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Dr Ahmed El Houssieny reviews the literature on aspiration for dermal fillers

! H C 4 CE AR 1 A M 3 & AT 1 S U IN

Dermal Filler Aspiration CPD

JO

VOLUME 7/ISSUE 4 - MARCH 2020

Special Feature: Injectable Case Studies Three interesting case studies from ACE 2020 speakers

Considering Facial Nerve Anatomy

Dr Munir Somji outlines facial nerve anatomy for safe treatments

Understanding VAT Exemptions VAT advisor Veronica Donnelly looks at aesthetic treatments and tax payment


Contents • March 2020 06 News The latest product and industry news 16 ACE 2020 Highlights

What you can expect at the leading UK event for non-surgical aesthetics

19 News Special: Associations for Aesthetic Practitioners

Aesthetics provides an overview of the industry associations and how they can support practitioners

CLINICAL PRACTICE 23 Special Feature: Injectable Case Studies

Industry key opinion leaders and ACE speakers share their treatment approaches using Galderma, Teoxane and Allergan products

In Practice: Enhancing Your Digital Reach Page 67

22 Advertorial: Cutera Trusculpt Flex

The newest muscle stimulation device that can replicate 54,000 crunches in 45 minutes

30 CPD: Considering Dermal Filler Aspiration Dr Ahmed El Houssieny reviews the evidence for aspiration when using

dermal fillers

35 Considering Facial Nerve Anatomy Dr Munir Somji outlines the importance of understanding facial nerve

anatomy for filler treatments

40 Choosing Lasers for Vascular Concerns

Dr Asif Hussein and Dr Sajjad Rajpar provide considerations for treating facial vascular concerns with lasers

45 Understanding Aesthetic Ideals of Asian Patients

Dr Varna Kugan explores the differences in aesthetic ideals when treating Asian versus Caucasian patients

49 Exploring the Skin and Gut

Nutritionist Sarah Carolides explains skin and gut health

53 Recognising Suspicious Lesions in the Periorbital Region

Miss Jennifer Doyle and Mr Richard Scawn detail which lesions should be treated with caution in the periorbital area

56 Advertorial: Gerard’s Cosmetic Culture Introducing the new holistic Gerard’s Cosmetic Culture skincare to the UK 57 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 59 Understanding VAT Exemptions

VAT advisor Veronica Donnelly explains when and how your aesthetic treatments may not be liable for tax payment

63 Mitigating Risks to Mitigate Costs Medical malpractice and risk specialist Martin Swann provides tips for

mitigating insurance risks

Clinical Contributors Dr Ahmed El Houssieny is a trained anaesthetist, currently working as an aesthetic specialist. He is a member of the British Society of Aesthetics an education provider on cosmetic procedures and is working on a Master’s in aesthetic medicine. Dr Munir Somji is the chief medical officer of Dr MediSpa clinics, specialising in facial aesthetics and hair restoration surgery. Dr Kugan is the founder of Dr MediSpa Academy, focusing on an anatomical based approach to facial aesthetics. Dr Asif Hussein specialises in cosmetic dermatology and cutaneous laser surgery. He is clinical director of DrHConsult and medical director at sk:n London Westminster. His specialist interests include fully ablative laser surgery and cutaneous vascular laser. Dr Sajjad Rajpar is a consultant dermatologist at Belgravia Dermatology, specialising in laser and surgical dermatology. He qualified from Birmingham University and has completed a specialist fellowship training in Mohs surgery and cosmetic dermatology. Dr Varna Kugan is a JCCP-registered aesthetic practitioner with more than five years of experience. He is the clinical director at PICO Clinics in London, Milan and Shanghai, specialising in Asian aesthetics. He is also the lead trainer and head of PICO Academy. Sarah Carolides trained in biochemistry, biology and genetics at Cambridge and McGill Universities and received a diploma with distinction from the Institute of Optimum Nutrition. She specialises in digestive and hormonal problems. Mr Richard Scawn is a consultant ophthalmologist and oculoplastic surgeon. He specialises in complex eyelid reconstruction and periocular skin cancer work, leading the oculoplastic service at Chelsea and Westminster NHS Trust and Buckinghamshire NHS Trust. Miss Jennifer Doyle has a Bachelor in Medicine and a Bachelor of Surgery with distinction, as well as a Master’s in Medical Sciences from the University of Oxford. She currently works as an NHS registrar in ophthalmology, as well as leading her clinic, Oxford Aesthetics.

67 Enhancing Your Digital Reach Digital specialist Alex Bugg explores best practice and shares advice on

understanding local SEO

71 In Profile: Dr Lee Walker

Dr Lee Walker details his journey to becoming an international trainer and key opinion leader

73 The Last Word: Questioning ‘Facts’ in Aesthetics

Dr Tahera Bhojani-Lynch encourages practitioners to challenge ‘best practice’

NEXT MONTH • IN FOCUS: BODY • Vaginal Rejuvenation • Mesotherapy Efficacy • Toxin and Snoring

13 & 14 MARCH 2020 / LONDON

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Editor’s letter Welcome to our ACE 2020 issue! Our Spring conference takes place on March 13 and 14, so if you’re reading this at the beginning of the month and haven’t registered yet, get to our website ASAP! We have two days filled with education Chloé Gronow from the UK’s leading suppliers, unmissable Editor & Content networking opportunities and the chance Manager to discover the very latest products and @chloe_aestheticseditor treatments to take home to your clinic. A number of the ACE speakers have contributed articles to this issue, allowing you to follow their advice in sessions and read in more detail here. Our Special Feature on p.23 presents excellent injectable case studies from the Galderma, Teoxane and Allergan speakers; Dr Christoph Martschin, Dr Raul Cetto and consultant ophthalmologist Miss Rachna Murphy, while Dr Munir Somji, who is speaking on behalf of Laboratories Vivacy, explores nerve anatomy on p.35. We also have informative pieces on SEO from digital marketing specialist Alex Bugg on p.67 and advice on when treatments can be

exempt from tax by VAT advisor Veronica Donnelly on p.59; both of whom will present these topics at the ACE Business Track. Sponsor of the Business Track, Enhance Insurance, also has a valuable piece on mitigating risks of insurance claims by director Martin Swann on p.63. If you’re attending ACE, I would also urge you all to consider Dr Tahera Bhojani-Lynch’s points in our Last Word on p.73. She reminds practitioners to always challenge ‘facts’ in aesthetics to evolve our learning and understanding of the science behind products and treatments. Following our CPD article this month, I’m interested to know, how many of you aspirate before injecting fillers? The benefit of doing so is often a much-debated topic at aesthetic conferences, so we’re delighted that Dr Ahmed El-Houssieny has reviewed the evidence for doing so on p.30, which we hope will help you make an informed on decision going forward. Please note that some sessions at ACE are only open to doctors, dentists and nurses, and evidence of your qualifications will need to be submitted in advance via DocCheck. Even if you have submitted evidence, remember that access is granted on a first-come, first-serve basis, so I’d encourage you to get to the session early to get a seat.

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?

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.

Dr Christopher Rowland Payne is a consultant dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies.

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 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.

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.

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.

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.

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ACE 2020

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

#Laser Dr Firas Al Niami @Drfirasalniami_ Great weekend spent doing a bespoke advanced teaching and training on laser treatments and combination therapy with wonderful dermatology colleagues @eraaesthetics in Riga city the capital of Latvia. #Training Agostina Murgia @agostinaskinade What a lovely team, such a pleasure training them all @pat_popat @skinade and #skinadets now all certified and ready to spread knowledge and confidence in #betterskinfromwithin #acne #cellulite #VitaminAandD #Speaker Miss Sherina Balaratnam @MissBalaratnam Thank you to @Cynosure_Lasers for inviting me to your Global Key Opinion Leader dinner. A pleasure to meet tremendous colleagues from across the world & exchange knowledge, protocols, ideas & innovations from the exciting field of laser dermatology. #aesthetics #Clinic Magdalena Bejma @dr_bejma A huge THANK YOU to everyone who attended our grand opening last night. Hope you enjoyed as much as we did and see you soon. #grandopeningparty #evolvemedical #bestclinicleeds #Launch Julia Kendrick @juliarosekendrick Fantastic press event this morning launching the new #12weekstowow programme for @officialmedik8 – thank you to @drjustinekluk and the #Medik8 team for leading the skincare speed dating!

Final content and sponsors confirmed for ACE Taking place on March 13-14, the Aesthetics Conference and Exhibition (ACE) 2020 is set to be an unmissable event for all involved in the medical aesthetic specialty. With the recent addition of global pharmaceutical company Merz Aesthetics, all of the UK’s injectable suppliers will be exhibiting at the event, giving delegates the unique opportunity to learn about all products on the market in one place. Maria Rodrigues, marketing assistant at Merz, said, “We are delighted to be taking part in ACE 2020 where we will be showcasing our innovative range of products, including Belotero, Radiesse and Ultherapy. We encourage all delegates to visit our stand to learn more about how we can support both their practice and their patients.” Two more Expert Clinic sessions can also be revealed for Saturday March 14; PDO threads company Hans Biomed will host an educational talk, before innovations from AnteAge, a company introducing new stem cell treatments to the UK market, will be discussed. On behalf of Business Track sponsor Enhance Insurance, representatives from the healthcare law firm Hill Dickinson LLP will add to the learning opportunities. On Friday Rohana Abeywardana will advise on photography consent, followed by recommendations from Emma Galland on how best to manage complaints on Saturday. Also confirmed is new dermal filler Yvoire from LG Chem as the Registration Sponsor and skincare company Endospheres as the Networking Sponsor for Friday 13. The Yvoire UK team commented, “As one of the largest dermatological chemical companies, LG Chem is proud to launch into the UK market at such a prestigious conference and sponsor the registration. It is an honour for us to welcome our new customers and guest to the conference this year.” All educational session are free to attend, however some clinical workshops are only open to doctors, dentists and nurses. Those interested must have provided evidence of their qualifications via DocCheck in advance of attending. Please check the session description and website for more information. Register now using code 15100 www.aestheticsconference.com

Education

Merz masterclasses launch The Merz Institute of Advanced Aesthetics (MIAA) launched its 2020 Masterclass Series this month. The masterclasses will be led by the Merz Innovation Partners across 13 clinical training facilities in the UK and Ireland, and have been designed to help expand knowledge and practical skills for healthcare professionals (HCPs). The series will include a new Masterclass; the Belotero range, which will focus on the holistic approach to full face rejuvenation and a handson experience of Belotero Volume in the mid-face. Classes will be accessible by invitation only. Maria Rodrigues, marketing assistant for Merz, commented, “Our vison is to deliver a highly valued innovative educational programme, that is bespoke to the Merz customer needs. Our goal is to build a network of Merz certified HCPs, who are confident and highly skilled in the use of Merz brands.” Merz will be exhibiting at ACE 2020 on stand L11.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Training

New cadaver training course launches

Vital Statistics 76% of aesthetic practitioners said that working in aesthetic medicine had met their expectations

(The Hamilton Fraser Survey, 2019)

Nurse prescriber and Aesthetics Media’s Clinical Advisory Board member Jackie Partridge has launched a new training company called Anatomy and Aesthetics, alongside consultant maxillofacial and cleft lip palate surgeon Mr Mark Devlin, and consultant oral and maxillofacial surgeon Mr Jeff Downie. The first training sessions will take place at The Royal College of Surgeons, Edinburgh, on April 25 and September 5, and Queen’s University Belfast on March 21 and June 13. Delegates can expect a full day of cadaver training, as well as an injection techniques demonstration, information on product science, complication and avoidance management, and patient assessment and product choice. Surgical demonstrations will also be included to allow practitioners the opportunity to see various treatments such as blepharoplasty and face lifts take place. The trainers explain that this will enable practitioners to understand what can be achieved both surgically and non-surgically, as well as what will be involved in such treatments should patients decide to go for a surgical approach. Mr Devlin said, “I believe that an understanding of anatomy is central to successful clinical practice. To have the opportunity to develop courses to meet the needs of colleagues is an exciting prospect. Our passion for anatomy and teaching, combined with the participation from delegates will make for successful educational events with the right amount of fun involved.”

In 2019, 74% of facial plastic surgeons experienced an increase in minimally invasive procedures for patients under 30 (AAFPRS, 2019)

One in 10 people are put off having cosmetic surgery due to future concerns, with 30% of them worrying that it would leave them looking unnatural (CynoSure, 2020)

More than 1,300 complaints following lip filler treatments were reported to Save Face in the last year, double that of 2018 (Save Face, 2019)

Regulation

ASA responds to surge in toxin enquiries An Enforcement Notice on January 31 highlighting the rules and concerns around botulinum toxin advertising and other prescription-only medicines on social media has prompted a surge of enquiries to the Advertising Standards Authority (ASA). In response, the ASA has published the top questions the team has been asked to help practitioners in their advertising efforts. Answers given by the ASA state that the enforcement notice applies to all marketing material and not just social media, meaning that botulinum toxin can only be referred to on individual websites in very narrow circumstances. The ASA also reminded advertisers not to say ‘wrinkle relaxing injections’ or ‘anti-wrinkle injections’ in lieu of botulinum toxin, and that non-compliance could result in involvement from the Medicines and Healthcare products Regulatory Agency (MHRA) or other professional regulatory bodies. Although the ASA state that the compliance team are focusing on posts done after the Enforcement Notice, it is recommended for marketers to remove or amend any previous posts that do not comply with guidelines.

In a survey of 650 patients, more than 20% of respondents did not tell their spouse or partner about their cosmetic procedure, and over one third didn’t tell friends or colleagues

(The Private Clinic, 2020)

In a survey of 51,000 UK Snapchat users, more than 50% said they viewed procedures like lip fillers as comparable to getting a haircut or manicure

(VICE Snapchat survey, 2019)

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Events Diary 11th March 2020 The Aesthetic Complications Expert (ACE) Group Conference acegroup.online 3rd-4th April 2020 18th Aesthetics & Anti-aging Medicine World Congress, Monte Carlo www.euromedicom.com 5th-7th May 2020 British Medical Laser Association Conference www.bmla.co.uk 19th May 2020 British Association of Sclerotherapy (BAS) Conference www.bassclerotherapy.com/events

13 & 14 MARCH 2020 / LONDON

March 13 & 14

The Aesthetics Conference and Exhibition www.aestheticsconference.com 1 & 2 October CCR www.ccrlondon.com

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Anniversary

Sinclair Pharma to celebrate treble milestone at ACE Pharmaceutical company Sinclair Pharma will be celebrating three important milestones at the Aesthetics Conference and Exhibition (ACE) 2020 on March 13-14. The company has recently distributed its one millionth syringe of Ellansé, and has also had its anniversary for being in production for 10 years. This comes alongside the news that the company is setting up new manufacturing facilities in the Netherlands as a result of company growth. Sinclair Pharma will be marking these milestones in the UK with a celebratory drinks reception on stand B8 at ACE 2020. Current Ellansé users will also have access to special anniversary marketing materials, including an updated 10th anniversary beauty book. Chloé Antunes, marketing manager for Sinclair UK, commented, “It is fantastic to be able to celebrate a decade of change. 10 years after its launch, Ellansé has more than met our expectations. Strong clinical data, a remarkable safety record and ability to answer patients’ needs by offering long-lasting and natural-looking results have proved to be a winning combination. We are very proud of the amazing results achieved so far and even more excited about the future of Ellansé!” Sinclair Pharma will be exhibiting at ACE 2020 on stand B8. Training

Lynton expands training course

Association

BCAM elects new president The British College of Aesthetic Medicine (BCAM) has confirmed aesthetic practitioner Dr Uliana Gout as its new president. Dr Gout is a long-standing member of BCAM and has most recently served on the board as director of PR and marketing, as well as being on the audit committee. Dr Gout said, “It’s a great honour to have been elected president of BCAM. I look forward to working closely with the Board and the members in the coming months to crystallise our vision and growth strategy for the future of BCAM, and I’m grateful to all for their continued support. I am excited to build BCAM as a leading voice for the industry.” BCAM’s immediate past president Dr Paul Charlson said, “I am delighted to see that BCAM will be going forward under Dr Gout’s leadership and her compelling vision for the future. I know our members and the team look forward to working with her.” BCAM will be exhibiting at ACE 2020 on stand G2.

Laser manufacturer Lynton is updating its skin and laser course, extending the training by an extra day. Alongside its original educational content, the programme now offers delegates an optional fourth day for additional practical training. This will include the use of radiofrequency and ultrasound devices for skin rejuvenation and collagen stimulation, scar and stretchmark treatment and body contouring. Course presentations will also discuss the company’s updated technology, including the Lynton Lumina, Synchro QS4, 3JUVE, ProMax Lipo, Onda and SmartXide CO2. Lynton has also appointed aesthetician and lecturer Jacqui Casey to its training team. Casey has more than eight years’ experience in the industry. Dr Samantha Hills, customer services director, stated, “We are thrilled to welcome Jacqui aboard, and expand upon what is already the largest team of laser trainers in the UK. We’re sure Jacqui will help us continue to deliver the award-winning training that Lynton are known for.” Casey said, “Working at Lynton Lasers combines my love of working in the aesthetics industry with my passion for training practitioners to expand both their practical knowledge and customer care skills. The commitment of the Lynton team, to improve practitioners’ knowledge and understanding of devices, along with keeping patient safety paramount, was what drew me to join the team.” Lynton will be exhibiting at ACE 2020 on stand D8.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Fillers

BioScience launches monophasic dermal fillers 13 & 14 MARCH 2020 / LONDON

Aesthetic product manufacturer BioScience GmbH has launched HYAProf, a new injectable line which combines monodensified and polydensified dermal fillers. The range consists of two products, the HYAProf Soft and the HYAProf balance, which the company states can be used individually or in combination for superficial dermis procedures and deeper injections. The HYAProf Soft is a monodensified dermal filler suitable for superficial and submucosal indications, designed to correct fine lines, crow’s feet, perioral lines, fine forehead lines, thin lips, facial atrophic scars and residual rhytids. The HYAProf Balance is a polydensified dermal filler with a greater degree of cross-linking. According to BioScience it is suitable for the correction of moderate and deeper lines, tear trough deformity, nasolabial wrinkles, glabellar lines, lip contouring, philtrum treatment, oral commissures and marionette folds. The UK distributors for BioScience products are Rosmetics and DermaMed Solutions. Donations

Aesthetics Media supports Facing the World charity Facial deformity charity Facing the World has been confirmed as the charity partner for Aesthetics Media, as part of Easyfairs, for 2020; the company behind the Aesthetics journal, ACE, CCR and the Aesthetics Awards. The UK-based organisation aims to create sustainable solutions for children in Vietnam who have severe facial differences. According to Facing the World, the occurrence of severe facial birth defects is 10 times higher in Vietnam than in neighbouring countries. Donations go towards funding missions to Vietnam where specialist teams work with their Vietnamese counterparts to operate on the children affected, training Vietnamese doctors to learn new techniques and approaches to treatment, as well as purchasing new equipment to improve efficiency. Aesthetics Media chose to support Facing the World following a recommendation from nurse prescriber, Sharon Gilshenan. She said, “Facing the World is such a pertinent charity for the industry we represent. As aesthetic practitioners, we are in the unique position to see and understand the value and importance out faces have on us in society.” Gilshenan continued, “I also have a special affiliation to this charity because if I had been born in Vietnam, I could have been one of the children in pain and unable to speak properly, eat or drink, or possibly shunned by my community, as I was born with a bilateral cleft lip and palate. I consider myself lucky as I was born in a society that had the ability to change my outcome and have consequently enjoyed a fulfilled life. I wish that for the children of Vietnam.” Editor and content manager at Aesthetics Media, Chloé Gronow, said, “Sharon approached me at the Aesthetics Awards and told me all about this worthy charity. After learning more and hearing about Sharon’s experiences of living with a cleft lip and the 25 operations she has undergone, I felt that it was imperative we used our platform to support Facing the World and encourage the aesthetics community to join us in raising much-needed funds. We will be encouraging donations throughout the year and hope you can support us.” To donate, visit www.justgiving.com/fundraising/aestheticsmedia

ACE 20 20 OP EN S ITS DOORS I N L ESS T H A N T WO WEEK S

A LL SESSIONS FR EE TO AT T E N D This year on 13 & 14 March, the Aesthetics Conference and Exhibition (ACE) 2020 will be showcasing a completely free agenda over the two days. With more sessions than ever before, this packed agenda has clinical education for everyone, whether you’re just starting in aesthetics or a more advanced practitioner. Topics will feature injectable innovations and skin science as well as the latest device developments and business building advice. This year’s faculty includes Dr Rita Rakus, Dr Tristan Mehta, Dr Anjali Mahto, Dr Sandeep Cliff, Anna Baker, Dr Raul Cetto, Emma Coleman, Mr Adrian Richards, Miss Sherina Balaratnam, Dr Munir Somji and Dr Mayoni Gooneratne to name but a few! Exclusive masterclasses from Galderma, Teoxane, Allergan, HA-Derma, Church Pharmacy and SkinCeuticals will be joining this star-studded line-up. As well as new Expert Clinic sessions announced from AestheticSource, AnteAGE and Hans Biomed. Experience all of this, a bustling exhibition and a networking drinks reception sponsored by Endosphere to top all others! All educational sessions are free to attend, however, some clinical workshops are only open to doctors, dentists and nurses. Those interested must have provided evidence of their qualifications via DocCheck in advance of attending. Please check the session description and website for more information.

REGISTER FOR FREE NOW aestheticsconference.com

USING CODE 15100 *Please note that these sessions are only open to doctors, dentists and nurses and access is limited. See programme online for more information. HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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

The BACN has now formally launched the ‘I AM A BACN NURSE’ campaign, which showcases the professionalism and commitment to patient safety that all BACN nurses adhere to by following the BACN Code of Conduct in their day to day practice. Marketing material has been created which BACN members can download in the member’s area of the website to promote themselves as a BACN nurse and the BACN will be displaying member testimonials and achievements on all social media platforms throughout spring and beyond. Members are encouraged to get in touch with Gareth Lewis, BACN Marketing and Membership Manager at glewis@bacn.org.uk to highlight their experiences with the BACN.

ACE 2020 BACN will once more be at ACE this year, promoting the association to new nurses and meeting existing members to catch up and aid any renewal processes. Come along to Stand G1 to say hello – we will be there over the two days and would love to have a chat about what the BACN can do for you, or help aid your membership in any way!

