and is ideal for use following ablative procedures including microneedling, microdermabrasion, microcurrent, and LASER. Celluma is hands-free, stand-free, affordable, portable, and ideally suited for spas, medi-spas, luxury spas and medical practices, alike. biophotas.com Aesthetics | June 2020

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beauty, e.

CONTRAD SWISS G11 They can be used as home therapy or they can enhance the results of aesthetic treatments when used during or post aesthetic applications. We are Contrad, a pharmaceutical company focused on making a change in people’s lives. We pride ourselves on breakthrough, innovative products that reframe the world of medicine to bring you effective bio-medical remedies unlike any other. www.contrad.ch

COSMETIC CULTURE (GERARDS) H43

CRISALIX SA D38 Crisalix is the world’s leading tech company in the field of 3D aesthetic simulation. Its unique technology is based on the most recent advances in Artificial Intelligence, Computer Vision and Augmented Reality and it permits the creation of highly accurate 3D reconstructions of human bodies and the simulation of aesthetic procedures on top. Its disruptive technology caters to some of the world’s most recognised plastic surgeons and clinics across five continents. www.crisalix.com CROMA PHARMA G30 Founded in 1976, Croma-Pharma is a pharmaceutical company based in Austria with 12 international offices. As a leading European manufacturer of hyaluronic acid, the company specialises in minimally invasive aesthetic medicine. They market HA fillers, PDO lifting threads, a Platelet Rich Plasma system and a personalised skincare technology at croma.at/home-en/

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CUTERA MEDICAL LTD C17; since 1998, Cutera has provided worldwide leading laser and light-based medical aesthetic systems. Our devices offer a wide range of medical aesthetic applications for the face and body, delivering class-leading results, faster and safer. The UK direct team can offer the perfect solution for patient satisfaction and practice growth. cutera.com/

CYNOSURE UK LTD J20 leads the world in aesthetic laser technologies and research, creating innovative, safe and efficacious procedures for the treatments that patients want most. Its technologies include hair removal, treatment of vascular and pigmented lesions, skin revitalisation, tattoo removal, body contouring, and the reduction in the appearance of cellulite. cynosureuk.com/

11.12.18 13:45

DERMALUX H25: Multi-award winning Dermalux is the trusted brand for professional LED Phototherapy. Five-time winner of Best Treatment and Best UK Manufacturer 2018 at the Aesthetics Awards, we manufacture the Dermalux systems in the UK for assured quality, clinical efficacy and compliance. As a medical device manufacturer, our investment in R&D and proprietary, cutting edge LED technology has secured Dermalux is a superior device with outstanding results. dermaluxled.com DEXLEVO F25 DSD PHARM G37 E-CLINIC A10 is a comprehensive and easy to use in-clinic management software system for clinics and practitioners, with the power and flexibility to deal with complex workflows and bespoke requirements. It’s used by some of the biggest cosmetic surgery groups and hundreds of aesthetic practitioners across Britain and in Europe, all of whom rely on the software for the smooth running of their businesses. e-clinic.co.uk

EDEN AESTHETICS C6 specialises in high quality, scientifically researched aesthetic equipment and skincare products which we distribute across the UK and Ireland. All our products are subject to full ongoing research and have been tested and endorsed by leading medical practitioners in the UK and Europe to ensure customer satisfaction. As part of our commitment to our customers we offer extensive ongoing training, marketing support and a comprehensive national PR campaign. edenaesthetics.com/n ELÉNZIA B32: As a family fronted brand house, skincare distributor Elénzia provides technical solutions aiming to improve customers health, beauty and wellbeing with scientifically proven products. The company is the exclusive distributor of the Endor Technologies aesthetics range, clinically proven to improve radiofrequency treatments by 18 times and laser treatments by 32%. elenzia.com

EMSLIM F2 EMSlim, brought to you by Harley Technologies Ltd part of the Harley Group, is the most advanced and intensive electromagnetic muscle stimulator. Using HI-EMT (High Intense Electro Magnetic Therapy) this cutting-edge technology not only burns fat and builds muscle but can help improve both endurance and strength which is key to a toned and healthy physique! www.emslim.co.uk

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ERCHONIA LASERS J12 : Cosmetic and medical laser manufacturer Erchonia Corporation has been working in the industry for the last 22 years, conducting research and development with leading physicians. The company advances the science of low level lasers, used to treat foot fungus and the appearance of cellulite, reduce body fat, eliminate pain, accelerate healing and treat acne. erchonia.com