BACN RENEWALS Now the BACN has moved to a flexible annual membership year, the focus on a strict renewals period will lessen – but there are still a number of members who will be renewing throughout March in order to not expire in April. It has really never been easier to join and remain a member of the association, especially as the BACN now offers flexible monthly payments for those who are looking to spread the cost over the year. To renew, all members have to do is login to their BACN account and follow the instructions on the screen – it takes about two minutes and members are encouraged to renew early in order to avoid any delays with their certificates and new membership packs. Members are able to download their certificates in the digital certificate section in the member’s area. This column is written and supported by the BACN

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Skincare

SkinMed releases new serum Dermatological research and distribution company SkinMed has released SkinVital Retimitate A.C.E, a new serum that aims to stimulate fibroblast activity to increase collagen, control pigmentation and improve the efficiency of skin cells. The company explains that the serum is a result of a 10-year research programme to develop the Retimitate molecule; an active molecule-like retinoic acid that was specifically designed to be an advancement of other retinoids, but with fewer side effects. Managing director and head trainer at SkinMed, Peter Roberts, said, “The Retimitate molecule is supported by the antioxidant properties of vitamin C and vitamin E, which potentiates the activity of the retinoid. The other associated ingredients in the serum are powerful antioxidants and boost absorption characteristics which also increases its ‘vitamin A’ activity.” Roberts explained that the launch strength is 1.5% and is comparable in efficacy to the ranges of retinoic acid strengths available ranging from 0.1%, 0.25%, 0.5% to 1%. “Due to the safety profile we have more flexibility in increasing the frequency of dosing and we see this as the core benefit,” he added. Regeneration

AnteAGE MD to launch at ACE 2020 AnteAGE MD, a division of biotech company Cellese, will launch its skincare range in the UK at ACE 2020. The company explains that AnteAGE MD is designed to start the skin’s natural regenerative processes, using a mix of synthetic human growth factors and peptides called Cytosignals, developed by the AnteAGE team. Fortified with Cytosignals, synthesised TGF- β3, anti-inflammatory stem cellstimulating defensins, and high molecular weight hyaluronic acid, the formulation aims to accelerate healing after aesthetic treatments such as laser, radiofrequency and microneedling. Ian Sanderson, president of AnteAGE, commented, “We spent three years developing a synthetic analog which conveys all the benefits of human stem cell conditioned media – without the human cell. We are excited to launch our AnteAGE MD Growth Factor Solution and related Serum and Accelerator skincare at ACE in March.” AnteAGE will be exhibiting at ACE on stand A11. Skincare

Pure Aesthetics launches new HA gel Aesthetic distributor Pure Swiss Aesthetics has introduced the BYONIK hyaluronic acid 5.Ecto gel to its BYONIK skincare range. The gel contains three vegan hyaluronic acids with different molecular weights, for penetration within all layers of the skin. According to the company, polyglucuronic acid boosts the natural formation of hyaluronic acid and hydration in the skin, whilst Ectoin promotes a multi-functional skin protection and repair response. Pure Swiss Aesthetics explains that the combination of these ingredients are effective at treating skin conditions such as acne, rosacea, dermatosis, neurodermatitis, psoriasis and scars.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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SPF

Sunscreen ingredients shown to exceed safety threshold A study conducted by the Food and Drug Administration (FDA) has indicated that many common sunscreen ingredients can result in exposure levels which exceed the FDA threshold for safety testing. The FDA’s division of applied regulatory science carried out a randomised clinical trial to assess the systemic absorption and pharmacokinetics of six active ingredients (avobenzone, oxybenzone, octocrylene, homosalate, octisalate, and octinoxate) in four over-the-counter sunscreens. The formulas were tested on 48 healthy study participants and revealed that sunscreen formulations were systemically absorbed and had plasma concentrations that surpassed the FDA threshold. No serious drug-related adverse effects were reported. The study acted as a follow-up to the same research carried out in 2019 on 24 volunteers, expanding the sample size and testing additional active sunscreen ingredients and formulations, which confirmed the previous results. The FDA highlights that the new findings do not indicate that sunscreen ingredients are unsafe, and has stated that individuals should continue using products for ultraviolet protection. Digital reviews

Research suggests patients rely on online reviews New research commissioned by patient booking platform EtreVous.com (EV), launched by Wigmore Medical founder Raffi Eghiayan, found that potential patients heavily rely on online reviews when deciding what clinic or practitioner to visit. Of the 500 women surveyed, 77% answered that they would be put off by bad reviews or negative comments online. While half of women across all age groups use online searches to vet potential clinics, and are likely to rely on review sites in order to gauge aesthetic practitioners’ reputation and skills before undergoing treatment. EV explains that this may cause patients to fall victim to fake reviews. Aesthetic plastic surgeon and EV editorial panel member Mr Ash Mosahebi commented, “As our research has highlighted, reviews are heavily relied upon when making treatment choices, and aesthetic practitioners must be vigilant towards online reputation management. Half of experts may be familiar with the problems posed by fake reviews (and in more serious cases, digital sabotage), they may not see these issues – that influence whether a woman chooses an aesthetic practitioner or not – as easy to counteract.” Other notable results of the study were that only one in five women recognise discount incentives as potential red flags. The website states that this means more work is necessary to convey the recognition of ethical marketing and help patients avoid cowboy practitioners. Wigmore Medical will be exhibiting at ACE on Stand B3. Recruitment

Sinclair Pharma expands team Pharmaceutical company Sinclair Pharma has appointed three new team members Two aesthetic account managers have been appointed. Jodie Mcluskie, who will be working within Scotland and the North East. Meanwhile, Patrick Molloy will be focusing on the Essex and East London territory. Linda Mousson will join the London team as an account executive, helping to manage new and existing Ellansé and Perfectha accounts. Sinclair Pharma will be exhibiting at ACE on Stand B8.

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Nancy Ghattas, Allergan Associate Vice President, Country Manager UK and Ireland Why is education in aesthetics more important than ever before? It is well known that the number of people seeking treatments is growing year-on-year, and, working as a world leader in medical aesthetics, Allergan’s research, its network of Key Opinion Leaders, and our education and training programmes, have helped to show how education can go a long way in improving patient safety and outcomes. Education, and the commitment to keep evolving these programmes, means that we can meet the needs of aesthetic practitioners, by teaching new techniques and technologies so that they can provide the best treatment options for their patients. As industry leaders, how does Allergan ensure ongoing high standard training is offered to practitioners? Globally, we have put training and education at the centre of what we do for over 10 years, and have always seen it as our responsibility to help improve the capabilities of all medical professionals in the aesthetics industry. As well as our face-to-face events and training sessions delivered by our Faculty and Global KOLs, we have also developed a suite of digital materials covering essential aesthetics skills and knowledge. Our SPARK program offers a ‘one stop’ destination to support newer practitioners wanting to grow their practice; by providing a range of materials created by dedicated specialists, to improve clinical skills and patient safety, as well as business skills and customer care for the best patient experiences. How does Allergan upskill consumers about their safety? Last year, we launched our largest consumer activation in medical aesthetics, ‘Beauty Decoded’. It’s an initiative, with a wealth of information, to educate, empower and engage consumers who are considering these procedures. Our topline message for consumers is to always seek consultation first and that Allergan products should only be administered by medical professionals. See Allergan at ACE 2020 on stand L10 UK-JUV-2050043 Date of preparation: February 2020 This column is written and supported by

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020

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Packaging

Biodegradable packaging for cosmetic products released Toxicologists from Heriot-Watt University in Edinburgh have worked with partners from across Europe to create compostable and biodegradable packaging for cosmetic products. The packaging is made from polylactic acid (PLA), and other materials include nanoclays, which aim to improve the barrier properties of the packaging, and rosemary extract which acts as an antioxidant to protect the cosmetic product from degradation. Associate professor of toxicology, Dr Helinor Johnston said, “Brands that develop natural and organic products need packaging that aligns with their philosophy and consumer demand for more environmentally-friendly packaging that reduces waste. This is a huge opportunity for the industry to gain a competitive advantage – a recent survey showed that over 70% of European consumers would be willing to pay more for greener packaging.” Website

New clinic finder established Glowday, a new marketplace where potential patients can find, review and book medically qualified practitioners for their non-surgical aesthetic treatments, has launched in the UK. Founded by Hannah Russell and Joby Russell, who had noticed challenges when finding the right practitioner for aesthetic treatments, Glowday enables clinics to create mini-sites where they can showcase their treatment portfolio. Anyone visiting the site will be able to find, review and compare practitioners and clinics, as well as view the availability of the one they choose, and book appointments instantly. Upon treatment completion Glowday will ask patients to leave a review and rate their experience. Hannah Russell commented, “We hope practitioners and clinics love the product we’ve built for them. We’ve worked hard to ensure it does all the things they’ve told us they would like. Glowday’s TV campaign will be launching as soon we’ve got enough clinic profiles and we’re confident it won’t be long before we’re sending them lots of new patients.” There are no subscription charges or annual fees, but clinics will pay a small commission for any treatments booked via Glowday. Glowday will be exhibiting at ACE on Stand B2. Skincare

Elénzia launches new Endor Technologies body cream Skincare distributor Elénzia has released the new Endor Technologies Firming and Body Shaping Cream. Elénzia explains that the cream aims to promote the development of muscle and lower the expression of the genes involved in the accumulation of fat, smooth and firm the skin, and have a moisturisation effect. The Firming and Body Shaping Cream combines Endor Technology’s nano gold technology, which, according to the company, combines gold particles and hyaluronic acid to improve the firmness of the dermal tissue. It also includes an ingredient called biotechnological active, which is a low molecular weight active ingredient that aims to mimic the effect of endurance exercise training to improve body tone. Elenzia will be exhibiting at ACE 2020 on stand A5.

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News in Brief AestheticSource appoints new business development manager Aesthetic distributor AestheticSource has welcomed Louise Kipling as its new business development manager. Her role will be to work with customers in her region to provide product knowledge, training and support, as well as assisting with product launches and events. Kipling said, “I am absolutely thrilled to have joined the AestheticSource family. With the vast range of brands they distribute, and their excellent reputation within the industry, I am very much looking forward to working within the team and with our customers.” AestheticSource will be exhibiting at ACE 2020 on stand D1. ACE Group conference announced The Aesthetic Complications Expert (ACE) Group will hold a conference on March 11 at the Birmingham Repertory Theatre. The event will focus on how to avoid, diagnose and manage complications from a range of aesthetic interventions. Speakers at the event will include aesthetic practitioners Dr Cormac Convery, Dr Lee Walker and Dr Martyn King, as well as independent nurse prescribers Linda Mather, Emma Davies and Gillian Murray. Information will be presented on delayed onset nodules, considerations for lip augmentation and vascular occlusion, and other aesthetic complications. CBD market value set to rise A report by market insight provider for the cannabis market, Prohibition Partners, has estimated that the cannabidiol (CBD) skincare market will rise by more than two million US dollars in the next four years, and account for 10% of global skincare sales within the next five to 10 years. An assessment of current estimates for CBD in beauty, Prohibition Partners valued the global CBD skincare market at US $710 million in 2018 with projected sales of $959 million by 2024. The number of people in the UK using CBD oil is estimated to be around 300,000. Paterson Inquiry released Following an investigation into regulations and guidance within the cosmetic surgery industry, the Paterson Inquiry report suggests that that there should be a single repository of the whole practice of consultant surgeons across England, setting out their practising privileges and other critical consultant performance data. Other key recommendations of the inquiry highlight clinicians being suspended whenever they are being investigated, patients receiving standard letters with their GPs copied in, and for the Care Quality Commission to check that all private hospitals are getting surgeons to discuss cases as part of multi-disciplinary team meetings.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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IMCAS Report

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On the Scene

IMCAS Annual World Congress 2020, Paris

The International Master Course on Aging Science (IMCAS), one of the largest continuing medical education congresses dedicated to dermatology, plastic surgery and aesthetic science, hosted its 22nd edition of the Annual World Congress from January 30 to February 1 at the Palais des Congrès in Paris. The event brought together a record-breaking 12,529 physicians, practitioners and industry representatives from over 120 different countries, of which 937 were expert speakers taking the stage, while 323 were aesthetic companies covering all three levels of the exhibition; the largest participation figures to date. The scientific programme was built upon 16 key themes including clinical dermatology, face surgery, breast and body surgery, injectables, lasers and energy-based devices, suspending devices, hair restoration, PRP and regenerative medicine, genital treatments, practice management and a new introduction of a new theme: artificial intelligence (AI) and robotics. This year’s edition unveiled sessions exploring AI and robotics in aesthetics and discovering their applications and implications in the fields of aesthetics, clinical dermatology, surgery, digital imaging and communication. Among the wide variety of educational sessions, the IMCAS-classic Anatomy on Cadaver Workshop sessions garnered much attention from participants. This unique series of sessions presented both anatomical lessons and procedural techniques through live cadaver dissections alongside live injections and thread procedures so that attendees could master minimally-invasive procedures and the related anatomy. The Live Aesthetic Surgery Course returned for the second consecutive year following its successful debut in 2019. This ISAPS (International Society of Plastic Surgery) and SOFCEP (French Society of Aesthetic Plastic Surgeons) endorsed course presented a series of sessions dedicated to board-certified plastic surgeons that incorporated live cadaver dissections with live surgery performances for a one-of-a-kind surgical training. Follow IMCAS congresses throughout the year, around the globe for the medical updates to flourish in practice. IMCAS Asia: Bangkok, Thailand – June 19 to 21 IMCAS Americas: Buenos Aires, Argentina – November 5 to 7 This report is written and supported by IMCAS www.imcas.com

BioDerma Pigmentbio launch, London On February 13, pharmaceutical company BioDerma hosted a product launch for the Pigmentbio skincare range. Journalists, influencers and healthcare professionals were welcomed into the AllBright hotel, Mayfair, by company representatives. Consultant dermatologist and dermatological surgeon Dr Emma Craythorne started the proceedings with a presentation on facial pigmentation, offering attendees the opportunity to learn more about skin balance. This was then followed by a talk from Sebastien Pergeaux, medical manager at NAOS UK, the distributor of BioDerma products, who discussed individual products and detailed the benefits of each. Alexia Medlock, brand manager for BioDerma UK, said, “For the Pigmentbio range, we took inspiration from two things. Firstly, the skin and how the skin works. We consider the skin as an ecosystem, so we try to understand how it interacts with the environment. We also took inspiration from a treatment called Kligman’s trio. With specific active ingredients and LumiReveal technology, specific to BioDerma products, we trigger the three stages of pigmentation.” The Pigmentbio range will be available for general purchase in April. On the Scene

Cosmetic Courses Open Evening, London Delegates who were interested in training with Cosmetic Courses or had attended a recent course were invited to meet with key aesthetic suppliers and network with other professionals at The Cosmetic Centre in Holborn, which also offers treatment rooms for hire. Drinks and canapés were served while practitioners met with representatives from Hamilton Fraser Cosmetic Insurance to learn about suitable insurance options, Healthxchange Pharmacy to discuss product supplies, Obagi Medical and Eden Aesthetics to find out more about skincare for patients, and Allergan to learn about its product portfolio. Nurse prescriber and Cosmetic Courses’ trainer Fiona Grant also performed a live demonstration of using Botox and dermal fillers from the Juvéderm Vycross range to rejuvenate the face of a male patient in his 20s. This offered delegates the chance to learn more about appropriate product selection and injection sites. Grant said following the event, “We’ve had such a nice day today. Delegates have learnt loads and got to see lots of new areas of treatment which they’ve not yet practised in, so it’s been really exciting for them to learn how they can develop their skills. It’s also been lovely to have a crossover from other providers for skin treatments and learn different approaches for an overall aesthetic result.”

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Sk:n acquires Adonia Medical Group Medical skincare clinic group sk:n has acquired Adonia Medical Group, the parent company of Courthouse Clinics, which can be found in 11 locations across the UK. CEO of Sk:n Darren Grassby, commented, “This is another great addition to our portfolio, which will allow us to reach into new clinic locations, while adding greater diversity to our group. Our aim is to continue to grow and to develop, whilst offering the same levels of service and support to all our patients and staff. 2020 will be a very exciting year for the group. We have great confidence in the future of the industry, and we look forward to giving our patients an enhanced experience in and out of clinic.” CEO of Adonia Medical Group Paul Wilkinson, added, “The acquisition is a fantastic opportunity for the Adonia Medical Group to join forces with the largest independent aesthetic clinic network in the UK. It is an exciting opportunity for all our employees, and I look forward to working with the senior team to continue to develop our businesses.”

Licenses proposed for nonmedic injectors in Scotland New legislation proposed by the Scottish Government, which could see non-medical practitioners requiring a license in order to perform injectable treatments, has been met with opposition from medical practitioners. Currently, medical professionals are regulated under Healthcare Improvement Scotland and must be registered to perform injectables, but there is no regulation for non-healthcare professionals administering treatments in beauty salons, hairdressers and other similar locations. The Government explained that the purpose of the new law would be to provide assurance for patients, with the license serving as evidence that practitioners have been properly trained to perform treatments safely and effectively. Scottish public health minister, Joe FitzPatrick, commented, “We are committed to patient safety and want to ensure that all those who carryout non-surgical procedures are competent and that the treatments take place in safe and hygienic premises.” However, the proposal has caused concern amongst medical professionals. Jackie Partridge, an aesthetic nurse prescriber based in Edinburgh stated, “Myself and my colleagues do NOT agree that nonmedics should be receiving ANY recognition or approval allowing them to put patients at risk, by injecting when they have no medical qualification. Therefore, we do NOT agree that these unqualified persons should be licensed, they should simply be stopped. Any form of license is, in itself, giving ‘approval’ that what they (non-medics) are doing is acceptable.” The Scottish Government are seeking views from interested parties in a consultation that will run until the end of April.

ACE 2020

On the Scene

Generational treatment approaches at ACE 2020 Treatment through the generations will be explored through Galderma’s educational agenda at ACE on March 13 and 14. Starting with Millennials on Friday afternoon, before moving to approaches for Generation X on Saturday morning and Baby Boomers on Saturday afternoon, delegates will learn about typical concerns, as well as valuable tips for assessment and treatment in these patients. The comprehensive agenda will be delivered by aesthetic practitioner and ACE Group founder Dr Martyn King, consultant dermatologist Dr Sandeep Cliff, consultant oral and maxillofacial surgeon Mr Jeff Downie and consultant dermatologist Dr Christoph Martschin. Galderma will also run a workshop called Inspire by Galderma: how to leverage social media for success in your clinic on Friday morning; featuring advice from award-winning journalist and creator of the Tweakments Guide Alice-Hart Davis, abd guidelines on promoting botulinum toxin from an Advertising Standards Authority spokesperson. Hart-Davis said, “I am delighted to have the opportunity to share my first-hand experience of engaging with the consumer and look forward to combining this with the expertise and industry insights from Galderma at ACE.” These sessions are only open to doctors, dentists and nurses. Those interested must have provided evidence of their qualifications via DocCheck in advance of attending. Galderma will be exhibiting at ACE 2020 on Stand D3 and E3.

The Private Clinic Breakfast Panel, London On January 29, The Private Clinic invited journalists to Asia House for a trends and innovations breakfast panel event, in light of its recent study surveying 650 patients. The event was hosted by journalist Olivia Falcon, featuring insights from The Private Clinic’s medical director and consultant plastic surgeon Mr Adrian Richards, and aesthetic practitioner Dr Tracey Mountford. Key topics of discussion included ongoing industry stigma, celebrity trends and future innovations. Mr Richards commented, “It was brilliant to have so many journalists here from across the country. The key points to take away from our clinic survey are, interestingly, that most patients want to look natural. The idea of people wanting to look good for Instagram and social media was very low, and people are more concerned about their safety.” The survey also suggested patients will continue to seek non-surgical facial treatments that were once only available as surgical, such as nose-reshaping or temple sculpting.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Skin science The importance of skin quality and health is constantly highlighted in this sector. From skin rejuvenation and scar revision to at-home cosmeceuticals, these presenters will cover everything you need to know to keep up-todate with best practice. You will discover the latest advice from renowned dermatologists including Dr Mayoni Gooneratne, Anna Baker, Dr Sandeep Cliff, Robert Sullivan and Dr Emma Wedgeworth.

The ACE 2020 Experience See what award-winning learning looks like at the long-awaited Aesthetics Conference and Exhibition on March 13 and 14 First-class clinical education If, like thousands of your peers, you take education and learning seriously, then there’s a good chance you’re reading the Aesthetics journal whilst exploring the Aesthetics Conference and Exhibition (ACE) in London! This year’s event is more comprehensive than ever, with the introduction of more clinical sessions and business workshops, expert speakers and brands never before seen at ACE and more exhibition space for eager delegates to explore. So, what does award-winning learning look like? See live treatment demonstrations, discover new techniques and protocols and enhance your learning on the science behind the most effective modalities at the Expert Clinic, Masterclass and Symposium agendas. All from the industry’s most reputable, experienced speakers and all CPD certified.

Device developments Machines and devices are technologies that can not only provide outstanding results for patients, but also provide lucrative business success. A huge range of devices are available to learn about at ACE, which treat skin, fat, muscle and feminine health concerns, among many other indications. The innovative discussions will be provided by leading aesthetic practitioners consultant plastic surgeon Mr Adrian Richards, Dr Rita Rakus, Dr Victoria Manning and Mr Ivor Lim to name but a few.

2020

Injectable innovations Injectables are among the most popular nonsurgical procedures in the aesthetics field, but there are hundreds of products to choose from, and even more techniques for successful outcomes. Speaking on the latest injectable procedures and providing advice on treatments such as dermal fillers, botulinum toxin and platelet-rich plasma will be Dr Raul Cetto, Mr Jeff Downie, Dr Christoph Martschin, Miss Rachna Murthy, Miss Sherina Balaratnam, nurse prescriber Anna Baker, Dr Benji Dhillon, Dr Patrick Trevidic, Dr Francesco Romeo, Dr Munir Somji, Dr Lee Walker, Dr Sophie Shotter, Dr Irfan Mian, and more!

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Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Business building advice Boosting your clinical skills and knowledge isn’t the only thing that will help you gain and retain patients to further progress your aesthetic career. The Business Track has an all new agenda for 2020 and 19 workshops delivered by leading brands, trainers and experts. How can you operate a successful clinic on a budget? Gain effective press coverage? Set achievable KPIs? Understand VAT? Or recruit and retain a team? The most effective practical tips to help grow your practice will be revealed by industry leaders on the Business Track agenda. Providing their best business tips and industry updates will be Dija Ayodele from the Black Skin Directory, award-winning practitioner Miss Sherina Balaratnam, business coach Alan Adams, digital advisor Adam Hampson, nurse prescriber Emma Coleman, leading consultant dermatologist Dr Anjali Mahto, JCCP Trustee Sally Taber, web marketing specialist Alex Bugg, consultant plastic, reconstructive surgeon and trainer Mr Dalvi Humzah, PR guru Julia Kendrick, digital marketer Danny Bermant, CEO of Harley Academy Dr Tristan Mehta, business consultant Danny Large, recruitment specialist Jean Johnston and VAT advisor Veronica Donnelly.

RE G IST E R F OR F RE E T ODAY USIN G CODE 1 5100 Attend the sessions that suit your learning needs the most, whether that involves laser treatments, body-contouring methods or skincare approaches – every session is worth CPD points. Please note that access to some of the clinical sessions is restricted to certain professionals and you will be required to supply your professional number upon registration via DocCheck. Spaces are very limited and are allocated first-come-first-served prior to the event.

A bustling exhibition It’s where connections are made, the latest innovations are showcased, live demonstrations are performed, and lifelong friends and colleagues share experiences. Set across an impressive 2,500m2 space, the Exhibition Floor really is the beating heart of ACE. The learning opportunities here are endless; discover the latest innovations and product launches from 100+ brands and meet valuable new contacts to further develop your business. You can even take advantage of exclusive show offers and discounts, with some companies advertising hundreds of pounds off their products and services!

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Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Connecting Practitioners Through Industry Associations Aesthetics share an overview of the industry associations and how they can support practitioners It’s well known that due to the nature of non-surgical aesthetic treatments being performed in private practice, most aesthetic practitioners work in isolation. In fact, recent statistics gathered by Hamilton Fraser Cosmetic Insurance suggests that 73% of practitioners spend their time in aesthetics working alone;1 something which has been on the rise in recent years.2 This highlights that many practitioners are likely to be working without a

What is BCAM? The British College of Aesthetic Medicine (BCAM) is the leading professional association for doctors and dentists working in aesthetic medicine. Conceived in the year 2000 by a handful of pioneers in the specialty, BCAM has grown to more than 400 members and has become a registered charity (1181666). The college is led by a board of trustees headed by president Dr Uliana Gout, who has been a longstanding member. According to the BCAM, Dr Gout is a passionate and globally renowned clinician and educator within the field of aesthetic medicine. What does it do? The aims of the college are to advance the effective, safe and ethical practice of aesthetic medicine through leadership, provision of information, education, support, professional development and maintenance of the highest professional standards. In 2019, 86% of members rated BCAM as being important to the conduct of their practice. Members of BCAM can attend the association’s annual conference in September. How can you join? Applications for college membership are welcomed for all doctors and dentists with experience in aesthetic medicine. This ranges from students to affiliates to professionals, who must have an up-to-date GMC or GDC registration, and costs £30, £250 and £370, respectively.

support network of other professionals, unlike common practice in the NHS. To ensure that those working within the aesthetic specialty are continuously developing and connected to their peers, there are a number of longstanding associations set up for practitioners of all backgrounds, with the sole purpose of providing education, information and continued support.

What is BACN? The British Association of Cosmetic Nurses (BACN) is the largest non-profit professional association for aesthetic nurses in the UK, with more than 800 members. Founded in 2010, the organisation is owned by its nursing members, maintains a management board led by nurse prescribers, chair Sharon Bennett and vice chair Sharon King, and is governed by an agreed constitution. What does it do? The BACN acts as an expert resource for its membership, providing guidance on best practice, supplying continual professional development, a competency framework and detailed resources, as well as facilitating networking through regional meetings and a large annual conference with leading speakers. It also offers a welcoming space for nurses who may feel isolated working in aesthetics. The BACN works with several partners in aesthetics, allowing the association to offer access to a number of courses at special discounted rates. How can you join? The BACN is open to nurses registered with the Nursing and Midwifery Council (NMC) who hold professional indemnity insurance to carry out treatments. Nurses who join must agree with the BACN Code of Conduct to uphold the standards of all members. The BACN offers several payment options: all new members join as associate members at £200 annually (or £20 per month) and, after a year of membership, are eligible to upgrade to full professional members at £300 annually (or £30 per month). Full members will benefit from extra marketing materials to promote themselves, including a dedicated full membership Charter Mark Certificate, and access to the Charter Mark for their marketing material. They will also get access to a bursary programme to help further their educational needs.

What is the ACE Group? The Aesthetic Complications Expert (ACE) Group is a non-profit, non-promotional organisation that was developed to help improve patient safety. What does it do? The ACE Group produces evidence-based, peer reviewed guidelines for the management of a wide variety of complications that can be caused by non-surgical cosmetic procedures. It also provides help and advice to practitioners who do run into difficulties, as well as an emergency hotline, a forum for practitioners, educational modules, workshops, an expert network, journal articles and lectures at various conferences, as well as hosting one annually. How can you join? Full membership is £50 per year, and is available to doctors, dentists, nurses, midwives and pharmacists.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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What is BAD/BCDG? The British Association of Dermatologists (BAD) is a registered charity, whose objectives are the practice, teaching, training and research of dermatology. It works with the Department of Health, patient bodies and commissioners across the UK, advising on best practice and the provision of dermatology services across all service settings. It is funded by the activities of its members. The British Cosmetic Dermatology Group (BCDG) is a section of BAD, and is a national group of dermatologists offering educational programmes and supporting clinical and laboratory research into cosmetic dermatology. What does it do? BAD aims to stimulate and promote medical scientific research and publish the results of such research in the British Journal of Dermatology and Clinical and Experimental Dermatology. It also advises the government, healthcare providers and other professional bodies on dermatology. How can you join? BAD has several membership options: ordinary, trainee, honorary, associate, associate trainee, GP, student, scientist and allied healthcare professional, honorary overseas and retired. An ordinary membership costs £325 per year.

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What is BAAPS? The British Association of Aesthetic Surgeons (BAAPS) is a registered charity that was set up to establish a code of ethics for surgeons to improve standards of safety. It is chaired by consultant plastic surgeons Mr Paul Harris and Miss Mary O’Brien. What does it do? Based at the Royal College of Surgeons, BAAPS is made up of 350 members and facilitates training in cosmetic surgery through annual meetings. BAAPS runs a CPD scheme, providing a framework for practitioners to assess their educational needs and to identify and plan appropriate learning activities on a continuous basis. The scheme is consistent with the Academy of Medical Royal Colleges CPD guidance and helps to ensure that General Medical Council (GMC) requirements for revalidation and CPD are met. BAAPS also provides mentors for young surgeons in aesthetics and cosmetic surgery, assisting them with advice and support during training and when starting out in independent practice. How can you join? Different membership options are available. Surgeons can apply for either trainee, provisional, full UK, overseas or retired memberships. All new membership applications are evaluated by the council of BAAPS and then voted on at the annual general meeting.

What is SoMUK? The Society of Mesotherapy of the United Kingdom (SoMUK) was founded in 2013. The goals and interests of the SoMUK are the spreading, promotion and development of mesotherapy in the UK. What does it do? The primary goal of the SoMUK is to provide an innovative forum for practitioners with a common interest in mesotherapy to exchange views and ideas, encourage research and improve patient management. SoMUK has a list of professional standards to ensure that practitioners are appropriately trained and experienced, follow current guidelines or protocols, are aware of additional responsibilities if they have prescribing privileges or if they train others, are able to safeguard their patients and that they are properly insured. SoMUK also offer a variety of training dates throughout the year. How can I join? SoMUK is open to a wide variety of medical practitioners including dermatologists, cosmetic surgeons, general practitioners, family practitioners, gynaecologists/obstetricians, anaesthetists, dentists, ophthalmologists, ENT specialists, nurses, and pharmacists. To be eligible for a regular membership costing an annual fee of £150, practitioners must be active in mesotherapy and have a medical degree. Associated membership is for anyone interested in mesotherapy who does not have a medical degree, and will cost £100. Associate membership includes all the same privileges except voting, holding office or taking part in board meetings.

What is BAS? The British Association of Sclerotherapists (BAS) is the professional association for UK and Ireland practitioners. A non-profit group formed in 2002, with the aim of raising standards and promoting best practice and education in foam sclerotherapy and microsclerotherapy, the BAS is a source of reliable information for practitioners, the public and the media. It is governed by a board of 10 surgeons, doctors and nurses who are experts in the field. Current office bearers are president Mr Philip Coleridge Smith, chairman Dr Stephen Tristram, treasurer Dr Martyn King and secretary to the board and operations manager, Hilary Furber. What does it do? Members benefit from ongoing professional development including annual conferences, member-only resources and updates, shadowing opportunities and workshops, and support from a network of experienced practitioners. The web-based member directory is a useful promotional tool for members as well as an important resource for prospective patients seeking guidance about treatment options and recommended practitioners. How can you join? Membership is open to practitioners over the age of 18 who comply with GMC, NMC or GDC rules and good practice guidelines and can demonstrate relevant qualifications and indemnity insurance. Membership costs £125 per year.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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What is BAHRS? The British Association of Hair Restoration Surgery was founded in 1996 to promote the understanding and reputation of hair restoration surgery in the UK and Ireland. The non-profit association aims to promote understanding and the reputation of hair restoration, as well as foster communication amongst members and other bodies. BAHRS is led by president Dr Greg Williams. What does it do? BAHRS runs an annual conference, as well as holding workshops and participating in larger-scale events throughout the year. All members are expected to sign a Code of Conduct which outlines honourable behaviour and professional standards that must be adhered to in order to remain a member. How can you join? Application for membership is open to a range of professionals with an interest in hair loss and hair restoration, which must be supported by a reference from a BAHRS surgeon member to be considered. Various membership options are available, including full medical for hair transplant surgeons who perform regular procedures that costs £400, affiliate hair transplant surgeon membership for those who do fewer procedures for £250, as well as categories for affiliate trichologists, dermatologists, scientists and scalp micropigmentation practitioners that cost £150.

What is BMLA? The British Medical Laser Association (BMLA) represents dermatologists, plastic surgeons, nurses, technologists, scientists, beauty therapists, manufacturers and safety advisers who have an interest in the application of lasers or energy-based devices. What does it do? Among its core activities, the BMLA informs national policy, ensures continual improvement of safety and educational standards in the field of medical and aesthetic lasers, and promotes collaboration between clinical, aesthetic, scientific and manufacturing disciplines. An annual conference is held each year, providing a unique platform for the exchange of knowledge, ideas, recent advances, and everything else in the field of lasers and light-based devices. How can you join? Basic membership costs £45 and a full membership costs £95 per year. Full BMLA membership means the individual is also a member of the European Laser Association (ELA) and can benefit from discounts for any annual ELA-convened conference advertised on the BMLA website.

What is BAPRAS? The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) is a non-profit organisation, started with the aim of raising awareness of the breadth of plastic surgery, to promote innovation in teaching, learning, and research and to increase overall understanding of the profession. BAPRAS has a governing body to formulate and implement policy and manage the affairs of the association, led by consultant plastic surgeon Mr Mark Henley. What does it do? BAPRAS runs a range of activities, largely for plastic surgeon members, but also with the aim of raising awareness amongst wider healthcare professionals. Besides holding bi-annual scientific meetings and running training courses, BAPRAS provides awards, scholarships and grants. How can you join? Prospective members working in plastic surgery can choose between 10 different membership types, depending on which is most applicable. Full membership costs £550 a year and applicants are approved by the BAPRAS standards committee.

Regional associations Practitioners across the UK can also join various regional associations. The Association of Scottish Aesthetic Practitioners (ASAP), the Welsh Aesthetic and Cosmetic Society (WACS), Dermatology Aesthetic Nurses Association of Ireland (DANAI) and the Irish Association of Plastic Surgeons (IAPS) have all been established as representative bodies for delegates in their areas. Both ASAP and WACS hold

annual conferences, while DANI and IAPS hold annual members’ meetings.

Voluntary registers As well as joining industry associations, practitioners can also choose to become registered with The Joint Council for Cosmetic Practitioners (JCCP) and Save Face. The JCCP is a UK charity that registers practitioners and approved education and training providers with the purpose of ensuring

Conclusion Membership with any of the groups listed above can benefit practitioners both old and new. By joining, you can ensure you stay connected to the aesthetic community, stay up to date with industry developments and help to ensure that all aesthetic procedures are carried out in the safest and most effective way possible. All contact information for the associations can be found in the Aesthetics online directory.3

patient safety. It aims to provide credible regulation, protection and guidance for the public/patients in a currently unregulated sector. Save Face is a national register of practitioners who provide non-surgical cosmetic treatments. Each practitioner on the register has been inspected to ensure they are following Save Face’s set of standards. Both registers are recognised by the government, and accredited by the Professional Standards Authority.

REFERENCES 1. Cosmetic Insurance – Annual Survey, February 2020, Hamilton Fraser Cosmetic Insurance <https://hamiltonfraser.co.uk/ knowledge/hamilton-fraser-cosmetic-insurances-annual-survey/> 2. Close, M, Survey Indicates 85 if those practicing aesthetics are female, April 2019, Aesthetics Journal <https://aestheticsjournal. com/news/survey-indicates-85-of-those-practising-aestheticsare-female> 3. Aesthetics journal <https://aestheticsjournal.com/directory>

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


Advertorial Cutera

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truSculpt flex ®

Introducing the newest muscle stimulation device that can replicate 54,000 crunches in 45 minutes A white paper has shown that a new muscle stimulation device manufactured by US aesthetic technology brand, Cutera, is capable of replicating the equivalent of 54,000 crunches. Research shows that on average, a healthy, fit adult has the ability to perform a maximum of 100 crunches before reaching a point of complete exhaustion; however, truSculpt flex technology has the ability to bypass the brain and send unique waveforms to the skeletal muscle, which can then challenge muscles at an intensity and duration that is beyond the level that can be achieved during regular exercise. A typical abdominal workout may include up to 10 minutes of various movements to contract, hold and relax the abdominal muscles. Although the rectus abdominis and external oblique muscle are the primary target, they are being assisted by other muscle groups, including but not limited to, latissimus dorsi and splenius capitis. Conversely, truSculpt flex allows for selective targeting of motor neurons to contract specific skeletal muscles without the assistance of surrounding muscle groups for 45 minutes.

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form new blood capillaries, repair muscle fibers, and manage the gain in muscle mass. The amount of released growth hormones depends on the intensity of the activity, hormone levels (which are higher in men, individuals with genetically more muscle mass, or individuals who frequently workout), and the metabolism level, which helps convert amino acids into protein to bulk up muscles.

How is the truSculpt flex different? Eight muscle groups can be treated simultaneously with truSculpt flex, covering the largest treatment area in the body sculpting industry, experts explain. Another benefit is that the device offers three treatment modes to simulate the effects of different workouts by replicating intensified twist, squat and crunch actions, which further differentiates truSculpt flex from other muscle toning devices on the market.

What is the Cutera truSculpt flex? truSculpt flex is a muscle-sculpting device that offers personalised treatments based on patient fitness level, shape, and goals. Only truSculpt flex with Multi-Directional Stimulation (MDS) deploys a unique method of electrical muscle stimulation to target specific muscle groups using three treatment mode options, covering the largest treatment area in the body sculpting industry. Low levels of energy achieve deep muscle contractions at high intensity via a proprietary handpiece design, with truGel to optimise results and increase practice revenue.

How does the treatment work? During a truSculpt flex treatment, similar to strength training, muscle fibers undergo trauma or microscopic tears, and then cells attempt to repair the damage, which results in increasing muscle size and strength. This repair process, known as hypertrophy, begins after each treatment and involves releasing hormones, such as testosterone, to activate cell recovery,

“The benefits of truSculpt flex compared to other muscle toning devices on the market are that it can treat a larger surface area per session and the treatment takes just 45 minutes” Dr Michael Somenek, US facial plastic surgeon

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Aesthetics | March 2020

1. Prep Mode creates a twisting motion to warm up the muscles and slowly build a tolerance to contractions. 2. Tone Mode contracts the muscles, holds it to the point of exhaustion, and then relaxes it to increase strength and enhance endurance. 3. Sculpt Mode creates fast, deep, sequential contractions of the muscle. This action develops new muscle fibres and increases basal metabolic rate (BMR). The truSculpt flex device consists of a touch screen LCD user interface and sixteen handpieces, which allow for simultaneous treatment of up to eight body areas. It’s easy to teach physician extenders how to operate the device.

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Injectable Case Studies Ahead of the Aesthetics Conference and Exhibition, journalist Allie Anderson speaks to three practitioners and ACE speakers who each discuss a case study of a patient they successfully treated with injectables Whether you’re a seasoned injector or just starting out in your aesthetics career, a great way to develop and build on your knowledge of these areas is to learn from others. At the forthcoming Aesthetics Conference and Exhibition (ACE) 2020 on March 13-14, there will be numerous chances to do just that, in our free educational sessions and live demonstrations. Among

Female Periorbital Rejuvenation Miss Rachna Murthy, consultant ophthalmologist, oculoplastic, aesthetic and reconstructive surgeon This 48-year-old patient presented to clinic because she felt she looked sad and tired, and that she had a saggy appearance. Her concerns were focused particularly around the eyes, but she’d had acne when she was younger, leaving some scarring and Miss Rachna enlarged pores. During the consultation, Murthy: Saturday we discussed the patient’s medical March 14 at and aesthetic history before exploring The Allergan the different options available to her. I Symposia always take a group of dynamic photos showing a range of facial expressions, including front-on, in profile, at an oblique angle, and with the chin tilted downwards with the eyes looking upwards, allowing for a better assessment, particularly of the tear trough and periocular area. This patient opted for a combination of toxin and hyaluronic acid injectables to address her concerns: Voluma to lift the cheeks and zygomatic arch; Volift to address volume loss in the suborbicularis oculi fat (SOOF) and tear trough; Volite to the whole face to improve the quality of her skin; and Botox around the glabellar and lateral canthal lines to lift the brows and soften the frown lines and wrinkles. Initially, I performed periocular Botox injections with a 30 gauge needle to the glabella, suprabrow and lateral orbicularis oculi (a total of 48 units). Two weeks later, I reviewed the need for further additional toxin and proceeded to treat with filler. I frequently use Dr Mauricio de Maio’s MD Codes system to SEE ME AT ACE

this year’s speakers are representatives from top injectable manufacturers Galderma, Allergan and Teoxane. Ahead of the event, three ACE speakers share their experience of injectables through a case study of a patient they have each successfully treated, giving a sneak preview of what you can expect to learn on the day.

determine my injection sites,1 with a few variations. For this patient, in the first instance I used a 27 gauge needle to apply Voluma to site CK1 – the outer part of the zygomatic arch – injecting straight down to the periosteum of the bone. I used a total of 0.3ml on each side, divided into three boluses – posterior, central and anterior – to lift and support the cheek laterally. I find that if you start off injecting the outer parts of the zygomatic arch, you need less product in the anterior parts of the cheek. So, after injecting CK1, I switched to a 25 gauge cannula to inject 0.2ml of Voluma deep to the SOOF at CK3 on each side, before moving on to the anterior cheek, where I used 0.3ml of Volift with a 25 gauge cannula into the SOOF, again at CK3, on each side. I also used a 25 gauge cannula to treat the tear trough at TT1-3, going down to the orbital rim and depositing 0.02ml, while projecting the globe with the index finger of my non-injecting hand. I find this approach ensures safety and prevents the Tyndall effect.2 This blueish tinge can occur when very hydrophilic fillers are injected in large volumes too superficially to the eyelid area, where the skin is thinnest.3 I reviewed my patient after three weeks, and re-treated the SOOF at CK3 and the tear trough with Volift, using a further 0.5ml on each side with a 25 gauge cannula. To address this patient’s skin concerns, I treated her intradermally with a 32 gauge needle using 2ml of Volite, which I find very effective in making the skin appear hydrated and plump.3 Using a combination of a needle and a cannula means I can direct each product to the desired plane. I used a needle onto the bone in the lateral aspect of the cheek; because it’s a safe area and injected at a shallow angle, one can reach the periosteum more easily and achieve more projection with a needle than with a cannula.4 On the other hand, injecting through a cannula in certain areas allowed me to minimise complications due to its blunt tip, the most common being damage to blood vessels and bruising, particularly

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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around the perioral and periocular areas.5 Whether I’m using a needle or a cannula, I always aspirate for at least five seconds before injecting because it can help to reduce the risk of bruising and vascular occlusion.6 Another crucial step to minimise bleeding and bruising is to make sure patients aren’t on blood-thinning medication, while arnica can be good to ease post-treatment bruising.6 The environment you work in is also important in considering the risk of complications, so I use aseptic techniques: I dress in surgical clothing, use sterile packs and wear sterile gloves, as if I’m performing a surgical procedure.7 I use Clinisept+ hypochlorous acid to reduce contamination risk, which is safe to use around the eyes.8 To other practitioners, I would say it’s essential only to treat areas according to your experience and competency. The periocular region is a high-risk area that requires a certain degree of expertise. If you have limited experience in this specific area you can make great Before

I would advise opting for a staged programme, rather than trying to treat all the patient’s concerns at once Miss Rachna Murthy

After

Figure 1: 48-year-old patient before and immediately after treatment using a portfolio of products from Allergan

Female Perioral Rejuvenation Dr Raul Cetto, aesthetic practitioner This 48-year-old female patient sought improvement and rejuvenation to her overall appearance. During our initial consultation we discussed the specific areas that were troubling her. She highlighted the area around her lips as a key concern. Although her Dr Raul Cetto: lips had always been well-defined, she Friday March 13 had lost volume and developed lines in at The Teoxane recent years, and she particularly noted Approach elongation and loss of anterior projection Symposium of the upper lip, while her lower lip had also inverted. The patient didn’t want her lips to be large and overly inflated, so I explained to her that in order to address the areas of concern, I would restore volume around the mouth and lips to restore their previously natural shape. In a female Caucasian patient, the lower third of the face should be proportioned such that the bottom of the nose to the top of the lower lip, with the mouth closed, occupies one-third of the vertical height, and the top of the bottom lip to the bottom of the chin, two-thirds.9 This patient had an elongated upper lip and almost appeared to have a 1:1 lower face SEE ME AT ACE

changes to the way someone looks and feels, while achieving very good outcomes by treating the lower two thirds of the face or focusing on the skin. I would also advise opting for a staged programme, rather than trying to treat all the patient’s concerns at once. You can achieve better, safer results that are kinder to the patient’s budget by spacing out your recommended treatments. Overall, using the right tools and products in the right planes allows you to be as safe as you can be and achieve a really good aesthetic outcome, as well as a happy patient.

ratio, so I proposed a lip and chin treatment to create balance. I always start from the top because the treatment will have an indirect impact on the areas below. So, I began by treating the lips before moving on to the chin. Initially, I injected Teosyal RHA Kiss into the lips. I employed an anterograde injection technique, using a 30 gauge 4mm needle to the vermillion border and four small boluses into the body of the lip. I used 0.2cc to the upper lip and 0.2cc to the lower lip at the vermillion borders, followed by two boluses of 0.05cc to the upper lip and two boluses of 0.1cc to the lower lip. This everted the lips without them appearing inflated or unnatural. One of the main advantages of RHA Kiss is that it has the strength required to restore volume and shape to the lips while still being stretchable and soft. The product is strong enough to evert the lip, yet malleable enough to appear and feel immediately natural, so the patient is unlikely to feel a solid implant in the lip. I then proceeded to treat the chin, to elongate it and create anterior projection. For this, I used two different products at two different layers, due to the different characteristics in each tissue plane. First, I injected a bolus of 0.3cc of Teosyal Ultra Deep to the pogonium of the chin to project it anteriorly. This product is very cohesive and has similar characteristics to the bone itself; it’s strong enough to displace the overlying structures, restoring bone volume and projection. Then I looked to restore the superficial fat of the chin. Due to the loss of superficial fat and the bony projection, some of the muscles around