EUROSURGICAL LTD G35 We are a family-run UK surgical distribution company. Our focus is bringing high-quality, innovative, plastic and reconstructive products to the market. We are pleased to supply Implantech facial implants; Design Veronique post-surgical garments; and liposuction kits, including Vibrasat PAL and nano, micro and macro fat grafting equipment. www.eurosurgical.co.uk FACE FOR BUSINESS E23: Pulse, a call handling service run by Face for Business, provides a specialist service to the aesthetic, health and wellbeing sector, designed to help practitioners secure appointments and enable them to manage business without interruption. The personal assistants will answer calls in your company name, pass on messages, agree diary bookings and take payments. ffb.co.uk

FCL HEALTH SOLUTIONS / APEX SURGICAL C25 FCL Health Solutions is a licensed manufacturer and international wholesaler of pharmaceuticals, veterinary medicines, aesthetic products, medical devices, surgical instruments and consumables worldwide. Our international sales division currently supplies over 25,000 branded and generic medical consumable products to doctors, dentists, pharmacies, healthcare professionals, public and private hospitals, (including the NHS), clinics, spas and licensed medical distributors worldwide. fclhealth.com

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H W ANDERSEN PRODUCTS LTD G36 Andersen Sterilisers is a low-volume, low-temperature sterilisation services and solutions provider. Inhouse or sterilisation services and solutions provider. In-house or outsourced. FDA approved systems. www.anderseneurope.com HAMILTON FRASER A15 has been providing insurance to the medical malpractice industry since 1996. Alongside medical malpractice, we offer insurance for clinic and surgery, directors and officers, and cyber liability. Not only do we offer competitive premiums, we also believe in providing expert customer service, to ensure that you and your business have the right protection. hamiltonfraser.co.uk/cosmetic-insurance HANSBIOMED UK B39: Originating from South Korea, MINT PDO is a safe and effective thread used to pull soft tissues of sagging skin to a desired position. The bi-directional and helically positioned barbs provide instant face lifting results with minimal pain and scarring. Used in 14 other countries worldwide, it is certified FDA and CE. hansbiomed.com/eng

HEALTHCARE21 D36 Established in 2003, Healthcare 21 is one of Northern Europe’s largest privately owned healthcare companies with operations across the UK, Germany, Austria and Ireland. We are a leading provider of sales, marketing, customer service, engineering services and logistics for a variety of market-leading, global medtech manufacturers. www.healthcare21.eu

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HEALTHXCHANGE PHARMACY F30 is the market leading distributor of aesthetics supplies. They offer reputable brands including Allergan Botox®, Juvederm Vycross® range, Obagi Medical Products, ULTRAcel, LIPOcel, ENVY Facial, AQUALYX and Dr LEVY. Committed to digital technologies, their e-pharmacy makes 24/7 ordering easy and efficient, while their latest project, Clever Clinic, a bespoke dermatology app, is set to revolutionise patient management in aesthetics. healthxchange.com HYDRAFACIAL G10 is an aesthetic facial treatment, manufactured in the US by aesthetic technology manufacturer the HydraFacial Company.

The device is non-invasive and multi-modality, able to treat skin of any age, type or tone. It utilises a patented roller-flex technology and combines an exfoliation service with a daily application of a take-home serum, providing instantly visible results. hydrafacial.co.uk

INCISION BAAPS LOUNGE SPONSOR

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INITIAL MEDICAL D2 specialises in healthcare waste management, providing a complete collection, disposal and recycling service for hazardous and non-hazardous waste produced by aesthetic practices within the UK. The company offers products and services including sharps and needle disposal, waste segregation, soft clinical waste and infection control products. initial.co.uk

INMODE D26 is a medical device company that develops a broad range of products for minimally - invasive cosmetic surgery based on patented proprietary RFAL (Radiofrequency Assisted LipoTightening) technology. InMode UK aesthetic devices creates a whole new category of minimally-invasive body recontouring and firming procedures offering reliable and effective applications for physicians, and safety and comfort for patients. inmodemd.co.uk KORU PHARMA H12 Koru Pharmaceuticals Co., Ltd. is a global biopharmaceutical company founded in 2014 specialising in medical aesthetic products for anti-ageing and skin rejuvenation. The company is deeply committed to providing innovative cosmetological solutions that meet the highest standards of safety and efficacy while satisfying the needs of patients and practitioners. Our company’s name originates from the spiral shape of a new unfurling silver fern frond, which symbolises new life, growth, strength and peace in the Maori culture. The name Koru emphasises the natural components used in all of our products and our commitment to innovation and continuous development. www.korupharma.com