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


2 THE DIGITRX AWARD FOR P R O D U C T I N N O V AT I O N OF THE YEAR

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Before

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After

After

blood vessels.10 To minimise the risk of complication, I used a cannula to treat the chin.11 Its blunt tip is less likely to injure a blood vessel and cause trauma and bleeding. In addition, when treating the lips, I used a very small needle – just 4mm – away from where the labial arteries are most commonly located, which lessens both the patient’s discomfort and the risk of any bleeding or bruising.12 I also minimised the number of injection points and sterilised the area repeatedly to minimise the risk of infection. This patient was able to see her Figure 2: 48-year-old female patient before and immediately after treatment using a portfolio of products from Teoxane. Images taken using VECTRA H2 handheld 3D camera system from Canfield/Surface Imaging Solutions. before and after images in 3D immediately following the procedure, the mouth and chin had become hyperactive. The depressor anguli and she was delighted with the result. She could see the improvement oris (DAO) muscle was pulling the corners of the mouth down. The in her lips and her lower face and, most importantly, she was relieved mentalis muscle was rotating upwards and creating what we call the that her lips looked natural for her, and were not over-volumised. The labio-mental crease – a deep line between the lower lip and the chin results are expected to last more than a year. – shortening the lower third of the face. To address this and to restore the length of the chin, I injected Teosyal RHA 4 between the skin and the muscle to provide structure and support for the skin overlying the muscle, thereby reducing the effect of the muscle pull. I used a 25 gauge 38mm cannula, and through a single-entry point on each side of the chin, I deposited 0.4cc of the product at the superficial fat level, and 0.2cc into the labio-mental crease. Teosyal RHA 4 is a unique product because its high strength and malleability makes it able to adapt to the movement around that area of the face. In treating this area, there is risk of several potential complications, and Dr Raul Cetto it’s important that we discuss them with the patient during the initial consultation. The most common are transitional redness, swelling and bruising, while rarer complications include infection and damage to the

I always start from the top because the treatment will have an indirect impact on the areas below

Female Lower-third Restoration Dr Christoph Martschin, senior consultant dermatologist, Sweden This very healthy 53-year-old patient came to see me because she felt her face looked tired and gaunt. She is a passionate marathon runner, and this repetitive exercise left her face depleted of volume. You could see the bony structure of the Dr Christoph face through the skin because she had Martschin: Friday almost no subcutaneous fat left, which and Saturday March creates a very aged appearance. She 13-14 at Inspire by wished to restore her face, and it was Galderma clear that this patient predominantly needed more volume in the lower third of her face, rather than lifting. I started by addressing the pre-auricular area, injecting each side with 1.5ml of Restylane Volume superficially with a 25 gauge cannula. This gave some padding to the region, which had become SEE ME AT ACE

very hollow. The second step was to treat the perioral region with Restylane Refyne. I find the soft gel texture of this product integrates very well, and it’s particularly suited to areas that are exposed to facial dynamics and high flexibility. In each side, I used 1ml of the product, again with a 25 gauge cannula. To complement this, I suggested that I do a light volumising treatment on the patient’s lips as well. She neither had nor wanted big lips, but the ageing process had caused her lips to be quite flat and sad-looking. I chose to deposit a total of 0.8ml of Restylane Kysse to both lips using a 25 gauge cannula, which replenished the volume she’d previously had. The last area I treated during the patient’s first visit was her chin. The muscles in the chin region were cramping, giving the skin an orange peel-like appearance. This is caused by a lack of structural support. Here, I used Restylane Lyft – which is a precise, firm gel texture – injecting 1ml through a 29 gauge needle straight down to the bone. This gave support to the muscle and projected her chin nicely. Together, the treatments I performed to the lip, perioral and chin regions perfectly restored her Ricketts’ line, bringing balance to her face in profile. When the patient came back a week later, I assessed the modiolus – the junction where the many muscles of the face join and pull on

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Before

After

the corners of the mouth – which was creating a bulge because of volume depletion in the buccal fat pad. This means there was no support for the zygomatic major muscle. My approach to correcting this was to use a 25 gauge cannula to inject Restylane Volume deep into the buccal fat pad compartment. Because the volume was so depleted, I needed to inject quite a lot of product here – 1ml on each side – and in doing so, it restored the patient’s face shape. It’s important to minimise the potential for complications; proper analysis and investigation of the treatment area, knowledge of anatomy, and the injection technique and plane all determine the risk profile. Due to its blunt tip, Figure 3: 53-year-old female patient before and two weeks after treatment using a portfolio of using a cannula to inject the lip, the perioral and products from Galderma pre-auricular regions lowers the risk of vascular complications. The same is true for the buccal fat pads, where there would be potential to cause an injury because the blood vessels go much deeper.13 In the chin, I use a needle down to the bone, because I find it gives better lift and projection than a cannula. So to avoid vascular damage, I aspirate for nine seconds before injecting very carefully while observing the area for signs of complications.6 In aesthetics, we come across very volume-depleted individuals like this once in a while, and they make great candidates for injectable facial fillers. I would recommend, in patients where you see the modiolus bulging due to loss of volume, to examine the buccal fat pad area and consider injecting in this region. Patients like this often require a large amount of product depending on their individual needs. But, like my patient who Dr Christoph Martschin was very pleased with the outcome, they are incredibly grateful because it makes such a difference. The results are expected to last 12 to 18 months. When you restore a patient’s facial shape, make them appear younger and healthier, it can have a significant impact on their quality of life.

In the chin, I use a needle down to the bone because I find it gives better lift and projection than a cannula

13 & 14 MARCH 2020 / LONDON

S E E T H E SE SP E A K E R S A N D MO R E AT AC E 2 0 2 0 !

Dr Raul Cetto: Friday March 13 at The Teoxane Approach Symposium

Dr Christoph Martschin: Friday and Saturday March 13-14 at Inspire by Galderma

Miss Rachna Murthy: Saturday March 14 at The Allergan Symposia

REGIS T ER FO R F RE E U S I N G CO D E 1 5 1 00 W W W. A ES T HE T I C S CO N F E RE N C E .CO M

REFERENCES 1. MD Maio, MD Codes. <https://www.mdmaio.com/md-codes/> 2. King M. Management of Tyndall Effect. J Clin Aesthet Dermatol. 2016;9(11):E6–E8. <www.ncbi.nlm.nih. gov/pmc/articles/PMC5300720/> 3. Niforos F et al. VYC-12 Injectable Gel Is Safe And Effective For Improvement Of Facial Skin Topography: A Prospective Study. Clin Cosmet Investig Dermatol. 2019;12:791–798. Published 2019 Oct 24. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6817835/> 4. Salti G, Rauso R. Facial Rejuvenation with Fillers: The Dual Plane Technique [published correction appears in J Cutan Aesthet Surg. 2016 Jul-Sep;9(3):211]. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4645140/> 5. Hwang CJ. Periorbital Injectables: Understanding and Avoiding Complications. J Cutan Aesthet Surg. 2016;9(2):73–79. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924418/> 6. Hamman MS, Goldman MP. Minimizing bruising following fillers and other cosmetic injectables. J Clin Aesthet Dermatol. 2013;6(8):16–18. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3760599/> 7. Cosmetic Practice Standards Authority, Dermal Filler Standards (Encompassing skin and soft tissue fillers). <http://www.cosmeticstandards.org.uk/uploads/1/0/6/2/106271141/20180303_cpsa_dermal_ filler_standards_final.pdf> 8. Clinicept+, Frequently Asked Questions. <https://www.cliniseptplus.com/clinisept-faqs/> 9. Harb A, The Last Word: Aesthetic Ideals, 20 December 2019, Aesthetics Journal. <https:// aestheticsjournal.com/feature/the-last-word-aesthetic-ideals> 10. Chiang Y et al, Dermal fillers: pathophysiology, prevention and treatment of complications. J Eur Acad Dermatol Venereol, 31: 405-413. <https://onlinelibrary.wiley.com/doi/abs/10.1111/jdv.13977> 11. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;6:295–316. Published 2013 Dec 12. <https://www. ncbi.nlm.nih.gov/pmc/articles/PMC3865975/#!po=80.3030> 12. Hotta TA, Lip Enhancement: Physical Assessment, Injection Techniques, and Potential Adverse Events. Plast Surg Nurs. 2018 Jan/Mar;38(1):7-16. <https://nursing.ceconnection.com/ ovidfiles/00006527-201801000-00003.pdf> 13. Zeichner JA, Cohen JL, Use of blunt tipped cannulas for soft tissue fillers. J Drugs Dermatol. 2012 Jan;11(1):70-2. <https://www.ncbi.nlm.nih.gov/pubmed/22206080>

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Considering Dermal Filler Aspiration Dr Ahmed El Houssieny reviews the evidence for aspiration when using dermal fillers and suggests ways to minimise risk of vascular compromise Injectable soft tissue fillers are an increasingly popular, non-invasive approach to treating a range of concerns, from correcting lines and folds to restoring volume to the skinâ&#x20AC;&#x2122;s structures.1 Fillers are usually made with hyaluronic acid (HA), poly-L-lactic acid (PLLA), or calcium hydroxylapatite (CaHA) and, of these, HA fillers are the most commonly used.2,3 Most adverse events associated with dermal fillers are considered to be transient and minor, requiring conservative management.1 Vascular compromise, however, is a potentially serious complication that can result from the accidental intra-arterial injection of a bolus of syringe contents or from the compression of an artery by surrounding filler.2,4 If not identified and treated promptly, the injected material may pass into circulation and lead to tissue necrosis.2 In the worst cases, this can result in scarring, blindness or brain injury.2,5,6 Aspiration of the syringe containing the dermal filler prior to injection is advised by many practitioners as a way to minimise the risk of vascular compromise.4,6 Blood in the hub of the needle is an indication of intravascular positioning and, if this presents, the injection should not proceed and the needle should be repositioned.7 However, there is a high rate of false-negative results associated with the procedure and reliance on the test has become a controversial issue.2,7,8 This review will consider the evidence from recent studies and the implications for best practice.

The risk of vascular compromise Although vascular complications are rare, with incidence previously estimated to be 0.001%,4 the occurrence may be rising as the number of dermal filler procedures increases.9 Further, it has been suggested that the number of vascular events is underreported.9 It is important to be aware that the risk of vascular occlusion after the injection of facial dermal filler differs according to facial area. Areas observed to be most frequently associated with vascular compromise are in the glabellar region, nasolabial fold and nasal area.4,10 One literature review found that of 61 cases of severe complications following HA, CaHA, PLLA and polymethylmethacrylate filler injections, but excluding autologous fat, the incidence of necrosis or impending necrosis resulting from injection was 33% (n=16) in the nasal area, 31% (n=15) in the nasolabial fold, and 20% (n=10) in the glabellar.10

Aspiration as a risk-reducing measure The process of pulling back the plunger of a syringe before applying pressure to inject its contents is very familiar to medical practitioners. Used primarily in intramuscular or subcutaneous injections, aspiration is a simple test to check that the needle has not been inserted into a blood vessel.11 If blood is drawn back into the syringe, it is highly likely that the needle tip has punctured a blood vessel.7 However, the absence of blood in the syringe may not necessarily mean that the needle has not been positioned in an artery.7

False-negative results have been found in around 50% or more of aspiration tests carried out.2,7 The Casabona study showed that the results were replicated when five dermal fillers were tested on a rabbit ear.2 The factors judged to affect the reliability of aspiration as a test include the consistency and cohesivity of the filler, the gauge and brand of the needle or cannula used, syringe dimensions, force of suction, and time taken under negative pressure as the needle is withdrawn.2,7,8 How these factors affect the sensitivity of the test, and how the practitioner might take these factors into account, has been the subject of a range of studies.2,7,8,9,12 It should be noted that the available results assessing aspiration with dermal fillers are from studies, with the exception on the Casabona testing referred to above.2 One author has noted that experiments of this nature face the difficulty of ensuring that the needle has indeed been placed in an artery during aspiration, which can lead to a true-negative rather than a false-negative result.7 While it cannot be assumed that the findings of these studies are reproducible, these findings may provide useful evidence for the value of aspiration and some guidance on best practice. Choice of needle and filler It is commonly accepted that a smaller gauge of needle is associated with less bruising, pain and fewer adverse events when administering dermal fillers.6,13 For example, it has been shown that individuals receiving multiple facial injections experienced less pain and bruising with a 33 gauge needle (n=20).14 However, one investigator suggests that CaHA requires at least a 27 gauge needle, and PLLA at least 2527 gauge needles due to potential clogging of finer needles.13 Further, several studies have demonstrated that some fillers require a larger needle size in order to achieve a positive aspiration test than that recommended or supplied by the manufacturer.2,7,8 Of two studies testing aspiration in a selection of dermal fillers in vitro, one showed that using the recommended or supplied needle yielded a positive reflux test in 53% and the other in 74% of products. When the fillers that tested negatively initially were used with a larger needle, many products yielded positive results.2,7 It should also be noted that some fillers were found to have a positive aspiration test with a smaller needle than that supplied for use.2 However, other factors have been shown to affect the reliability of aspiration, including the time required for the aspiration test.2,7 Van Lohem and colleagues demonstrated that the reliability of the aspiration test varied greatly depending on the length of aspiration from the start of the test to the appearance of liquid in the syringe, ranging from 37% reliability at one second to 74% reliability at 10 seconds.7 Study findings also show that differences in response to aspiration appear to be accounted for in part by the viscosity of a given dermal filler, in relation to both the gauge and length of the

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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needle. That is to say, depending on the rheological properties of the dermal filler product, a larger gauge needle may not necessarily allow blood flow into the needle if the needle is also longer.7 Nonetheless, larger-gauge needles are recommended when injecting dermal fillers by the authors of the studies discussed, as well as other practitioners, as they claim they are more likely to allow reflux of blood into the hub and are less likely to pierce the lumen of a blood vessel than a small sharp needle.2,7,8,9 Conversely, other practitioners advocate the use of a small-gauge needle, prioritising greater control of quantity of filler or a requirement for less pressure on the plunger as factors which reduce the risk of any adverse events.6,15 In the face of these recommendations, how should a practitioner proceed? The studies discussed show that using an appropriate needle and filler can help to make aspiration a possible way of detecting intra-vascular positioning of a needle. Familiarity with the published data on the relationship between needle size and brand of filler can be helpful. While further data would be of value in confirming study findings to date, the available data does offer some evidence for guiding the choice of filler and needle combination. Equally an awareness of areas in the face where risk of vascular compromise is greater can guide the practitioner in terms of needle and filler choice for a particular area or, indeed, whether the procedure should be carried out.2,16 Time to reflux in aspiration testing A further factor that should be taken into consideration when aspirating prior to injection is that of time taken to carry out the test. The traditional method, and one which may be said to reflect typical

Cannulas as an alternative choice While needles have traditionally been used to administer dermal filler, blunt-tipped cannulas are a more recent alternative to administering dermal fillers and have been identified as a measure to help minimise the risk of vascular injury.4,6,7,17 A discussion paper on the practice of several individual practitioners demonstrates that choosing between a cannula or needle depends on facial area, filler choice, level of experience and patient history.18 In guidance on the use of HA fillers, the Global Aesthetic Consensus Group strongly recommends that aspiration prior to injection is carried out with cannulas as well as needles, particularly in high risk areas.18 Some practitioners do aspirate when using a cannula,19 but further study is required on the efficacy of the process in different sizes of cannula and the time taken to aspirate, as discussed below. One cadaver study (n=4) demonstrated that using a cannula instead of a needle can present a lower risk of vascular occlusion and can enable more precise placement of filler.20 The precise application of filler using a cannula was also evidenced by a 2017 cadaver study (n=9), which showed

The absence of blood in the syringe may not necessarily mean that the needle has not been positioned in an artery practice, is to both pull back and release the plunger quickly.7,8 However, while withdrawal of the plunger may easily draw back a solution with similar rheological properties to blood, emptying a preloaded needle of a dermal filler with its gel-like consistency may be more difficult.8 While greater pressure may need to be exerted to pull the plunger back, it should be remembered that negative pressure caused by a quick movement of the plunger can result in the collapse of a blood vessel and give a false-negative result when assessing intravascular needle placement.8 A comparison between a rapid and a slow withdrawal and release during aspiration with different needle sizes and a range of fillers, showed that a rapid pull-back and release did not allow for sufficient

that in 60% of injections using a needle, the implanted material moved from the horizontal plane, where the filler was injected, to a vertical, more superficial plane; this was not observed with cannula (0%;p=0.003).21 It is important that filler remains in the area intended; for example, injection of a dermal filler at a superficial level in the infraorbital hollow can be associated with adverse events such as affecting lymphatic drainage.22 A further advantage of a cannula is that multiple puncture points are not necessary with a cannula, which also reduces the risk of vascular injury by limiting the number of times the skin is punctured.6,23 Administering a dermal filler by cannula is also reported to produce less pain, oedema and bruising.16,23 Some authors recommend cannulas of 25 gauge or larger to avoid the more likely penetration of blood vessels by smaller gauges â&#x20AC;&#x201C; defined by one author as 27 gauge or smaller.7,9,24 Indeed a 2019 study showed that 20, 22 and 25 gauge cannulas required greater force for intraarterial penetration than correspondingly sized needles.25 One literature review found that vascular occlusion occurred

with both needle and cannulas ranging in size from 27 to 23 gauge.26 Further, 27 gauge cannulas required the same force as a needle to achieve penetration of the vessel, suggesting that there may be no advantage to using a cannula of this size in minimising risk of vascular penetration.21 Conversely, others prefer smaller cannulas, which can deliver controlled amounts of filler.6,27 It is important for practitioners to recognise that using a cannula will not eliminate the risk of vascular compromise, although according to the literature, it can reduce the risk.20,23 The option of using ultrasonography-guided cannula placement and laser speckle flowgraphy has recently been explored in a small study of one individual to enable safe placement and monitor interrupted blood flow.28 There is a need for further evidence with larger groups of participants to establish the optimal use of cannula in dermal filler application. Until then, practitioners should take into consideration existing evidence and recommendations on cannula size and aspiration when choosing the most appropriate treatment option.2

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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The need for additional measures to support aspiration

Supraorbital Artery

Parietal Branch of Sup Temporal Artery

Supratrochlear Artery

Frontal Branch of Sup Temporal Artery Angular Artery

Superficial Temporal Artery Superior Labial Artery External Carotid Artery Inferior Labial Artery

Facial Artery

Figure 1: Arterial structure of the face and ophthalmic area

removal of the filler from the needle in most cases to allow flash-back of blood.8 When aspirating slowly, the syringe plunger was retracted over a period of around 10 seconds to achieve a negative pressure of 0.4ml and held under that negative pressure for up to five seconds before release.8 The results of this slow pull-back and release showed some difference between filler products in terms of extent of negative pressure required to obtain a positive test result.8 This finding has been confirmed by a 2019 study showing that pull-back volume and time required until blood was visible in the needle depends on the physiochemical properties of the filler product.29 The study by Carey and colleagues also demonstrated a greater rate of positive aspiration tests when the slower approach was compared with the rapid retraction and release with the same product and needle size.8 These findings suggest that a slow execution of the test and achievement of negative pressure in the syringe can contribute to obtaining a true positive result in aspiration, but that this will vary according to the product used.8

According to many authors, aspiration plays an important role in signalling risk of vascular complications when applying dermal fillers.4,6,9,10,30 However, due to the potential for a false-negative result, it cannot be the sole strategy employed. Even when the considerations discussed above are taken into account and an appropriate filler and needle combination is used and administered slowly, there are other factors of which to be aware. Anatomic variation between individuals can mean blood vessel location is not always exactly the same.2 Van Loghem and colleagues suggest that as a practitioner is repositioning their fingers on the syringe, after drawing back the plunger during aspiration before injecting the syringe contents, care needs to be taken in order not to move the needle into a blood vessel, having just established during pull-back that the needle was in an extra-vascular position.7 Consequently, should a practitioner choose to aspirate, it should be part of a range of measures taken to minimise risk of vascular occlusion.4

Facial anatomy Knowledge of vascular structure of the face is central to enabling the practitioner to use dermal fillers effectively while ensuring that risk of side effects is kept to a minimum (Figure 1).2,16,31 Familiarity with how vascular pathways and anastomosis may result in transmission of emboli, into sensitive areas in particular, is crucial in the prevention of vascular complications.2,22 For example, a 2019 literature review of visual complications associated with filler reported that of 48 cases, 27 (56.3%) resulted from injection into the nasal area.26 The practitioner should be aware that the dorsal nasal and the angular artery of the nose are proximal branches of the central retinal artery, so intra-arterial injection into the nasal area can introduce a column of filler which may occlude the small arteries around the eye and lead to blindness.15 In addition to this, the extensive anastomosis of arteries in the nasal area connect the internal and external carotid branches, enabling the transport of filler across the facial region if injected intra-arterially.9

Aspiration

Additional measures

✓ Aspirate with needle or cannula, but ensure measures are taken to minimise risk of false-negatives

✓ Ensure you have a detailed knowledge of facial vasculature

✓ Consider cannula versus needle

✓ Check the anatomical plane and depth for any filler injection

✓ Consider risks associated with specific facial area to be treated

✓ Always take a patient history

✓ Check density of filler and recommended needle/cannula size and compare with study findings

✓ Use a low volume of filler

✓ Aspirate using slow retraction of the plunger and sustained negative pressure before release

✓ Inject slowly and with low pressure ✓ Choose a reversible HA filler ✓ Ensure you are familiar with how to identify and treat signs of vascular compromise

Table 1: Checklist for measures that can help to minimise risk of vascular compromise during dermal filler procedures2,4,6-10

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Further, it is important to know the anatomical plane and depth required for each injection and to proceed with caution, particularly in areas at high risk of necrosis such as the glabella and nasal ala.4,3 Where there is minimal collateral circulation in the small calibre vessels at the glabella, for example, all injections should be superficial to avoid intra-arterial injection.4,16

of risk of vascular compromise. It is incumbent upon practitioners to be aware of published data when it comes to aspiration methods, assessing their own practice and following recommendations. When aspiration is used, it should be used alongside a wider range of measures to minimise the risk of complications, including vascular occlusion when administering dermal fillers.

Patient history Always take a detailed patient history, paying particular attention to patients with previous surgical and cosmetic procedures as well as current medication and allergies.3,4 Be aware that deep tissue scars can fix arteries in place making them more vulnerable to needle penetration.9

Dr Ahmed El Houssieny is a trained anaesthetist and currently works as an aesthetic specialist in Warrington and Hale. He is an honorary lecturer at the University of Chester and an education provider on cosmetic procedures. Dr El Houssieny is an associate member of the British College of Aesthetic Medicine. Qual: MBBCH

Volume of filler It is broadly acknowledged that low volumes of filler administered in two or more treatment sessions reduces the risk of vascular injury.6,24,30 Injecting a large bolus filler into an artery in error can lead to a column of filler with a greater chance of occluding the vessel.23 The Aesthetic Interventional Induced Visual Loss (AIIVL) Consensus Group published guidelines which echo the recommendations of other experts that small volumes of less than 0.1ml per bolus of filler should be injected for all filler procedures in the head and neck region.6,24,32 A small cadaver study focusing on the anatomy of the facial vasculature found that the volume of the supratrochlear artery to be 0.085ml on average, supporting the recommendation for filler volumes of under 0.1ml.33 Other practitioners recommend different volumes, some as small as 0.05ml or less than 0.04ml depending on facial area, but the principal is to use the smallest volume of filler that is practical and administer the overall required amount in more than one session.7,16 Time taken for filler injection In addition to using low volumes for each injection, it is widely advised that dermal filler should be injected slowly.4,6,8,34 This method aims to decrease the risk of occlusion by limiting the amount of filler injected at any one time and is widely recommended.4,6,8 Pressure applied to the syringe during injection should be low.6 The slow, low-pressure method means that even if needle or cannula placement is intraarterial, the contents of the syringe will not be propelled retrograde in the vessel.6 Slow injection also enables immediate discontinuation of the injection if symptoms and signs such as blanching, signifying vascular compromise, occurs.4,10,15

Summary It is vital to know how to identify and respond to vascular compromise if it occurs.4,9,34 Choosing a reversible filler means the practitioner has an additional treatment approach to the other recommended options if vascular compromise is identified. It would be difficult to name a procedure carried out in aesthetic medicine that does not carry risk. As dermal filler injections are increasingly used, it is of vital importance for practitioners to do what is possible to mitigate the risk of rare but serious complications brought about by vascular occlusion. Much of the research around minimising this risk has been conducted or in cadaver studies and with small numbers. While the evidence this provides is valuable, further evidence from large-scale studies would be of great value in establishing best practice. We do know that aspiration prior to injection can result in a false-negative; however, it can also give a true positive result. As such, it is a quick and noninvasive test that can make a valuable contribution to the reduction

REFERENCES 1. Haneke, E. Managing complications of fillers: rare and not-so-rare. J Cutan Aesthet Surg. 2015 Oct-Dec; 8(4):198–210. 2. Casabona G. Blood aspiration test for cosmetic fillers to prevent accidental intravascular injection in the face. Dermatol Surg. 2015;41:841–847 3. Park TH, Seo SW, Kim JK, Chang CH. Clinical experience with hyaluronic acid-filler complications. J Plast Reconstr Aesthet Surg. 2011 Jul;64(7):892–896. 4. 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. 5. Roberts SA, Arthurs BP. Severe visual loss and orbital infarction following periorbital aesthetic poly(L)-lactic acid (PLLA) injection. Ophthal Plast Reconstr Surg 2012;28:e68–e70. 6. Lazzeri D, Agostini T, Figus M, Nardi M, et al. Blindness following cosmetic injections of the face. Plast Reconstr Surg 2012;129:995–1012 7. Van Loghem JA, Fouche JJ, Thuis J. Sensitivity of aspiration as a safety test before injection of soft tissue fillers. J Cosmet Dermatol. 2018 Feb;17(1):39-46. doi: 10.1111/jocd.12437. Epub 2017 Oct 7. 8. Carey W, Weinkel S. Retraction of the Plunger on a Syringe of Hyaluronic Acid Before Injection: Are We Safe? Dermatol Surg 2015;41:S340–S346 9. DeLorenzi C. Complications of Injectable Fillers, Part 2: Vascular Complications. , Volume 34, Issue 4, May 2014, 584–600. 10. Ozturk CN, Li Y, Tung R, Parker L, et al. Complications following injection of soft-tissue fillers. Aesthet Surg J 2013;33:862–77. 11. Sepah Y, Samad L, Altaf A, Halim MS, Rajagopalan N et al. Aspiration in injections: should we continue or abandon the practice? 2017; 3:157. 12. Aguilera SB, Tivoli YA, Seastorm SJ. How to make calcium hydroxlapatite injections safer. J Drugs Dermatol.2014 Sep;13(9):1015 13. Alam, M, Dover JS. (2007). Management of Complications and Sequelae with Temporary Injectable Fillers. Plastic and Reconstructive Surgery, 120(Supplement), 98S–105S. 14. Sezgin B, Ozel B, Bulam H, et al. The effect of microneedle thickness on pain during minimally invasive facial procedures: A clinical study. Aesthetic Surg J 2014;34(5):757-765 15. Carruthers et al. Blindness caused by cosmetic filler injection: a review of cause and Therapy. Plast Reconstr Surg. 2014;134:1197. 16. Sykes JM, Cotofana S, Trevidic P, Solish N, et al. Upper face:clinical anatomy and reginoal approaches with injectabkle fillers. Plast reconstr Surg.2015:136:240S 17. Beer K, Downie J, Beer J. A Treatment Protocol for Vascular Occlusion from Particulate Soft Tissue Augmentation.2012;5(5):44–47. 18. Signorini M, Liew S, Sundaram H et al. Global Aesthetic Consensus:avoidance and management of complications from HA acid fillers-evidence and opinion based review and consensus recommendations. Plastic Reconstr Surg.2016;137:961-971 19. Kontis TC, Bunin L, Fitzgerald R. Injectable Fillers Panel Discussion, Controversies, and Techniques. Injectable Fillers. Facial Plastic Surgery Clinics of North America, 2018;26(2), 225–236. 20. Van Loghem JA, Humzah D, Kerscher M. Cannula Versus Sharp Needle for Placement of Soft Tissue Fillers: An Observational Cadaver Study. Aesthetic Surgery Journal 2018; 38(1): 73–88. 21. Pavicic T, Webb KL, Frank K et al. Precision in dermal filling: a comparison between needle and cannula when using soft tissue fillers. 22. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatement approaches.Clin Cosmet Investig Dermatol. 2013 Dec 12;6:295-316 23. Niamtu J. Filler Injection with Micro-Cannula Instead of Needles. Dermatol Surg 2009;35:2005– 2008. 24. Coleman SR. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesthet Surg J 2002 Nov;22(6):555–557. 25. Pavicic T, Webb KL, Frank K et al. Arterial wall penetration forces in needles versus cannulas. 2019 Mar;143(3):504e–512e. 26. 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. 2019;39:662–674. 27. Cohen J. Integrating cannulas into your filler practice. https://www.the-dermatologist.com/content/ integrating-cannulas-your-filler-practice. Accessed 30th Oct 2019 28. Iwayama T, Hashikawa K, Fukumoto T. Ultrasonography-guided cannula method for hyaluronic acid filler injection with evaluation using laser speckle flowgraphy. Plast Reconstr Surg Glob Open. 2018 Apr; 6(4): e1776. 29. Torbeck RL, Schwarcz R, Hazan E, Wang J, et al. In vitro evaluation of preinjection aspiration for hyaluronic fillers as a safety checkpoint. 2019 Jul;45(7):954–958. 30. Cohen JL. Understanding, avoiding, and managing dermal filler complications. 2008;4(s1):S92– S99. 31. Sieber DA, Scheuer JF, Rohrich RJ. Review of three-dimensional facial anatomy: injecting fillers and neuromodulators. 2016;4(12 suppl):e1166. 32. 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;18:71–76. 33. Khan TT, Colon-Acevedo B, Mettu P, DeLorenzi C, Woodward, JA An Anatomical Analysis of the Supratrochlear Artery: Considerations in Facial Filler Injections and Preventing Vision Loss. 2017:37(2);203–208. 34. Emer J, Waldorf H. (2011). Injectable neurotoxins and fillers: There is no free lunch. . 2011;29(6):678– 690.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Forehead The forehead is a highly sensitive area and knowledge of the nervous distribution in this area is recommended not only for safety but also the comfort of the procedure. The supraorbital nerve and supratrochlear nerve traversing the forehead, in my practice, are anesthetised. The supraorbital nerve is one of the terminal cutaneous branches of the frontal nerve, which is a branch of the ophthalmic division of the trigeminal nerve. It provides sensation to the forehead skin and anterior scalp. The supraorbital nerve originates from the supraorbital notch, which can be identified upon palpation of the supraorbital rim.3 The deep branch of the supraorbital nerve appears to have a reproducible location. In a study examining 75 patients undergoing endoscopic browlifts, the location of the deep branch was observed at an average of 0.56mm from a vertical line drawn tangentially to the medical limbus of the iris.4 This reproducible location allows us to perform a supraorbital block with consistency. I insert the syringe immediately Dr Munir Somji outlines the importance of inferior to the eyebrow and inject understanding facial nerve anatomy for safe anaesthetic proximal to the supraorbital and successful dermal filler treatments notch. The supratrochlear nerve is also one of the terminal branches of the frontal branch The goal of every injectable procedure is to perform an effective, of the ophthalmic division of the trigeminal nerve. In 30% of cases, safe treatment with minimal pain. Therefore, a thorough knowledge the supratrochlear nerve arises together with the supraorbital nerve. of the neurovasculature in this area is desirable. Injectable vascular It provides sensation to the midline forehead.5 anatomy features heavily within literature, with good reason, given the possibility of intra and extra vascular occlusion and its sequela. There Fat is, in contrast, a paucity of guidance and appreciation for the nervous Facial nerves compartments distribution of the face when injecting dermal fillers.

Considering Facial Nerve Anatomy

Nerve distribution in the face The facial nerve and the trigeminal nerve are the two major nerves we encounter upon injecting the face. The trigeminal nerve splits into three main parts: the ophthalmic nerve, the maxillary nerve and the mandibular nerve. The trigeminal nerve passes through the foramina of the skull and divides into independent facial sensory components. In contrast, the facial nerve has one nerve trunk that passes through the stylomastoid foramen and separates into two divisions: the cervicofacial and temporofacial divisions within the parotid gland. Later, it branches off into temporal, zygomatic, buccal, marginal mandibular and cervical branches.1 Nerve injury secondary to dermal filler injection may be transient, reversible or permanent. Inadvertent nerve damage is a rare complication of dermal filler procedures and can occur as a result of both sharp and blunt force trauma where the nerve is encountered by the needle or cannula. This can cause the nerve to either be pierced or partially lacerated by the needle. Other possible methods of nerve injury are direct injection into a nerve, tissue compression secondary to dermal filler placement and excessive moulding and massage of dermal filler into a nerve foramina. Neuropraxia would almost certainly occur and will result in sensory and/or motor deficits.2

Sensory nerves Deep lateral eyebrow (Charpy)

Motor nerves Supra-orbital

Lateral Infra-orbital Medial Infra-orbital Deep Medial Cheek

Supratrochlear Auriculotemporal Infraorbital Zygomaticofacial Fronto-temporal branch (facial nerve) Zygomatic branch (facial nerve) Facial

Deep Lateral Cheek

Buccal branch (facial nerve) Marginal mandibular branch (facial nerve) Mental Cervical branch (facial nerve)

Figure 1: Facial nerves and deep fat compartments. CopyrightŠ 2020 Philippe Plateaux/Laboratoires VIVACY. All rights reserved.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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However, in most cases, I find that a supratrochlear block requires a separate injection lateral from the facial midline at the level of the superior orbital rim. When treating the lateral limits of the forehead, a regional local anaesthetic injection may be required. I find this especially useful if one is using a cannula entry point at this location.

Temple There are a number of different planes of injection when treating the temple. The most commonly used technique is the plane between the temporalis muscle and the bone of the temporal fossa. A superomedial temple injection in this plane would negate vascular risk, along with avoiding the zygomaticotemporal nerve.6 The second plane is the area between the superficial and deep layer of the deep temporal fascia. The third plane is the area between the deep temporal fascia and temporalis muscle.6,7 Another plane I use in patients with significant hollowing is the area between the superficial temporal fascia and the deep temporal fascia. In this area, I only use a cannula. This is because I wish to minimise the possibility of damaging the superficial temporal artery and vein, as well as the frontal branch of the facial nerve. In order to prevent damage to neurovascular structures in this plane, I use a 22 gauge cannula as opposed to smaller gauges.

risk within and this plane and should be avoided.14 The mental nerve is of significance within this region. During chin augmentation, a mental nerve block is required. This can be performed either intraorally or extraorally. Care should be exercised whilst performing the block to prevent trauma to the nerve, which may result in lack of sensation to the front of the chin and lower lip.8 Supraperiosteal dermal filler injections in the area should also be treated with caution.

Prevent nerve injury Nerve injury secondary to dermal filler injection may be transient, reversible or permanent. Care should be taken when performing nerve blocks prior to dermal filler injections. The appropriate choice of cannula or needle should be assessed dependent upon the plane of injection, as well as the presence of neurovascular structures. Aftercare given to the patient must also state to avoid aggressive or firm massage of filler to avoid post-injection iatrogenic nerve injury. Certainly, with the use of hyaluronic acid, many of these complications are theoretically reversible given the widespread use of hyaluronidase. Extra caution should be advised when using permanent fillers near danger areas.

Cheek In the malar region, location of the infraorbital foramen is vital to prevent neuropraxia in this region. Nerve injury can result from performing an infraorbital nerve block.8 Fortunately, most dermal fillers are premixed with lidocaine, reducing the need for infraorbital nerve blocks in the area. Augmentation of the upper lip, however, can require such a block and, if performed either intraorally or extraorally, caution should be exercised to avoid injecting the anaesthetic inside of the orbit, which can result in diplopia as well as dysaesthesia and paraesthesia.9 As mentioned previously, it is possible for dermal filler to be moulded towards a foramina. Aldbagh and Cox noted in a single case study how overzealous massage of dermal filler post injection could cause this exact phenomenon. The patient experienced paraesthesia over the distribution of the infraorbital nerve. It was concluded that excessive massage post dermal filler injection was not advised.10 The incidence of Bell’s palsy has been seen post dermal filler injections.11 Most patients have been shown to recover spontaneously (71%), however there is a significant proportion of patients with lifelong residual hemifacial weakness. The acute management of Bell’s palsy remains a short course of oral steroids. Surgical decompression, and other treatments have been proposed such as electrotherapy, physical therapy and acupuncture; none of which have any supporting evidence. Given the debilitating consequences, this further highlights the importance of comprehensive injectable facial anatomy when injecting the face.12

Lower face The marginal mandibular nerve can be injured during cheek injections, as well as around the jawline and neck. Care should be taken when injecting the mid-mandibular border even with a cannula, as blunt force trauma can cause injury to the nerve resulting in motor deficit.13 In most cases, the nerve travels anteriorly above the mandibular border, but in 19% of cases the nerve is located below the border of the mandible.14 Injury in the neck can occur in the subplatsymal plane. Neck dermal fillers should be exercised with caution, with particular attention being paid to whether the injections are not directed to the subplatysmal plane. The cervical branch of the facial nerve is also at

13 & 14 MARCH 2020 / LONDON

Dr Munir Somji will be speaking at ACE 2020 in an Expert Clinic titled Laboratories Vivacy: Art of Face Volumisation and Contouring Using STYLAGE Dermal Fillers on March 14. Register free using code 15100 aestheticsconference.com Dr Munir Somji is the chief medical officer of DrMedispa clinics in Marylebone and Essex, specialising in facial aesthetics and hair restoration surgery. He is the founder of Drmedispa Academy, which focuses on a safe anatomical based approach to facial aesthetics. Qual: BSc (Hons), MBBS, MRCS, PGCert (Clinical Education) REFERENCES 1. Moore, Keith L, and Arthur F. Dalley. Clinically Oriented Anatomy. Philadelphia: Lippincott Williams & Wilkins, 1999. Print. 2. Funt D, Pavicic T, Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Plast Surg Nurs (2015) 35:13–32 3. Agthong S, Huanmanop T, Chentanez V. Anatomical variations of the supraorbital, infraorbital, and mental foramina related to gen- der and side. J Oral Maxillofac Surg 2005;63(6):800–804 4. Cuzalina AL,Holmes JD.Asimple and reliable landmark for identication of the supraorbital nerve in surgery of the forehead: an in vivo anatomical study. J Oral Maxillofac Surg 2005;63(1):25–27 5. Beer GM, Putz R, Mager K, Schumacher M, Keil W. Variations of the frontal exit of the supraorbital nerve: an anatomic study. Plast Re- constr Surg 1998;102(2):334–341 6. Moradi A, Shirazi A, Perez V. A guide to temporal fossa augmentation with small gel particle hyaluronic acid dermal filler. J Drugs Dermatol 2011;10(6):673-6. 7. de Maio M, Rzany B. Injectable Fillers in Aesthetic Medicine. Berlin, Germany, Springer; 2014:75. 8. Hadzic A, Carrera A, Clark TB, et al. Hadzic’s Peripheral Nerve Blocks and Anatomy for UltrasoundGuided Regional Anesthesia. 2nd ed. New York, New York: McGraw-Hill;2012. 9. Kanakaraj M, Shanmugasundaram N, Chandramohan M, Kannan R, Perumal SM, Nagendran J. Regional anesthesia in faciomaxillary and oral surgery. J Pharm Bioallied Sci 2012;4:S264–S269. 10. Bishr Aldabagh, MD; Sue Ellen Cox, MD. Temporary Infraorbital Nerve Sensory Disturbance Following Perioral Injection of a Soft Tissue Filler – Case Report Cosmetic Dermatology 2013. 11. Fitzgerald R, Bertucci V, Sykes JM, Duplechain JK (2016) Adverse reactions to injectable fillers. Facial Plast Surg 32(5):532–555 12. Glass GE, Tzafetta K (2014) Optimising treatment of Bell’s Palsy in primary care: the need for early appropriate referral. Br J Gen Pract 64(629):e807–e809 13. Anthony DJ, Oshan Deshanjana Basnayake BM, Mathangasinghe Y, Malalasekera AP. Preserving the marginal mandibular branch of the facial nerve during submandibular region surgery: a cadaveric safety study. Patient Saf Surg. 2018;12:23. Published 2018 Aug 23. doi:10.1186/s13037-018-0170-4 14. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg Transplant Bull 1962;29(3):266–27

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Selecting the correct wavelength There are numerous peaks in the Hb/HbO2 absorption spectra as shown in Figure 1. Because melanin absorption is relatively high, in the 400-500 nm range, lasers in this wavelength are not specific enough for Hb/ HB02 and would risk side effects such as permanent hypopigmentation.3 Wavelengths in the 500-600 nm (green to yellow light) range are the mainstay for vascular lesions as they are highly absorbed by Hb and relatively less well absorbed by melanin.3 Lasers which are suitable for vascular indications are:5

Choosing Lasers for Vascular Concerns Dr Asif Hussein and Dr Sajjad Rajpar share considerations for treating facial vascular concerns with lasers With various options available on the market, selecting a laser for vascular lesions can be a challenge, especially to less experienced practitioners. This article discusses the core principles that determine choice of laser and considerations for successful results for facial vascular concerns.

Light-tissue interaction A sound understanding of laser-tissue interactions is required as this underpins clinical laser dermatology. The target chromophore in the treatment of vascular lesions is haemoglobin.1 Water can also be a secondary target. Haemoglobin comes in various oxygenation states: oxyhaemoglobin (Hb02), methaemoglobin and deoxyhaemoglobin.2 The varying oxygenation states have subtle differences in absorption spectra as shown in Figure 1. This is an important consideration when refining choice of laser.

Molar extinction coefficient (cm-1 M-1)

Molar extinction coefficient vs. wavelength

105

104

103

• 532 nm KTP (potassium titanyl phosphate) • 578 nm copper bromide laser • 585-595 nm PDL (flashlamp pumped pulsed dye laser) Melanin absorption is still significant for these wavelengths and is mitigated by cooling the epidermis and selecting an appropriate pulse duration to target vessels. Despite this, these lasers should be used with caution in darker skin types (defined as Fitzpatrick IV-VI), as the risk of dyspigmentation may outweigh treatment benefits.6 The 800-1100 nm (infrared light) range is also very useful for treatment of vascular lesions including:3 • 810 nm diode • 940 nm diode • 1064 nm long pulsed Nd:YAG Due to lower melanin absorption, these wavelengths are safer on darker skin types.7 Importantly, water absorption increases dramatically from 800-1100 nm, which can lead to bulk heating of tissue.3 Cooling of nontarget tissue is essential when using these lasers, otherwise indiscriminate thermal injury and scarring may result. Longer wavelength lasers penetrate deeper, with the Nd:YAG being the deepest penetrating laser in human tissue. It is important to be cautious of deeper-end arteries such as the alar artery when treating nasal thread veins, which may become inadvertently coagulated, leading to necrosis. Periorbital veins must be treated with caution as well and the use of internal metal eye shields is mandatory.8

Selecting the correct pulse duration 300

400

500

600

700

800

900

Wavelength (nm)

Figure 1: HbO2 (oxyhaemoglobin) and Hb (deoxyhaemoglobin) absorption spectra2,4

1000

When selecting laser parameters, a pulse duration that is close to the thermal relaxation time of the target should be selected.9 This ensures energy is confined

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Blood vessel diameter (telangiectasia 0-1mm)

TRT of whole structure

100 micrometres

10 milliseconds

400 micrometers

80 milliseconds

800 micrometers

300 milliseconds

Figure 2: Thermal relaxation times of blood vessels <1mm in diameter10

Dermal Structures

TRT of whole structure

Melanosome 0.5 micrometers

25 nanoseconds

Melanocyte 10 micrometers

1 microsecond

Hair follicle 200 micrometers

40 milliseconds

Figure 3: Competing structures in the skin and their thermal relaxation times10

to the target. Targets within the skin and their relevant thermal relaxation times are listed in Figure 2 and 3. Larger vessels have greater thermal relaxation times than smaller vessels and therefore require delivery of energy over a longer period of time. Telangiectasia (blood vessels <1mm in diameter) require pulse durations in the region of 1-60 milliseconds.3,10

Selecting the correct spot size

Tips for treating facial concerns Redness, rosacea and telangiectasia are common vascular facial concerns that can be effectively treated using lasers. Facial telangiectasia are upper dermal vessels measuring less than 1mm in diameter.2 They can occur from: intrinsic ageing of the skin, photodamage, rosacea, poikiloderma of Civatte, Osler-Weber-Rendu (hereditary haemorrhagic telangiectasia), CREST syndrome (spider angiomas), generalised essential telangiectasia, following chronic topical steroid usage, following radiotherapy or around a surgical scar in fair skin types.2 The principal chromophore for facial telangiectasias is HbO2, and the 532 nm and long pulse PDL (585-595 nm) are suitable laser choices for facial telangiectasias under 1mm in diameter as both wavelengths approximate to the Hb02 absorption peaks.2,3 When treating a smaller blood vessel, shorter pulse durations are required as smaller blood vessels will have smaller thermal relaxation times. Short pulse durations may lead to vessel wall rupture