LABORATOIRES ARION E50

LABORATORIES VIVACY G20 Founded in 2007, Laboratoires VIVACY is a French manufacturer specialising in the development, production and distribution of injectable hyaluronic acid-based medical devices for aesthetic and anti-ageing medicine. The company has also created new technologies for use in gynaecology, ophthalmology and rheumatology, and exports to more than 80 countries around the world vivacylab.com/en LIPOELASTIC D37 LIPOELASTIC is a family-owned business and leading manufacturer of post-surgical compression garments, bras, and compression anti-embolism stockings since 2002. Its products are used in over 70 countries in five continents and have become a market leader in Europe with almost two million garments sold. LIPOELASTIC products are recommended to patients by their doctors to assist in the healing process to speed up recovery and enhance post-operative care. LIPOELASTIC uses new and functional materials and the latest technology on a wide range of products and in combination with elegant designs. LIPOELASTIC products are highly certified such as ISO 13485, Oeko-Tex. www.lipoelastic.co.uk LUMINERA C30 is a research and development company, and manufacturer of injectable medical devices in the field of aesthetic medicine.

The company’s portfolio includes hyaluronic acid based dermal fillers (Hydryalix and Hydryal), calcium hydroxyapatite based dermal filler (Crystalys) and the composite matrix dermal filler composed of calcium hydroxyapatite and hyaluronic acid (HArmonyCa). luminera.com

LYNTON LASERS D15: UK laser manufacturer, Lynton Lasers Ltd has been providing equipment to private clinics and the NHS for the last 25 years. Winners of the Aesthetics Awards ‘Best Manufacturer in the UK’ award, the company offers an up-to-date range of equipment and product development and demonstrate excellent customer service and support for practitioners using their products. lynton.co.uk

MINT INSURANCE BROKERS LIMITED J15 MINT offers a bespoke insurance policy designed for medical malpractice practitioners in the cosmetic industry. We can offer cover to protect you from the treatments and procedures you perform to safeguard your clinic and surgery against insured losses. We are a recommended insurance broker and work in partnership with leading insurers. We have been insuring cosmetic practitioners and clinics for a number of years and have a dedicated team with a wealth of knowledge and experience in the industry.

Mint provides the reassurance that in the event of a claim, we will be able to offer quick and professional support. www.mint-insurance.co.uk MEDICAL AESTHETIC GROUP K30 The Medical Aesthetic Group (MAG) is one of the UK’s leading aesthetic suppliers and seeks out the most innovative products and systems available, including DCL, PRX-T33, MELINE, V Soft Lift, Innoaesthetics, Mene & Moy, MELINE and Innoaesthetics. Dr Beatriz Molina now leads MAG’s medical standards compliance, ensuring products and treatments meet all clinical requirements, strengthening its commitment to bring only the very best medical aesthetic products to the profession. magroup.co.uk MEDICAL UP Medical-Up is a medical device and services distribution company specialising in weight-loss solutions and aesthetic treatments. Our goal is to create new opportunities for clinics from a portfolio of established and new, innovative products. medical-up.co.uk

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MENTOR C35 Part of the Johnson & Johnson family of companies, Mentor is a leading manufacturer and supplier of breast implants for the global aesthetic medicine market. Mentor has made breast implant devices for more than 20 years. Our breast implants are for use in both breast augmentation and breast reconstruction and are of the highest quality. breastimplantsbymentor.net/global MIRADRY C22 The miraDry® System safely and effectively treats underarm sweat and underarm hair with the fi st and only FDAcleared, non-invasive breakthrough technology. miraDry® can now be administered with greater ease and confidence in one hour. www.miradry.com MOTIVA IMPLANTS UK E36 Since 2004, Establishment Labs has remained unwavering in its mission to create safe, beautiful, and long-term solutions for patients’ aesthetic and reconstructive needs. Its vision is to transform the industry by focusing on women’s health by providing sixth generation, advanced, smooth Motiva Implants®. www.motiva.health NATURASTUDIOS E12 We focus on providing superior results across three core areas; aesthetic equipment, skin finishing products and our nationwide clinics. All these areas benefit from our experience and expertise alongside the medical grade standard we adhere to. www.naturastudios.co.uk BeedleConcept.pdf