Larger spot sizes permit deeper penetration of laser energy. Deeper vessels therefore require larger spot sizes. Facial telangiectasia are usually superficial within the papillary or upper reticular dermis; comparably, leg telangiectasia are usually deeper, 1mm or more below the skin surface.3 With a 1064 nm, a small spot size of 3mm is adequate for facial telangiectasia, but inadequate for deeper leg telangiectasia. A spot size of >6mm would be much more suitable for leg telangiectasia over 3mm in diameter.11 A spot size of 4-6mm on the face, however, would be extremely dangerous as the additional penetration from the larger spot size could lead to bulk thermal heating and coagulate superficial end arteries, such as the alar artery. As a general principle, treatment on the face should be confined to small spot sizes and to the smallest fluence sufficient to heat a blood vessel.3 Larger spot sizes are required for leg veins where a greater depth of penetration is required – larger spot sizes ensure a greater chance of panvessel heating. However, there is greater bulk Figure 4: Patient presenting with type 1 rosacea and two heating and risk of damage weeks after one session of treatment with 532 nm, 8mm 12 to collateral tissues. spot. Photos courtesy of Dr Asif Hussein.

and purpura. Purpura is an annoyance for patients as the bruising can last for several days, leading to undesirable downtime, which must be discussed during consent.3 Historically, the PDL has been considered the gold-standard for treating vascular lesions.2 Compared to the original 532 nm which used KTP, the PDL had a large enough spot size with adequate power to have utility for the greatest indications. Historically, KTP-based 532 nm lasers had spot sizes of 2mm or less, lacked power, and relied on shot stacking to create a quasi-continuous laser to achieve a therapeutic result with increased risk of epidermal injury.13 These features effectively excluded KTP lasers for diffuse redness, rosacea, and larger port wine stains, despite the fact that the absorption by Hb02 of 532 nm is five times greater than it is for 595 nm.3 Melanin absorption is, however, only 10% greater for 532 nm compared to 595 nm; consequently the ‘vascular to melanin damage’ ratio is much greater for 532 nm than for 595 nm.3 Since 2007, KTP lasers have offered larger spot sizes with adequate power. This allows for effective treatment of diffuse redness and larger port wine stains – yet their generalised use has been less widespread. More recently, 532 nm lasers using lithium triborate (LBO) crystals instead of KTP have offered stability, larger spot sizes and enhanced power.3 Figure 4 shows a Type 1 rosacea patient treated with a single session of large spot 532 nm LBO laser. In our experience, multiple treatments with combined Nd:YAG and PDL would be required to get this level of clearance. A single-blind, split face, controlled comparison study involving 15 subjects with facial redness and telangiectasias indicated

Figure 5: Treatment of larger nasal telangiectasia with Cutera Excel V+ 3mm spot 1064 nm. Photos courtesy of Dr Asif Hussein.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Optical coherence tomography Optical coherence tomography (OCT) is a non-invasive way of looking at small structures under the skin. OCT can determine the depth and diameter of cutaneous vessels.16 While not a standard procedure, increasing utility for OCT in inflammatory and malignant skin conditions is being reported.17 We find that OCT provides Figure 6: Optimisation of laser parameters with Vivosight optical coherence tomography. Photo valuable information selecting the courtesy of Dr Asif Hussein. correct parameters, especially for complex lesions. A vascular laser workstation can safely and effectively treat the majority of cutaneous vascular lesions in practice.

vessels and cause transient vasoconstriction, giving a false impression of clearance. The Nd:YAG is the preferred choice by most for vessels >1mm in diameter.3 We use the long pulsed Nd:YAG for these indications, as this provides a deeper penetration. Facial telangiectasias are treated with a 2-3mm spot size to limit collateral damage to deeper facial arteries that may occur with larger spot sizes. Intra-ocular metal eye shields must be used when treating vessels near the orbital margin. Treatment within the bony orbit should be carried out with extreme caution. Treatment with the long pulsed Nd:YAG for facial vasculature of >0.5mm in diameter is well established.15 Bulk heating is mitigated by cooling the skin well and never overlapping shots. A spot-welding technique with spatial gaps between shots is used. Figure 5 shows a gentleman who has relatively large >0.5mm nasal telangiectasia. These were completely cleared with two sessions of long pulsed Nd:YAG treatment four weeks apart.

Longer wavelength lasers penetrate deeper, with the Nd:YAG being the deepest penetrating laser in human tissue

that large spot 532 nm KTP was superior to 595 nm PDL in all treated subjects.14 There was more transient swelling and erythema with the KTP. This has always proven to be true in our experience. In line with this paper, we find that the large spot laser is generally more effective than the large spot 595 nm PDL in treatment of rosacea, facial redness and red telangiectasia. Greater swelling and oedema arises with KTP and this is probably due to increased 532 nm wavelength absorption by melanin and haemoglobin, resulting in more diffuse epidermal and superficial dermal inflammation. However, even though 532 nm is more highly absorbed by epidermal melanin, the relative ratio between haemoglobin to melanin absorption is much greater with 532 nm compared to 595 nm.3

Larger facial telangiectasias The penetration of laser energy becomes insufficient to heat the full cross section of greater than 0.6mm in diameter. The KTP/PDL may thermally damage the ceiling of larger

Summary We offer both 532 nm and 595 nm wavelengths in practice. However, for the everyday common indications of rosacea, facial redness and telangiectasia, we find a 532 nm/1064 nm (NdYAG) vascular workstation offers superior outcomes and greater stability, with lower running costs compared to the 595 nm/1064 nm (PDL/ Nd:YAG).

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Dr Asif Hussein specialises in cosmetic dermatology and cutaneous laser surgery. He is clinical director of DrHConsult and medical director at sk:n London Westminster. Dr Hussein partners and operates with Dr Sajjad Rajpar at Belgravia Dermatology London and his specialist interests include fully ablative laser surgery and cutaneous vascular laser. Qual: MBBS DHMSA DipDerm Dr Sajjad Rajpar is a consultant dermatologist at Belgravia Dermatology, specialising in laser and surgical dermatology. Dr Rajpar qualified from Birmingham University in 2000 and completed dermatology training in the West Midlands, which led to a specialist fellowship training in Mohs surgery and cosmetic dermatology in New Zealand. Qual: MBChB (Hons) FRCP REFERENCES 1. Bencini PL, Tourlaki A, De Giorgi V, Galimberti M. Laser use for cutaneous vascular alterations of cosmetic interest. Dermatol Ther 2012; 25: 340–351. 2. Joo J, Michael D, Kilmer S. ‘Laser Treatment of Vascular Lesions.’ In Lasers in Dermatoloy and Medicine. Nouri K, editor. Springer International Publishing; 2018. 3. Ross EV, Anderson RR. Laser Tissue Interactions. Book chapter in Goldman M, Fitzpatrick R, Ross EV, Kilmer S, Weiss R eds. Lasers and Energy Devices for the skin. 2ned Ed. CRC Press, 2013 4. Oregon Medical Laser Center, Generic tissue optical properties, 2015. <https://omlc.org/news/feb15/generic_optics/index.html> 5. Adamič, M., Pavlović, M., et al., (2015), Guidelines of care for vascular lasers and intense pulse light sources from the European Society for Laser Dermatology. J Eur Acad Dermatol Venereol, 29: 1661-1678. 6. Bain Jayanta, Sarkar Arindam, et al., Clinical experience using neodymium-doped yttrium aluminum garnet laser in cutaneous vascular malformations among Indian patients. J Nat Sc Biol Med 2019; 10(2): 184-188. 7. Karen J, Callahan S. Laser Treatment of Leg Veins. Lasers in Dermatoloy and Medicine. Nouri K, editor. Springer International Publishing; 2018; 8. Huang A, Phillips A, Adar T, Hui A. Ocular Injury in Cosmetic Laser Treatments of the Face. J Clin Aesthet Dermatol. 2018;11(2):15–18. 9. Nelson JS, Milner TE, et al., Laser pulse duration must match the estimated thermal relaxation time for successful photothermolysis of blood vessels. Laser Med Sci (1995) 10: 9. 10. Abramson Lloyd A, et al., Laser-Tissue Interactons. In In Lasers in Dermatoloy and Medicine. Nouri K, editor. Springer International Publishing; 2018. 11. Asiran SerdarZ, Fisek IzciN. The evaluation of long‐pulsed Nd:YAG laser efficacy and side effects in the treatment of cutaneous vessels on the face and legs. J Cosmet Dermatol. 2019;00:1–6. 12. Sadick N, Sorhaindo L. Laser treatment of telganiectasias and reticular veins. In: The Vein Book. Bergan JJ, Bunke-Paquette N. 13. Lanigan S.W. (2005) Laser Treatment of Vascular Lesions. In: Goldberg D.J. (eds) Laser Dermatology. Springer, Berlin, Heidelberg). 14. Nathan S. Uebelhoer DO, et al., A Split‐Face Comparison Study of Pulsed 532‐nm KTP Laser and 595‐nm Pulsed Dye Laser in the Treatment of Facial Telangiectasias and Diffuse Telangiectatic Facial Erythema, Dermatologic Surgery, 2007. 15. Kemal Ozyurt, et al, Treatment of Superficial Cutaneous Vascular Lesions: Experience with the Long-Pulsed 1064 nm Nd:YAG Laser, The Scientific Would Journal, 2012. 16. Waibel JS et al., Angiographic optical coherence tomography imaging of hemangiomas and port wine birthmarks. Lasers Surg Med. 2018 Mar 22 17. Olsen, J, et al., Advances in optical coherence tomography in dermatology—a review, J. of Biomedical Optics, 23(4), 040901 (2018).

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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References: 1. Juvéderm® VOLBELLA with lidocaine DFU. 72525JR12. Revision 2017-07-19. 2. Juvéderm® VOLIFT with lidocaine DFU. 72383JR14. Revision 2017-07-19. 3. Juvéderm® VOLITE DFU. 73140JR11. Revision 2017-07-19. 4. Juvéderm® VOLUX DFU. 72778JR10. Revision 2018-07-26. 5. Juvéderm® VOLUMA with lidocaine DFU. 72475JR13. Revision 2017-07-19. 6. Allergan. Unpublished Data. INT/0771/2016(2). JUVÉDERM®, the world’s leading brand of hyaluronic acid facial fillers. Feb 2019. Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026. ©2020 Allergan. All rights reserved. Model treated with JUVÉDERM®. Individual patient results may vary. Material developed and produced by Allergan. UK-JUV-2050023 | February 2020


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Understanding Aesthetic Ideals of Asian Patients

structural features.1 There is a growing number of Chinese tourists, students and working professionals coming to the UK. In fact, the number of visitor visas granted to Chinese nationals in 2018 rose by 11% to 587,986 and the number of Tier 4 (sponsored study) visas rose by 13% to 99,723 when compared to the previous year.2,3 The medical aesthetics market in 2018 in China totalled US $32.4 billion and in the past three years, the average annual growth rate of this industry was 31.83%.4 The significance of these statistics, coupled with the differences in aesthetic ideals, warrants a greater understanding of this demographic for UK-based aesthetic practitioners so that they can provide better treatment outcomes with higher patient satisfaction.

Assessment

When assessing and treating the Asian patient it is important to first consider the face shape. A large national survey on the ideals of facial beauty amongst the Chinese population, published by aesthetic practitioner and Aesthetics Clinical Advisory Board member Dr Souphiyeh Samizadeh Dr Varna Kugan explores the aesthetic ideals and Singaporean plastic surgeon Dr Woffles Wu in and key differences when treating Asian versus 2018, found that the most preferred facial shapes oval (38.94%, long, thin face with pointy chin), Caucasian patients and why this is important to were followed by heart shape (24.06%, inverted triangle).5 consider in today’s clinical practice The next important element to take into account is the deficiency in the projection of midline facial This article draws upon publications and my clinical experience structures such as the forehead, glabella, medial cheek, nose and at PICO Clinic in London to outline the key differences in chin; giving a flatter appearance. By providing anterior projection to treating and managing the aesthetic expectations of Asian these midline structures one can create the illusion of ‘narrowing’ the versus Caucasian patients requesting non-surgical aesthetic whole face, as well as adding a more three-dimensional profile.6,7 treatments. Asians are not a homogenous group but rather An overview of the key objectives in treating Asian patients is comprise many varied ethnic origins.1 It is important to note that outlined in Table 1, and discussed in more detail according to when referring to ‘Asian’ patients, I will be referring to females anatomical area below. from mainland China. The majority of my patients are from mainland China, with very Upper face considerations different perceptions of beauty and, hence, treatment requests Whilst upper face volumisation of the forehead and glabella is when compared to Caucasians. They are also predominantly common in East Asia to enhance projection and to create a more students and young working professionals in the age range of convex upper third of the face,6 in my practice I am seeing younger 20-35. Their perceptions and requests are mainly influenced by Asian patients requesting volumisation for temple hollowing. differences in facial morphology, cultural beliefs (physiognomy) The hollowing in this age range, in most cases, is due to the and social trends. Notably, the most common treatment concerns anterolateral projection of the zygoma creating a wide bizygomatic among younger Asian patients are the result of underlying distance,1 together with a lower frontoparietal index.8 By volumising Anatomical area

Structural deficiency

Presenting complaint

Treatment objective

Temple

Low frontoparietal index, wide bizygomatic distance

Temple hollowing

Smooth transition from upper face to mid-face

Medial malar

Hypoplastic medial maxilla

Flat, concave central mid-face and perialar recession

Anterior projection

Infraorbital region

Hypoplastic infraorbital rim

Infraorbital fat herniation, tear trough deformity

Support lower eyelid and treat tear trough deformity

Nose

Low nasal bridge and recessed anterior nasal spine

Flat, short nose with retruded columella

Anterior projection, columella support

Chin

Hypoplastic mandible

Retrognathic chin

Anterior and vertical projection

Table 1: Summary of the key objectives in treating Asian patients1,8

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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the temples, one can create a smoother transition from the upper face to the mid-face, and thus also diminishing the prominence of the zygomatic arch. As such, lateral cheek contouring with hyaluronic acid is not welcomed by this demographic of patients, which contrasts with Caucasians.9,10 It is also important to note that Asian patients often have fewer rhytids in the upper face compared with age-matched Caucasians,11 which is due to lower recruitment of muscles in facial expression and communication in the forehead area.12

Mid-face considerations Cheeks The first area that I will discuss with my patients in the mid-face is the medial malar and infraorbital regions. A lack of anterior projection in the midline is a contributing factor to the lack of three-dimensional profile in the Asian population.1,13 There is an important relationship between the infraorbital region and the medial cheek; East Asians tend to display undergrowth of the medial maxilla, and, as a result, the orbit appears smaller with a hypoplastic infraorbital rim. This can result in a tired, depressed look, with flattening of the medial cheek and infraorbital region.1,13 A common presentation is the flat medial malar and the request for central projection, so-called ‘apple’ cheeks. By volumising this region, one can add fullness to the medial cheeks and, hence, anterior projection in this area. I prefer to treat the medial cheek with a cannula technique due to the close proximity of the infraorbital neurovascular bundle.14 My entry point is at the intersection between a vertical line from the lateral canthus and a horizontal line from the tragus to the alar fossa. I place the product in retrograde threads in the deep medial cheek fat and inferior part of the medial suborbicularis oculi fat (SOOF) planes, followed by a gentle massage, and I use between 0.5ml to 1ml of Juvéderm Voluma on each side depending on the degree of concavity. I usually see Asian patients present for correction of the tear trough deformity in isolation, but, in most instances, there is also lower eyelid bulging in association with a concave medial cheek. As such, I explain to the patient that by treating the tear trough as well as the medial cheek with hyaluronic acid fillers, we can provide more support to the lower eyelid and lid-cheek junction15 in addition to adding volume to the mid-face to enhance the anterior projection (Figure 1). Nose Another common treatment request by Asian patients is nonsurgical rhinoplasty. There are common nasal anatomic features in the Asian population which include a wide, flat dorsum and a

Figure 2: A 25-year-old Asian patient before and immediately after non-surgical rhinoplasty using 0.5ml of Juvéderm Voluma.

Figure 1: A 23-year-old Asian patient before and immediately after medial malar treatment using 0.6ml of Juvéderm Voluma on each side and tear trough treatment with 0.4ml of Teosyal Redensity II on each side.

wide, flat alar base associated with a short columella and low radix point.16 It’s important to understand that in general, I find the Asian population do not want to look ‘Western’ but rather would prefer subtle enhancements that add anterior projection in the midline.1 Chinese cultural beliefs suggest that a person with a short, flat nose is likely to be weak, inquisitive and dependent in nature.17 In addition, a higher nose signifies better self-confidence.18 In my experience, the most common presenting complaint with regards to the nose is a flat dorsum and low radix point. I add anterior projection to the dorsum with a cannula using an entry point at the nasal tip and I place the product in the midline in the supraperiosteal and perichondrial planes. When treating the dorsum, I will also treat the radix if necessary with a deep bolus injection onto the bone so that it is in line with the upper eyelash line to further enhance the aesthetic outcome. My product of choice is a highly cohesive one such as Restylane Lyft or Juvéderm Voluma. In most cases, there is also treatment indication for a short columella due to a recessed anterior nasal spine and so I will deposit a small bolus at this point using the same cannula entry point (Figure 2).

Figure 3: A 22-year-old Asian patient before and immediately after lower-face treatment using 3ml’s of Juvéderm Volux to reconstruct the chin using a combination of injection and cannula techniques. This was following the injection of 4 units of BoNT-A into each mentalis.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Key points from Dr Souphiyeh Samizadeh Aesthetics Clinical Advisory Board member Dr Souphiyeh Samizadeh is the founder of the Great British Academy of Aesthetic Medicine and has trained over 5,000 aesthetic doctors, dermatologists and plastic surgeons in China and internationally. She practises and trains in both China and London and holds an annual scientific congress in the field of aesthetic medicine in China. She has published works on the aesthetic ideals of the Chinese patient. Here are her key points for treatment success: 1. Be aware and familiar of general ethnic preferences.5 2. Be cognisant of your personal bias as practitioners. According to a paper I published, there are differences in the ideals of beauty between laypersons and aesthetic practitioners.22 3. Amongst Asians, and in particular Chinese, ideals of beauty are more than morphology differences.23 4. Most importantly, respect ethnicity, anatomical differences, personal choices, and patient expectations. The above references are a good guide, but do not generalise for your patients.5,22,23

Lower face considerations The Asian lower face is generally characterised by a wide bigonial distance due to well-developed mandibular angles, giving the appearance of a square shape from the frontal view.1,19 According to Samizadeh et al., the majority of Asian females prefer an obtuse jaw angle in comparison with an angular well-defined jaw angle.5 Masseteric hypertrophy in non-East Asians is mainly due to bruxism compared to the East Asian population, where it is mainly due to benign masseteric hypertrophy.20 Treating hypertrophic masseters with neuromodulators can help to create a more obtuse angle to the jaw and thus help achieve the aesthetic ideal. This is one of the most common treatment requests in young Asian women and I have also noticed this in my practice.19 Cultural beliefs state that a woman with a wide and square face is thought to bring unhappiness to her husband and that a person with a square jawline can imply that they are stubborn or ill-fated.19 I use 24 units of botulinum toxin A (BoNT-A) spread across three injection points in a triangular configuration on each side, ensuring I stay 1cm away from the anterior border of the masseter to avoid the risorius muscle. I also place my injections deep onto the mandible using a 20mm needle in the region of the inferior pole of the muscle belly for optimal results. A hypoplastic mandible can be a common finding in the Asian population, resulting in a retrognathic or retruded chin.1 This can also be associated with a hyperactive, high-riding mentalis, which exacerbates the poor vertical height and chin contour.21 By enhancing the vertical and anterior projection of the chin, one can create a more balanced three-dimensional profile. At the same time, I will usually augment the shape of the chin to create a slightly pointy chin with a rounded to triangular apex, which helps create the Asian aesthetic ideal chin shape.5 The patient in Figure 3 provides a good treatment example.

you. With the growing influx of Asian tourists, students and working professionals to the UK, it would be highly advantageous for aesthetic practitioners to educate themselves to respect and be familiar with the main structural differences, cultural differences, presenting complaints and treatment objectives when treating this demographic. Thus, ensuring better aesthetic outcomes, higher levels of patient satisfaction and retention. Dr Varna Kugan is a JCCP-registered aesthetic practitioner with more than five years of experience and a special interest in treating Asian patients. He is the clinical director at PICO Clinics in London, Milan and Shanghai, specialising in Asian aesthetics. He is also the lead trainer and head of PICO Academy. Qual: MUDr (MD) REFERENCES 1. Liew S, Wu WT, Chan HH, Ho WW, Kim HJ, Goodman GJ, Peng PH, Rogers JD, ‘Consensus on Changing Trends, Attitudes, and Concepts of Asian Beauty’, Aesthetic Plast Surg., 40 (2) (2016), 193-201 2. British Embassy Beijing, 2018 visa statistics show 11% growth in China (gov.uk, 2019) <https://www.gov. uk/government/news/2018-uk-visa-statistics-show-11-growth-in-china> 3. National statistics, Immigration statistics year ending December 2018, summary of latest statistics (gov.uk, 2019) <https://www.gov.uk/government/publications/immigration-statistics-year-endingdecember-2018/summary-of-latest-statistics> 4. Zheng Yiran, Allergan to offer training programs to medical cosmetics professionals (China Daily, 2019) <http://www.chinadaily.com.cn/global/2019-07/02/content_37486854.htm> 5. Souphiyeh Samizadeh and Woffles Wu, ‘Ideals of Facial Beauty Amongst the Chinese Population: Results from a Large National Survery’, Aesthetic Plast Surg., 42 (6) (2018), 1540-1550 6. Wu WT, Liew S, Chan HH, Ho WW, Supapannachart N, Lee HK, Prasetyo A, Yu JN, Rogers JD, Asian Aesthetics Expert Consensus Group, ‘Consensus on Current Injectable Treatment Strategies in the Asian Face’, Aesthetic Plast Surg., 40 (2) (2016), 202-214 7. Bae JM, Lee DW, ‘Three-dimensional remodeling of young Asian women’s faces using 20-mg/ ml smooth, highly cohesive, viscous hyaluronic acid fillers: a retrospective study of 320 patients’, Dermatol Surg., 39 (9) (2013), 1370-1375 8. Hee-Jin Kim et all, ‘Characteristics of Asian (Korean) Skull and Face’, in Clinical Anatomy of the Face for Filler and Botulinum Toxin Injection, (Springer, 2015), p.47 9. Y.Gao, J.Niddam, W.Noel, B.Hersant, J.P. Meningaud, ‘Comparison of aesthetic facial criteria between Caucasian and East Asian female populations: An esthetic surgeon’s perspective’, Asian Journal of Surgery, 41 (1) (2018), 4-11 10. Rho NK et al., ‘Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxyapatite Fillers’, Plast Reconstr Surg., 136 (5) (2015), 940-956 11. Nouveau-Richard S, Yang Z, Mac-Mary S, Li L, Bastien P, Tardy I, Bouillon C, Humbert P, de Lacharrière O, ‘Skin ageing: a comparison between Chinese and European populations. A pilot study’, J Dermatol Sci., 40 (3) (2005), 187-193 12. Tzou CH, Giovanoli P, Ploner M, Frey M, ‘Are there ethnic differences of facial movements between Europeans and Asians?’, Br J Plast Surg., 58 (2) (2005), 183-195 13. Yim HW, Nguyen AH, Kim YK, ‘Volume Augmentation in the Lower Eyelid and Cheek Areas’, Semin Plast Surg., 29 (3) (2015), 184-187 14. Hee-Jin Kim et all, ‘Facial vessels and their distribution patterns’, in Clinical Anatomy of the Face for Filler and Botulinum Toxin Injection, (Springer, 2015), p.35 15. Lee JH, Hong G, ‘Definitions of groove and hollowness of the infraorbital region and clinical treatment using soft-tissue filler’, Arch Plast Surg., 45 (3) (2018), 214-221 16. Park J, Suhk K, Nguyen AH, ‘Nasal Analysis and Anatomy: Anthropometric Proportional Assessment in Asians- Aesthetic Balance from Forehead to Chin, Part II’, Semin Plast Surg., 29 (4) (2015), 226-231 17. Oommen A, Oommen T, ‘Physiognomy: A critical review’, J Anat. Soc., 52 (2) (2003), 189-191 18. Wong FTC, Soo G, Ng W, van Hasselt CA, Tong MCF, ‘Implications of Chinese Face Reading on the Aesthetic Sense’, Arch Facial Plast Surg., 12 (4) (2010), 218-221 19. Kyle K Seo, ‘Different Facial Shapes and Different Aesthetic Standards Between Asians and Caucasians’ in Botulinum Toxin for Asians, (Springer 2016), pp. 39-41 20. Liew S, Dart A, ‘Nonsurgical reshaping of the lower face’, Aesthet Surg J., 28 (3) (2008), 251-257 21. Hsu AK, Frankel AS, ‘Modification of Chin Projection and Aesthetics with OnabotulinumtoxinA Injection’, JAMA Facial Plast Surg., 19 (6) (2017), 522-527 22. Samizadeh, S, The Ideals of Facial Beauty Among Chinese Aesthetic Practitioners: Results from a Large National Survey, Aesthetic Plastic Surgery, February 2019, Volume 43, Issue 1, pp 102–114 23. Samizadeh S, Chinese facial physiognomy and modern day aesthetic practice, J Cosmet Dermatol. 2020 Jan;19(1):161-166.

Education is key There is a Chinese proverb that states, ‘learning is a weightless treasure you can always carry easily’, which means that unlike material goods, your education is something you always take with

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Exploring the Skin and Gut

a healthy digestive system, fats, proteins and carbohydrates break down into fatty acids, amino acids and sugars, which are passed through the intestinal lining, then absorbed into the bloodstream and distributed to where they are needed. If incompletely digested, proteins leak from the gut into the bloodstream, immune cells detect them as ‘foreign’ – just like would – and mount an immune response. Because Nutritionist Sarah Carolides explains the microbes of this, we can suddenly develop intolerances to foods that we relationship between skin and gut health are not allergic to and had previously been able to eat without adverse effects.12 Leaky gut causes both systemic and local Science is increasingly showing us that if we want perfect skin inflammation, which may then manifest itself as skin problems.12,13,15-18 1 on the outside, we need to look after our ‘skin on the inside’. A 2008 study of 173 participants found that patients suffering from The relationship between food and skin rosacea were significantly more likely to have small-intestinal bacterial Many patients will make a connection between their food and skin. overgrowth (SIBO) than healthy people.2 Moreover, the skin condition A survey of more than 400 patients by the National Rosacea Society improved once the SIBO had been treated. According to a 2017 stated that 78% had altered their diet due to rosacea. Of this group, study, patients with inflammatory bowel disease (IBD) will often 95% reported a subsequent reduction in flares.5 We know that present with inflammatory skin conditions, such as acne, rosacea, dermatologists frequently recommend dietary modification to patients atopic dermatitis or psoriasis.3 Researchers looked at 39,353 patients with rosacea, with recommendations to avoid ‘trigger’ foods and with IBD and 77,947 control subjects to evaluate the associations beverages. Anecdotally, many patients describe rosacea flares with between IBD and various skin diseases. Patients with IBD were at spicy foods or with hot drinks. Food allergies and sensitivities and significantly increased risks of ISDs, including psoriasis, rosacea, and their relationship to skin are perhaps best researched with respect to atopic dermatitis, whereas lower or nonsignificant associations were eczema.19 According to a presentation I attended by Dr Helen Cox, evident between IBD and auto-immune skin conditions and alopecia clinical lead consultant paediatric allergy at Imperial College NHS Trust, areata.3 A 2019 paper reviewed the research on a link between coeliac children with eczema are 30% more likely to suffer from food allergies, disease and skin conditions, concluding that this digestive disorder and removing the common triggers of dairy, wheat, egg, soy and nuts clearly manifests on the skin, with several hypotheses being offered has become standard practice for paediatric allergists. She advised for the as yet unconfirmed mechanisms. The paper suggested that that this approach is just as valid for adults with eczema. With psoriasis, pemphigus, dermatitis herpetiformis and linear IgA bullous dermatosis there is an increased correlation with coeliac disease, or non-coeliac may be related to coeliac disease.4 The main function of our skin is gluten sensitivity.20 This is thought to be due to an abnormality in the to act as a barrier to the dangers of the outside world – just like our cytokine pathway, which also increases the likelihood of autoimmune ‘skin on the inside’ it provides a physical, chemical and antimicrobial conditions occurring alongside the psoriasis.21 This is now recognised 5 defence. Stress and inflammation in the gut can break down that by the National Psoriasis Foundation (NPF), which devotes an entire protective barrier and impair its protective function. According to a section of its website to going gluten-free.22 So, what are the problems paper by Slominski, this in turn can lead to a decreased production of when it comes to gut health and how do these affect the skin? antimicrobial substances in the skin, leaving it vulnerable to infection and inflammation.6 There is no longer any doubt that gut health and Insufficient stomach acid and the microbiome: Digestion begins in skin health are closely connected, and more and more researchers the mouth. Chewing stimulates the stomach and intestines to release think that it is intestinal hyperpermeability – better known to many as acid, bile and enzymes. If we eat extremely fast, there isn’t sufficient ‘leaky gut’ – that lies at the root of the problem.3,4,7 time for all of those messages to come through in time, resulting in insufficient stomach acid, bile and enzymes. This means the food Gut anatomy is unlikely to be sufficiently broken down before it gets passed on The skin has up to seven layers of cells, in contrast to the intestinal lining, which only has one.8 Although the epithelium is folded over and over, the villi consist of only a single layer of cells separating the outside world (whatever is travelling through our digestive Microvilli system) from our bloodstream. This one layer of cells has the difficult job of providing a barrier to intruders, such as bacteria, viruses, parasites and toxins, while at the same time having to Nucleus let vital nutrients through.9,10 Anything that is meant to enter the Mucosa bloodstream has to travel through the epithelial cells, not around them, so they can control what gets in. The epithelial cells are Nerve closely linked by tight junctions, which prevent anything sneaking Lymph vessel in unchecked. Reinforcing this delicate barrier is a thick mucous lining that collaborates with non-specific antibodies and beneficial Artery bacteria.9,10 If, for whatever reason, this barrier breaks down, a lot can 11 Submucosa go wrong. Common disruptors of the intestinal lining are antibiotics, 12 13 stress, certain medical drugs (proton pump inhibitors, NSAIDs) Vein and alcohol.14 The intestinal lining loses its integrity and anything can now get in: microbes, toxins or even partially digested food. In Figure 1: Anatomy of the intestinal villi

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Normal tight junction

Inflammation

1 2

1

Paracellular

2

Transcellular

Pathogens

Food allergen

Figure 2: Normal gut and leaky gut

to the small intestine. In a healthy digestive system, nutrients are absorbed in the small intestine. But undigested, larger food particles are much harder for the small intestine to absorb, and so undigested food items will carry on through the tract into the large intestine.23 This is where the majority of the gut microbiome resides. The microbiota is the overall name for the trillions of bacteria, fungi and viruses that populate our gut. The microbiome is the name for all the genetic material contained in the microbiota, although the two terms are used interchangeably.23 A healthy gut is home to around 2kg of between 500-1,000 different bacterial species; however, this depends on the person and factors such as what they are eating and whether they are stressed, exercising, sleeping well can have an impact. The majority of these bacterial species are beneficial, and we are so dependent on our microbiota that it is regarded as an organ all in itself.23Our gut bacteria – the microbiota – can break down fibre and extract more nutrients from it, not just producing energy, but also some vitamins, particularly those of the B complex and vitamin K. They also create short-chain fatty acids; the preferred fuel to nourish our epithelial cells. The composition of the microbiota very much depends on what we eat and how we digest our food.23 A change in diet can bring about a change in the microbiota within days. If poorly digested fats, proteins, and carbohydrates – maybe even paired with next to no fibre – reach the gut flora, it will start consuming those, which results in putrefaction and fermentation. This not only creates more and different kinds of gas but also feeds undesirable bacteria, causing an overgrowth and what is known as dysbiosis.23 The gut microbiota plays a role in skin health in various ways. For example, the findings of one study of 114 participants with acne vulgaris suggested 54% of

Thoughts from Dr Christopher Rowland Payne, Aesthetics Media Clinical Advisory Board member and consultant dermatologist, The London Clinic Skin is affected by what is put into the gut and what lives in the gut. The most obvious clinical example is rosacea, which is exacerbated by any vasodilatory stimuli. Apart from stress, the premenstrual week and thermal stimuli, rosacea is aggravated not only by many foods, notably alcohol, chili, curry, spicy food, black pepper, coffee, tea, black chocolate, cheese, citrus fruits and orange juice, but also by the microbiota, Helicobacter pylori being an important aggravator. Sarah Carolides presents an engaging and compelling review of the relationships between skin and gut. As the mysteries of the dark organ are incrementally illuminated, understanding of the skin-gut axis is gradually growing.

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patients had a significantly altered microbiota.7 It would therefore be logical to suggest that the gut microbiota may influence the production and composition of sebum. We also host some bacteria that – if they became dominant – could cause damage to the gut and make us sick. A weakened beneficial flora and our feeding of the wrong kind of bacteria can achieve just that. Once the lining becomes compromised, more toxins can pass through into the blood stream, from where they will need to be eliminated. This often happens through the skin, causing issues.24,25 The most important food for the microbiota is fibre. As well as providing feeding grounds for the beneficial bacteria, fibre is also needed for proper gut motility and to carry away the waste we need to eliminate. Soluble fibre combines with old hormones and other waste the liver has conjugated for elimination and is released into the gut with the bile. Moreover, fibre soaks up fluids and bulks up the stool, thus allowing the muscles surrounding the gut to ‘get a grip’ and propel the stool towards the anus.26 A lack of fibre may lead to constipation, causing waste to sit in the large intestine for too long. The bile acids in stool can irritate and damage the intestinal lining, and toxins and hormones can become released and reabsorbed, resulting in outbreaks of spots and acne.26 The microbiome is extremely vulnerable and easy to disrupt. Insufficient fibre or a poor diet in general, microbial infections, food poisoning, alcohol, stress and courses of several different types of medication can all lead to longer term problems that often manifest in the skin.27 Antibiotics, in particular, can severely disrupt the precarious microbial balance in the large intestine. Long-term use of topical and oral low-dosage antibiotics for acne may work in the short-term, but they can be damaging to gut health in the long-term.27 In addition, non-steroidal anti-inflammatory drugs and steroid drugs can cause serious damage to the intestinal lining.28 The resultant overgrowth of undesirable bacteria may also alter the pH of the digestive tract, creating a climate that benefits them, but not the good bacteria. This means that our intestinal lining loses part of its protection at a time when there are more bad bacteria to attack it. To make matters worse, bacteria may also travel back up into the small intestine, which, although not sterile, should normally only contain small numbers of certain bacteria. If bacteria manage to colonise the small intestine, it will feed on our food there, wreaking even more havoc than it would in its usual home.26,28 Fungi: While infection means the introduction of an invader from the outside, problems can also arise as a result of overgrowth of microbes that are already there, as mentioned. We all host different species of yeasts, which are harmless and normally kept in check by our beneficial microbiota. However, yeasts can cause serious problems if they overgrow. This can happen after infection and/or antibiotic treatment, when good bacteria are diminished.29 As yeasts are fungi and a different kind of organism, they remain unaffected by antibiotics. With the defences down and perhaps even the right food available (yeasts thrive on sugar and refined carbohydrates), these opportunistic microbes can spread, poke holes in the intestinal lining and travel to other areas of the body, which may cause fungal infections and inflammation that can result in redness and swelling of the skin.29 Helicobacter pylori: Stomach acid not only increases the surface area of foods and stimulates bile and enzymes production, but it also acts as a barrier in itself, protecting the body from infection from microbes entering the body via the mouth. One of those is called Helicobacter pylori. Until its discovery in 1982, stomach ulcers were thought to be a result of stress, but we now know that Helicobacter pylori is usually responsible. Helicobacter pylori infection is common,

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


ARMS

SCULPT EM GS LE

and most carriers never develop symptoms. It can harm the stomach in many ways, including damage to the endothelial cells and tight junctions, and stimulating the immune system to produce a large number of inflammatory mediators, which can lead to the occurrence and aggravation of rosacea.8,9 One 2018 meta-analysis concluded that epidemiological investigations and experiments have confirmed that Helicobacter pylori infection is associated with the development of rosacea. It also stated that the effect of anti-Helicobacter pylori therapy, which usually involves a mixture of antibiotics for between 10-30 days, is better than the routine therapy for rosacea.9

SCULPT AND TONE ARMS AND LEGS NO SURGERY – NO DOWNTIME

Summary Research proves a link between gut and skin health. A combined approach with practitioners focusing on the microbiota, food allergies or sensitivities may increase the efficacy of treatments. Sarah Carolides trained in biochemistry, biology and genetics at Cambridge and McGill Universities and received a diploma with distinction from the Institute of Optimum Nutrition. She has 20 years’ experience and specialises in digestive and hormonal problems and lectures regularly. Qual: MA, MPhil (Cantab), Dip ION (Dist), MBant REFERENCES 1. Schagen SK, Zampeli VA, et al., Discovering the link between nutrition and skin aging. Dermatoendocrinol. 2012 Jul 1;4(3):298-307. 2. Parodi A, Paolino S, Greco et al., Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication. Clin Gastroenterol Hepatol. 2008 Jul;6(7):759-64. 3. Kim M, Choi KH, Hwang SW et al., Inflammatory bowel disease is associated with an increased risk of inflammatory skin diseases: A population-based cross-sectional study. J Am Acad Dermatol, 2017. 76(1): p. 40-48. 4. Abenavoli L, Dastoli S, Bennardo L et al., The Skin in Celiac Disease Patients: The Other Side of the Coin. Medicina (Kaunas). 2019 Sep 9;55(9). 5. Weiss E, Katta R, Diet and rosacea: the role of dietary change in the management of rosacea. Dermatol Pract Concept. 2017 Oct; 7(4): 31–37. 6. Slominski A, A Nervous Breakdown in the Skin:Stress and the Epidermal barrier. J Clin Invest. 2007 Nov 1; 117(11): 3166–3169 7. Volkova LA, Khalif IL, Kabanova IN: Impact of the impaired intestinal microflora on the course of acne vulgaris. Klin Med (Mosk). 2001;79(6):39-41. [Article in Russian] 8. Argenziano G, et al., Incidence of anti Helicobacter pylori and anti CagA antibodies in rosacea patients, International Journal of DermatologyVolume 42, Issue 8, 2003. 9. Yang E, Relationship between Helicobacter pylori and Rosacea: review and discussion, BMC Infectious Diseases, 2018; 18: 318. 10. Kanwar AJ, Skin barrier function. Indian J Med Res. 2018 Jan; 147(1):117-118. 11. Feng Y, et al, Antibiotics induced intestinal tight junction barrier dysfunction is associated with microbiota dysbiosis, activated NLRP3 inflammasome and autophagy. PLoS One. 2019; 14(6). 12. Farhadi A, Banan A, Fields J, Intestinal barrier – An interface between health and disease. J Gastroenterol Hepat. May 2003 18:5:479-497. 13. Sikora M, Chrabąszcz M, Maciejewski C, et al, Intestinal barrier integrity in patients with plaque psoriasis. J Dermatol. 2018 Dec;45(12):1468-1470. 14. Bsihehsari F, et al, Alcohol and gut-derived inflammation. Alcohol Res. 2017; 38(2):163-171. 15. Bowe W, Patel NB, Logan AC. Acne vulgaris, probiotics and the gut-brain-skin axis: from anecdote to translational medicine. Benef Microbes. 2014 Jun 1;5(2):185-99. 16. Assimakopulous, Triantos C, Maroulis I, Gogos C, The role of the gut barrier function in health and disease. Gatroenterology Res. 2018 Aug; 11(4):261-263. 17. Pike MG, Heddle RJ, Boulton P, et al, Increased Intestinal Permeability in Atopic Dermatitis. Journal of Investigative Dermatology.1986;86:101-104 18. Slominski A: A nervous breakdown in the skin: stress and the epidermal barrier. J Clin Invest. 2007 Nov 1; 117(11): 3166–3169. 19. Rosenfeldt V, Benfeldt E, Valerius NH, et al, Effect of probiotics on gastrointestinal symptoms and small intestinal permeability in children with atopic dermatitis. J Pediatr. 2004 Nov;145(5):612-6. 20. Daniel Pietrzak et al, Digestive system in psoriasis: an update, Arch Dermatol Res. 2017; 309(9): 679–693. 21. W, JJ, et al., The association of psoriasis with autoimmune diseases. J Am Acad Dermatol. 2012 Nov;67(5):924-30. 22. National Psoriasis Foundation, Do gluten-free diets improve psoriasis?, 2015. <https://www. psoriasis.org/advance/do-gluten-free-diets-improve-psoriasis> 23. Makki K, et al., The Impact of Dietary Fiber on Gut Microbiota in Host Health and Disease. Cell Host Microbe. 2018 Jun 13;23(6):705-715. 24. Pike MG, Heddle RJ, Boulton P, et al, Increased Intestinal Permeability in Atopic Dermatitis. Journal of Investigative Dermatology.1986;86:101-104 25. Hamilton I, Fairris GM, Rothwell J, Cunliffe WJ, Dixon MF, Axon AT. Small intestinal permeability in dermatological disease. Q. J. Med. 1985; 56: 559 – 67 26. WP Bowe and AC Logan, Acne vulgaris, probiotics and the gut-brain-skin axis - back to the future? Gut Pathog. 2011; 3: 1. 27. Farhadi, Intestinal barrier: an interface between health and disease, J Gastroenterol Hepatol. 2003 May;18(5):479-97. 28. Langdon A, Crook N, and Dantas G, The effects of antibiotics on the microbiome throughout development and alternative approaches for therapeutic modulation Genome Med. 2016; 8: 39. 29. David M. Underhill and Iliyan D. Iliev, The mycobiota: interactions between commensal fungi and the host immune system Nat Rev Immunol. 2014 Jun; 14(6): 405–416.

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Recognising Suspicious Lesions in the Periorbital Region Ophthalmologists Miss Jennifer Doyle and Mr Richard Scawn explore which lesions should be treated with caution in the periorbital area With the removal of benign skin lesions no longer being widely funded by the NHS,1 the public are turning elsewhere to seek the removal of skin lesions for cosmetic purposes. Whilst this can be done surgically,2 cryotherapy may offer a cost effective accessible therapy.3 Cryotherapy was traditionally used by dermatologists and general practitioners with specific training in diagnosing skin lesions.3 However, cryotherapy devices are now widely available to aesthetic practitioners who may have limited experience in the area.

Importance of appropriate recognition The periorbital region is a common location for skin cancer, with non-melanoma skin malignancies of the periorbital region making up 5-10% of all skin cancers.4,5 Early detection of cancerous lesions is particularly important in the periorbital region, with invasion of the orbit in 2-4% of cases leading to extensive morbidity and even proving fatal.4,6 It is important for practitioners to be able to recognise lesions that may be cancerous, so that they are not erroneously removed. With half of all malignancies involving the skin, and an estimated 5-10% of these involving the eyelid,4,5 periocular skin cancer is common and may present by way of aesthetic clinics. Cryotherapy devices are becoming increasingly popular in aesthetic clinics and are being marketed as a good way of expanding one’s aesthetic practice.7,8 If used correctly they can be a safe and cost-effective method of removing unsightly benign skin conditions including acrochordons viral infections, actinic keratosis, solar lentigines and seborrheic keratoses.9,10,11 Being a relatively quick and simple procedure to perform, cryosurgery has many advantages, with minimal post-operative wound care and a low risk of complications such as infection and scarring.11 The more difficult aspect of utilising cryosurgery safely comes in identifying which lesions are appropriate to be removed in this manner. For any lesion where there is doubt in the diagnosis, cryotherapy is not suitable because histological examination and assurance of complete excision are not possible.3 Cryotherapy therefore does not offer an actual diagnosis compared to a surgical excision biopsy. Practitioners in an aesthetic clinic should therefore only remove lesions that they are 100% sure are benign. Experience levels with dermatological lesions will vary between aesthetic practitioners depending on their background, and we would recommend that if practitioners are in any doubt as to the nature of a lesion, they do not attempt removal with cryosurgery.