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NEEDLE CONCEPT D20, based in Biarritz, France, specialise in designing injection technology, including the first micro-cannula called Magic Needle and the Meso and PRP meso-injector U225. The U225 is a high precision device that can make painless injections into any area of the body. Hand made production and high quality spare parts allow the needles to be reliable tools for large medical applications. needleconcept.lacom.info NESSA LASERS C20 We manufacture and supply professional medical-grade aesthetic laser & SHR equipment including an all new ventilator machine to help with patients recovering from COVID-19. All of our machines are hand-built at our own facility in Turkey where our team of engineers and developers have over 20 years of experience building the highest quality medical equipment. This extensive manufacturing expertise combined with our innovative design team has allowed us to now supply our products to the UK and Europe via Nessa Lasers UK. www.nessalasers.co.uk

NEXTMOTION L25: Based in France, Nextmotion is a company that develops and markets innovative products for doctors in aesthetic medicine, cosmetic surgery and dermatology. The Nextmotion app offers standardization of before and after documentation in motion, digitization of the medical office and 3D capture and simulation tools. nextmotion.net

NOVO NORDISK B35 is a global healthcare company that manufactures and markets pharmaceutical products and services. Its focus is on helping people with obesity, haemophilia, growth disorders and other serious chronic diseases. Headquartered in Denmark, Novo Nordisk employs approximately 41,600 people in 80 countries and markets its products in more than 170 countries. novonordisk.co.uk

NOVUS MEDICAL C15 Novus Medical UK has a complementary product portfolio offering the ultimate in clinically proven technology for medical aesthetic clinics through to national chains. Its expertise lies in the winning combination of technological innovation balanced by clinical knowledge, industry experience and accredited training. www.novusmedicaluk.com OBSERV LIMITED J2: Many skin conditions originate from the deeper skin layers and are difficult to diagnose with the human eye. The Observ Skin Analysis System exposes those conditions by using a patented skin fluorescence and polarised light technology. Using this technology, you can instantly reveal skin conditions, create awareness and propose treatments. observ.uk.com

OPATRA H20 brings together the latest technological leaps and scientific innovations to create potent skincare solutions and dynamic tools that are redefining the beauty industry. As a leading device manufacturer and wholesaler, Opatra recognises that our remarkable success is a reflection of your happiness with our easy-to-use instruments that help to produce healthy, youthful, and glowing skin. opatra.com

PABAU A12 is a complete practice management application used by hundreds of healthcare practitioners in the UK. Manage schedules, treatment notes, invoices, payments, marketing and lots more. It works great for all sizes, from large teams, solo practitioners and anything in between. pabau.com

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PROTECT - LASERSCHUTZ E52 PROTECT-Laserschutz GmbH is a manufacturer of laser safety, welding protection and work safety products, committed to the needs of the customers. Excellent consulting, comprehensive quotations, competitive prices and conditions, immediate order processing, as well as fair dealing with all of our partnersl is our top priority. Eyesight is irreplaceable! PROTECT-Laserschutz GmbH always provides qualified advice according to the valid laser safety standards. We provide a large variety of laser safety products for all kinds of laser applications. www.protect-laserschutz.de

PPS A17 offers a highly configurable appointments diary which allows you to manage multiple practitioners, treatment rooms and locations! Once you’ve booked your patients in, it’s over to your practitioners for treatment. Our clinical notes cover all bases including customisable forms, document attachment and image upload and annotation meaning that you can spend less time on admin and more time with your patients! privatepracticesoftware.co.uk

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Q MEDICAL TECHNOLOGIES LTD F35 Founded in 2004, Q-Medical Technologies is an award-winning UK-based medical distributor for the aesthetics industry and the NHS. Its products are sourced globally, including; AccuVein Vein Finders, Ellman radiofrequency devices and the NovaClinical aesthetic treatment range. qmedical.co.uk

RECOVA POST SURGERY D52 At Recova® Post Surgery we are dedicated to supplying the highest quality medical-grade compression garments and bras designed for post-operative recovery for men and women. Made in Spain by Voe Compression Garments. www.recovapostsurgery.com

SEBBIN UK LIMITED E35 Sebbin is a Paris-based manufacturer of high quality medical devices. We offer a bespoke range of high quality breast prosthesis. In addition to breast implants we manufacture a range of testicular, calf, gluteal, facial implants and skin expanders of various shapes. In cases where specific dimensions are required we use computer-aided designs which enable us to produce technically advanced custom-made implants with the 3D technology. www.sebbin.com/en/

SESDERMA K40

SKINADE, BOTTLED SCIENCE G26 is the team behind Skinade – better skin from within®, an innovative skincare drink that works from the inside out. Recommended by top skin professionals, its unique liquid formulation promotes smoother, younger and more hydrated skin by targeting the skin’s natural production of collagen, hyaluronic acid and elastin. Launched in March 2013, it now has more than 1100 stockists nationwide. skinade.com

SKINCEUTICALS G15: Born from decades of research, SkinCeuticals’ high potency formulas are proven to be absorbed optimally into the skin. Our mission is to improve skin health. Dedicated to this purpose, we make one simple promise – to provide advanced skincare backed by science. Originating in the US, we provide skincare solutions recommended by dermatologists, plastic surgeons, medispas and other skincare professionals worldwide to both correct and prevent the signs of ageing. skinceuticals.co.uk

SKINGLO G2: Nutrivitality lead the way in supplements with their invention of NutriProtect Technology, which uses liposomes to protect vitamins and nutrients on their way to your bloodstream. This allows for up to eight times more absorption than other supplements on the market. Products that use this technology include collagen drink ‘SkinGlo.’ skinglocollagen.com

SINCLAIR PHARMACEUTICALS LTD K25 Sinclair has a portfolio of differentiated, complementary aesthetics technologies with a focus on collagen stimulation. Our products are experiencing significant growth as we target clinical demand for effective, high quality, longer duration, natural looking and minimally invasive treatments. sinclairpharma.com

SLICK COMPRESSION GARMENTS F52

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SOLTA MEDICAL B45 Solta Medical is a pioneer and global leader in non-invasive skin tightening, providing innovative, safe and effective solutions for patients whilst enhancing and expanding the practice of medical aesthetics for physicians. Solta Medical’s devices address a range of skin treatments under the industry´s premier brands: Thermage®, Fraxel® and Clear + Brilliant®, as well as offering precise body contouring and sculpting with Vaser® Lipo. www.solta.com

SPECLIPSE H37 Speclipse Inc., founded by Stanford University graduates and a dermatologist, developed a real-time, non-invasive skin cancer diagnostic device based on laser spectroscopy and deep learning algorithms. Its world first LIPS & A.I. based skin cancer diagnostic solution, Spectra-Scope® brings you a new experience of unprecedented high accuracy without sacrificing efficiency in skin cancer diagnosis. www.spectra-scope.com

STELLAR BIOMOLECULAR C2 SBR engages manufacturing consultants, biochemist and biomolecular research therapists to innovate a diverse array of healthcare and aesthetic products and services for consumers who seek alternative regenerative solutions against premature ageing and debilitating chronic diseases through its brand MF Plus and LAB RMS. www.mf-plus.com

SURGISOL LTD G40 Specialising in products for plastic, cosmetic, dermatology and other skin-related surgery. From PermaLip™ the safe alternative to injectable lip fillers to a range of single-use bipolar forceps including diathermy machines, Heine dermatoscopes, headlights and loupes. www.surgisol.com

VENN HEALTHCARE D17 Why choose Venn Healthcare? Other than supplying some of the most advanced aesthetic technologies on the market that offer your patients excellent clinical outcomes, your clinic will also benefit from expert CPD accredited training to ensure your devices are being used safely and to their full potential. Benefit from our in-house service engineers, value for money maintenance contracts and quick access to consumables, guaranteeing your treatment offering is never interrupted. www.vennhealthcare.com/aesthetics

VENUS CONCEPT B30 is a company driven to create progressive technology and products. We create a partnership with our customers, based on innovative products supported by unparalleled marketing and customer service support, allowing business owners to confidently enhance their clinic’s offerings with a safe, painless and profitable treatment solutions. venusconcept.com/en-gl

WIGMORE MEDICAL H30 is an established aesthetic distribution company in the UK, with more than 35 years of industry experience.

Wigmore Medical provides for all your aesthetic needs, from filler to toxin, consumables to laser equipment, topical anaesthetics to advanced skin care. Wigmore Medical is the sole distributor for a large range of brands including the award-winning ZO Skin Health.

Wigmore Medical hold bespoke training courses in every skill associated within aesthetics. wigmoremedical.com

ZEMITS COSMETOLOGY EQUIPMENT C21 Zemits, founded in 2010, is a modern figure in the aesthetic industry. The technology and engineering of all projects are created in California, USA; each step of production is tested for quality assurance so that we can guarantee the best standard in our products. Zemits provides a large portfolio of advanced aesthetic technology, with an innovative and elegant design to all our units. Zemits’ aim is to elevate aesthetic practices internationally, adding a luxuriousness to any establishment. zemits.co.uk

For your complementary visitor’s pass, please log on to the CCR website www.CCRLondon.com CCR 2020 brought to you

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