Risk factors for malignant lesions Malignant skin lesions encountered in the periocular region include basal cell carcinomas, squamous cell carcinomas and melanoma. UV radiation is a key risk factor in the development of malignant skin lesions, and it can be difficult to apply sunscreen to the periocular region, leaving it exposed.17 It is important to identify any risk factors that may increase your suspicion of a lesion being malignant. These include:17 • • • • • •

Age Previous skin cancer Evidence of sun damage History of excess sun exposure Lighter Fitzpatrick skin type Immunosuppression

Non-pigmented malignant skin lesions For non-pigmented skin lesions, worrying features include changes in appearance, growth, bleeding and ulceration.23,24 It is important to check for any of these features before attempting removal with cryosurgery, as this can lead to delayed diagnoses, increased morbidity and even mortality. Basal cell carcinomas Basal cell carcinomas (BCC) are the most common form of skin cancer in Europe, Australia and the US.17 They make up 90% of all eyelid malignancies.18 Around the eye they are most commonly found on the lower lid, followed by the medial canthus, eyebrow, upper lid and lastly the lateral canthus.17 They can vary widely in their presenting features and can be categorised into nodular, cystic, superficial, morphoeic, keratotic and pigmented variants.17 Due to this variation in presentation, a biopsy to confirm a histological diagnosis is recommended for all suspicious lesions.17

Squamous cell carcinomas It’s important to note that even in experienced hands, clinical diagnosis is not 100% Squamous cell carcinomas (SCC) are the accurate,12,13,14 and histological analysis of a biopsy specimen is the only way of second most common form of periocular determining the exact nature of the lesion. The Royal College of Ophthalmologists has issued guidelines stating that all small lid biopsy tissue should be sent for histopathological examination, with the exception of chalazions with no atypical features, and excess skin removal after blepharoplasty or other cosmetic procedures unless there is any clinical abnormality.15 Skin lesions on the face are particularly troublesome to patients given their prominent position and difficulty to cover up the lesion. The periocular region is an aesthetically important unit and is frequently treated for cosmetic concerns.16 It’s therefore vital that practitioners understand the risks of treatment, how to Figure 1: Example of basal cell carcinoma. Many would think the BCC is the diagnose and when to refer. nodular lesion, however it is actually the subtle ulcerated area medial to this.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Pigmented malignant skin lesions The incidence of malignant melanoma (MM) skin cancer has risen over the past years, with an estimated one in 54 people being diagnosed with melanoma during their lifetime.25 Practitioners should follow the seven point checklist recommended by the National Institute for Health and Care Excellence (NICE) when assessing pigmented skin lesions, and should refer any patient scoring three or more, or any patient with any one feature for whom there are strong concerns about.26 This referral should be done via the two-week wait pathway.26 Weighted 7-point checklist26 Major features of the lesions (scoring 2 points each): • Change in size • Irregular shape or border • Irregular colour

Minor features of the lesions (scoring 1 point each): • Largest diameter 7mm or more • Inflammation • Oozing or crusting of the lesion • Change in sensation (including itch)

Conclusion

Figure 2: Example of squamous cell carcinoma

skin cancers, making up for approximately 5% of eyelid malignancies.19 Like BCCs they can vary in presentation from nodules, ulcerations or plaques.20 They are particularly important to recognise in the periocular region as they can cause significant morbidity and even mortality due to local invasion or distant spread.21,22

Referral NICE guidelines state that all patients with a suspicious pigmented skin lesion, with a skin lesion that may be a high-risk BCC, SCC or MM, or where the diagnosis is uncertain, should be referred to a doctor trained in the specialist diagnosis of skin malignancy.27

If practitioners have any doubt about the diagnosis of the lesion, they should refer it for an expert opinion. Do not attempt removal with cryosurgery in these cases as, if it is a malignant lesion, it could lead to a delay in diagnosis. This is particularly important in the periocular region as we want to minimise tissue loss in order to achieve the best outcome.17 Be aware of the risk factors for developing malignant skin lesions and check for them in patients seeking removal of lesions with cryotherapy, as it may heighten suspicions as to the nature of the lesion. Miss Jennifer Doyle has a Bachelor in Medicine and a Bachelor of Surgery with distinction, as well as a Master’s in Medical Sciences from the University of Oxford. She has completed the Level 7 in Injectables and is a lead trainer at Harley Academy. Qual: BM BCh MA (OXON) L7Cert FRCOphth Mr Richard Scawn is a consultant ophthalmologist and oculoplastic surgeon. He specialises in complex eyelid reconstruction and periocular skin cancer work, leading the oculoplastic service at Chelsea and Westminster NHS Trust and Buckinghamshire NHS Trust. Qual: MBBS, BSc, FRCOPHTH

REFERENCES 1. NICE Melanoma and pigmented lesions, 2017. <https://cks.nice. org.uk/melanoma-and-pigmented-lesions#!diagnosisSub> 2. Abhishek Bhattacharya, et al, Precision Diagnosis of melanoma and other skin lesions from digital images. Jt Summits Transl Sci Proc, 2017. 220-226. 3. Abraham JC, Jabaley ME, Hoopes JE. Basal cell carcinoma of the medial canthal region. Am J Surg 1973; 126(4): 492–495. 4. Andrews, Mark D, Cryosurgery for Common Skin Conditions. American Family Physician, 2004, Vol. 69. 5. BAPRAS. Benign Skin Conditions, 2015. <http://www.bapras. org.uk/public/patient-information/surgery-guides/benign-skinconditions> 6. Cranwell, William C, Optimising cryosurgery technique. Australian Family Physician, 2017, Vol. 46. 7. Donaldson MJ, Sullivan TJ, Whitehead KJ, et al. Squamous cell carcinoma of the eyelidsBritish Journal of Ophthalmology 2002;86:1161-1165. 8. Hillson TR, et al., Sensitivity and specificity of the diagnosis of periocular lesions by oculoplastic surgeons. Can J Ophthalmol, 1998, Vols. Dec;33(7):377-83. 9. Howard GR, et al., Clinical characteristics associated with orbital invasion of cutaneous basal cell and squamous cell tumors of the eyelid. Am J Ophthalmol 1992; 113(2): 123–133. 10. BAD, Patient Information Leaflets, BASAL CELL CARCINOMA. <http://www.bad.org.uk/for-the-public/patient-informationleaflets/basal-cell-carcinoma/?showmore=1&returnlink=http %3A%2F%2Fwww.bad.org.uk%2Ffor-the-public%2Fpatientinformation-leaflets#.XiBXJhf7Q0o> 11. BAD, Patient Information Leaflets, SQUAMOUS CELL CARCINOMA. <http://www.bad.org.uk/for-the-public/patientinformation-leaflets/squamous-cell-carcinoma/?showmore =1&returnlink=http%3A%2F%2Fwww.bad.org.uk%2Ffor-thepublic%2Fpatient-information-leaflets#.XiBXpxf7Q0o> 12. Oakley, A, DermNet Nz, Cutaneous squamous cell carcinoma, 2015. <https://dermnetnz.org/topics/cutaneous-squamous-cellcarcinoma/> 13. Marcus M. Marcet, et al, Squamous Cell Carcinoma, American Academy of Ophthalmology, 2019. <https://eyewiki.aao.org/ Squamous_Cell_Carcinoma> 14. Cancer Research UK, What you need to know about skin cancer, 2017. <https://www.cancerresearchuk.org/sites/default/ files/gp_june_2017_-_sun_and_skin_cancer_guide.pdf> 15. NHS England Medical directorate and Strategy and Innovation directorate Evidence-Based Interventions: Guidance for CCGs, November 28, 2018. <https://www.england.nhs.uk/wp-content/ uploads/2018/11/ebi-statutory-guidance-v2.pdf.> 16. Ho-equipment, Cryopen For Estheticians, 2020. <https://www. ho-equipments.com/practitioners/esthetics/> 17. NaturaStudios, Cryopen device <https://www.naturastudios. co.uk/equipment/cryopen-cryotherapy-device/≥ 18. The Royal College of Ophthalmologists, Histopathology and cytology specimens - what should you send, and to whom? <https://www.rcophth.ac.uk/wp-content/uploads/2014/08/ Focus-Winter-2010.pdf> 19. Jones, Carole A, Periocular Basal Cell Carcinoma. The Royal College of Ophthalmologists Focus, 2011, Vol. Winter. <https:// www.rcophth.ac.uk/wp-content/uploads/2014/08/FocusWinter-2011.pdf> 20. Keng-Ee Thai, Rodney D Sinclair, Cryosurgery of benign skin lesions. Australasian Journal of Dermatology, 2001, Vol. 40. 21. Accuracy of clinical diagnosis of cutaneous eyelid lesions. Ophthalmology, 1997, Vols. Mar; 104(3):479-84. 22. Leatherbarrow B. Oculoplastic Surgery. 2nd ed. Informa Healthcare: London, 2011. Kersten RC, et al., 23. Mark C Luba, et al., Common Benign Skin Tumours. American Family Physicina, 2003, Vol. 67. 4. 24. Neimkin M.G., Holds J.B. Evaluation of eyelid function and aesthetics. Facial Plast Surg Clin N Am. 2016;24:97–106. 25. NICE., Improving Outcomes for People with Skin Tumours including Melanoma. <https://www.nice.org.uk/guidance/csg8/ evidence/full-guideline-2006-pdf-2191950685> 26. Telfer NR, et al., British Journal of Dermatology, 159, pp35–48, 2008. 27. Tyers AG. Orbital exenteration for invasive skin tumours. Eye 2006; 20(10): 1165–1170.

Figure 3: Example of a patient with multiple pigmented lesions in the periocular region. A detailed assessment as per the NICE 7-point checklist will be necessary to elucidate whether onward referral is warranted.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


Advertorial Gerard’s Cosmetic Culture

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New Holistic Skincare Launches Introducing the new holistic Gerard’s Cosmetic Culture skincare to the UK market About Gerard’s Cosmetic Culture Skincare brand Gerard’s is bringing Italian innovations to the UK, with its exciting introduction to the market and the launch of two new ranges. A pioneer in the beauty and personal wellbeing industry, Gerard’s was founded in the Franciacorta region of Italy in 1970, with the aim to utilise eco-friendly elements. The company combines nature with cosmetic technologies to deliver long term and immediate results, with a portfolio of products that provide a holistic approach to skin ageing. When creating products, Gerard’s has three principal objectives: 1) To prevent and block the appearance of imperfections and signs of ageing skin 2) To protect the skin from irreversible ageing caused by internal factors 3) To fight imperfections With this in mind, two new ranges have been designed to reflect their new-age approach, placing value on the individual and maintaining the beauty and radiance of the skin.

Recreage Gerard’s laboratories are the first professional and retail system to create a product which reprogrammes the skin’s age with incredible resurfacing effects. The Recreage Multi-Acid Complex programme uses the regenerating properties of alpha-hydroxy acid and epigenetic technology, designed to transform the skin’s overall appearance. The range consists of three products: • Recreage Perfecting Face Cream with epigenetic action, transforming uneven skin tone with a flawless effect by combining glycolic acid and the replenishing complex of elastin and collagen. • Recreage Ultra Replenishing Night Cream with perfecting action; single-dose ampoules with a lightweight and fine texture that blend onto skin, perfecting it with an immediate filler effect and silky skin feel. • Recreage Ultra Replenishing Face Programme with epigenetic action, incorporating single-dose ampoules with a transparent and clear texture to perfect the skin with an intense smoothing and illuminating action, using triple acid peel complex, curculigo orchid extract and the astringent properties of lemon. The key component within all three formulas is the epigenetic active ingredient RNAgeTM. This guarantees anti-gravity action and regulates cutaneous architecture, optimising the regeneration of 56

cellular DNA and stimulating the production of youth protein. In just four sessions, the face restores its natural compactness and radiance, complexion becomes more uniform, texture is smoothened and pore sizes are minimised.

Aesthetic nurse practitioner, Heidi Dollimore, has been using Gerard’s products since September, specifically Recreage. “With other peel treatments, there is often a lot of down time whereas with Recreage you get results instantly on day one. It gives you the ‘wow’ result that makes patients want to come back. That’s the main thing for me, you get client retention, so you get client satisfaction. It’s not a process.”

Mood Masks Gerard’s has also designed five extraordinary single-dose masks, which take care of both the skin and the mind by incorporating aroma therapeutic ingredients. The formulas are paraben, petrolatum and silicon free. Research shows that there is a 40% improvement in mood after being exposed to pleasant scents. Patients can choose what mask they want depending on what mood they are in, with a choice from: • Zen Mood: a mousse face mask with purifying and reoxygenating action • Party Mood: a gel face mask with illuminating and lifting action • Sleepy Mood: a night face mask with ultra-regenerating action • Sweetie Mood: a sheet face mask with de-stressing and unifying action • Sharing Mood: a scrub face mask with exfoliating and energising action

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A summary of the latest clinical studies Title: How to Best Utilize the Line of Ligaments and the Surface Volume Coefficient in Facial Soft Tissue Filler Injections Authors: Casabona G, et al. Published: Journal of Cosmetic Dermatology, February 2020 Keywords: Infraorbital Hollows, Ligaments, Dermal Filler Abstract: Recent advances in facial anatomy have increased our understanding of facial aging and where to best position facial soft tissue fillers. The aim of this study was to investigate a novel injection protocol which makes use of concepts like the line of ligaments or the surface - volume coefficient. A total of 306 Caucasian patients (270 females, 36 males) were retrospectively investigated after the injection following a standardized protocol. This protocol comprised a total of six boluses and one retrograde fanning injections in the infraorbital area utilizing a 22G and a 25G blunt-tip cannula, respectively. Medial midfacial distances were measured using skin surface landmarks and compared after the injection of the partial and the total algorithm. Distances between the dermal location of the lateral SOOF and the dermal location of the mandibular ligament increased by 0.17 ± 0.11 mm with P < .001, to the corner of the mouth by 0.20 ± 0.09 mm with P < .001 and to the nasal ala by 0.20 ± 0.11 mm with P < .001. The results revealed that utilizing these novel anatomic concepts, a mean amount of 0.32cc high G-prime soft tissue filler injected in the lateral SOOF can change midfacial distances by an average of 0.19 mm. Title: Complications Associated with Medical Tourism for Facial Rejuvenation: A Systematic Review Authors: Raggio BS, et al. Published: Aesthetic Plastic Surgery, February 2020 Keywords: Complications, Medical Tourism, Surgery Abstract: Medical tourism for cosmetic surgery has become increasingly popular in recent years. The existing literature has identified poor outcomes associated with general cosmetic tourism; however, the complications associated with cosmetic tourism for facial rejuvenation remain poorly understood. The aims of this study are to delineate the risk profile associated with medical tourism for facial rejuvenation. A systematic review of PubMed, MEDLINE, and Embase was performed through January 2019 using the PRISMA guidelines. Articles published in English relevant to medical tourism for facial rejuvenation and its associated complications were examined. We identified six retrospective studies including 31 patients who had obtained facial rejuvenation procedures abroad and experienced treatment-associated complications. Twentyfive of 26 listed patients were female. Departure nations included the USA, Switzerland, England, Ireland, Australia, and Thailand. Destination nations included the Dominican Republic, Cyprus, the USA, Colombia, Thailand, India, and China. Procedures included blepharoplasty, facelift, rhinoplasty, chin lift, and injections with botulinum toxin and dermal fillers. Complications included abscess, poor cosmesis, facial nerve palsy, and death. No definitive conclusions can be made given the paucity of relevant data, its clinical and statistical heterogeneity, and small sample size. Additional research is warranted to understand the health system implications associated with cosmetic tourism for facial rejuvenation.

Title: Efficacy and Safety of High-Intensity Focused Ultrasound for Non-invasive Abdominal Subcutaneous Fat Reduction Authors: Hong JY, et al. Published: Dermatologic Surgery, February 2020 Keywords: Abdomen, Surgery, Ultrasound, Fat Abstract: Demand for non-invasive body contouring has increased. We evaluated the efficacy and safety of a thermal high-intensity focused ultrasound (HIFU) device for abdominal body shaping. Adults with a body mass index ≤30 kg/m and an abdominal subcutaneous fat tissue thickness ≥2.5 cm were enrolled for HIFU treatment at energy levels of 150 J/cm (first session) and 135 J/cm (second session). The primary end point was a change from baseline waist circumference at post-treatment Week 8. Secondary efficacy end points were: changes in body weight, waist/hip ratio, and fat thickness assessed by ultrasound, caliper, and a fat CT scan. The Global Aesthetic Improvement Scale was evaluated by both investigators and subjects. The primary assessment achieved statistical significance, showing a reduction of 3.43cm in mean waist circumference. The treatment effect was cumulative, with a steady decrease in waist circumference and fat thickness. The mean pain scores immediately after treatment were 4.45 ± 2.74 on a scale of 1 to 10 with 10 being the most painful, which decreased to 1.10 ± 1.33 after 1 week. High-intensity focused ultrasound is an effective and safe treatment modality for reducing waist circumference in non-obese individuals with focal fat accumulation. Title: Types of Errors Made During Breast Augmentation Authors: Batiukov D, et al. Published: Aesthetic Plastic Surgery, February 2020 Keywords: Breast Augmentation, Implants, Breast Surgery Abstract: Implementation of polyurethane-covered (PU) implants into practice requires a reassessment of the experience and a learning curve period. Occasional publications describe a few difficulties in this regard. However, there are no publications covering the spectrum of errors. The absence of definite information and contradictory findings makes the learning curve longer leading to many unsatisfactory results. The systematization is based on the 12 years of experience with over 1,000 patients and previously published data. A literature review was conducted using PUBMED with the following keywords: polyurethane or foam or sponge and breast and implant. A total of 285 articles were found. All articles concerning polyurethane implants were studied along with any articles found describing the surgical techniques applied to them. Additional references found in the above-mentioned articles were also included in the study. All errors can be divided into planning errors, errors in pocket development and surfacedependent errors, for which the polyurethane surface is the main reason. Surface-dependent errors include the errors connected to positioning and bio integration. The systematization of errors with PU implants facilitates a decision-making process during the primary and secondary surgery and lowers the risk of the unsatisfactory results.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Understanding VAT Exemptions VAT advisor Veronica Donnelly explains when and how your aesthetic treatments may not liable for tax payment As most of you know, medical treatments and health services are exempt from VAT, meaning those offering them do not have to pay tax on their supply.1 There is, however, often confusion over whether aesthetic treatments can be considered medical and are thus exempt from tax. The most common misconception I come across in my work is that there is some magical trick to making aesthetic supplies exempt from VAT, which involves a form of VAT planning. There is no magic, nor is there VAT planning; just a simple test against the services you already deliver to establish what you are actually doing on a day-to-day basis and whether your services are exempt from VAT.

The VAT test The test comprises two parts, detailed below, both of which need to be met. If you fail one or both then the treatment is considered cosmetic for VAT purposes and subject to VAT. If your cosmetic turnover, along with any other taxable supplies, exceeds the VAT registration threshold in any 12-month rolling period, then you are required to register for VAT and pay tax on those sales. Taxable supplies could include sales of products (separately from treatments) or provision of training. The current VAT registration

threshold is £85,000, although it is worth noting this has been less in previous years.2 Law states that for the VAT exemption to apply there needs to be:3 1. A person registered on a medical register 2. Provision of medical care So, if you are a doctor, surgeon, dentist, nurse or other practitioner on a medical register you pass the first part of the test, provided you are working within your training, qualifications and experience. The second test gives more food for thought. No one is going to challenge that surgery in a hospital theatre, for example, is a medical procedure, but that is not the relevant question for VAT. It is not enough for a treatment to be medical; for VAT purposes, the treatment must be given for a medical purpose.4

Case law HMRC’s guidance on what is exempt comes from two cases; Dr Peter d’Ambrumenil and Dispute Resolution Services (DRS) Ltd (D’Ambrumenil), and Future Health Technologies.4 Dr d’Ambrumenil was a qualified doctor who offered medical and legal support through his company DRS. The case considered whether services of medical examinations for insurance companies and

medical certificates, as well as all services carried out by a person on a medical register, would fall within the exemption. The court concluded that, ‘The medical services affected for a purpose other than that of protecting, including maintaining or restoring; human health may not, according to the court’s case-law, benefit from the exemption’.4 Future Health Technologies is a European Court of Justice (ECJ) case which dealt with the extraction of stem cells that were frozen for possible future use.5 The decision stated that to be medical, a treatment had to comprise, ‘Services which had as their purpose the diagnosis, treatment and, in so far as possible, cure of diseases or health disorders’. It went on to say medical services, ‘Effected for the purpose of protecting, including maintaining or restoring, human health could benefit from the exemption’. This was in the context that at the time the stem cells were extracted for freezing, there was no medical purpose for the procedure. In the court’s view, the medical purpose arose at a later date when the cells were thawed for use in treatment and so were exempt at that time, but not before. The Skatteverket v PFC Clinics (PFC) ECJ case in 2012 is an aesthetic hospital case which went to the European Court of Justice to clarify whether: 1. The treatments needed to be in a hospital to be medical 2. The patient’s view of why they wanted the treatment was relevant This case answered ‘no’ to the first question and in relation to the second question, expanded the medical definition by saying, ‘To be a medical assessment, it must be based on findings of a medical nature which are made by a person qualified for that purpose’ and, ‘The subjective understanding that the person who undergoes plastic surgery or a cosmetic treatment has of it, is not in itself decisive in order to determine whether that intervention has a therapeutic purpose’. The case also made clear that, ‘It follows from the case-law that the health problems covered by exempt transactions may be psychological’,6 which I discuss in more detail below. Both the Future Health Technologies and PFC cases clearly stated that where a treatment is carried out for purely cosmetic reasons, that treatment cannot be for medical purposes and so cannot be exempt from VAT. Where confusion can arise is that whilst the

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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two ECJ cases described exclude only purely cosmetic treatments from the exemption, HM Revenue and Customs is applying VAT decisions relating to mixed supplies i.e. supplies with different components which have VAT liabilities. As an example, consider the case where biscuits (which are zerorated) were sold in a decorative tin (which are standard rated). It had to be determined whether the customer was actually buying the biscuits or the tin in order to arrive at the VAT liability. The test is ultimately one of the predominant or main supply.7 HMRC is applying those decisions and assessing the VAT liability on the primary purpose of the treatment, rather than only excluding the purely cosmetic supplies and treating everything else as medical. The recent Skin Rich (SRL) tribunal case was the first UK VAT tribunal specifically involving an aesthetic business, which analysed whether the primary purpose of treatment was medical or not.8 It was decided on this basis when the tribunal chairman stated, “We recognise that where the primary purpose of a client seeking treatment is for these reasons then, in line with the decision in Skatteverket, this may be medical care. However, the evidence did not support this being the primary purpose for which treatment was sought from SRL.” This statement is particularly interesting because whilst it recognises that there can be medical care, it pushes the purpose back on the patient rather than the practitioner, which is likely to be challenged in the courts going forward as being contrary to the PFC clinic decision.

Demonstration of medical purpose So, basically, no magic. If exemption is to apply then there must be a clear diagnosis of a physiological or psychological condition by a person on a medical register acting within their training, qualifications and experience, undertaking a treatment plan for the primary purpose of protecting, maintaining or restoring the health of that patient. Where Skinrich appeared to fail was through not producing sufficient evidence of the primary purpose in court. It is no surprise that when HMRC carries out reviews of aesthetic businesses, they are asking for copies of consultation notes to confirm that there has been a diagnosis by a suitably qualified person and that the primary purpose of the treatment plan is to treat that condition and not just deliver cosmetic results. My advice is that you should therefore

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provide details of the registration numbers and qualifications for your medical staff, even if HMRC has not asked for these yet. These take care of test one. You should also provide an agreed sample of your medical notes. These must be redacted. Your patients are covered by medical confidentiality so HMRC is not entitled to go through your patient records. The HMRC officer must give you a period for which they can ask to see all records, which must be a reasonable number,9 and you should ensure all personal details of the patient are removed. It is important to recognise that HMRC officers are not qualified in medicine. You should therefore always either translate or explain medical terms and give a history of why the treatment was being given, if it is not clear from the notes. While most patient records will now be paperless, HMRC can look at records from the commencement of the business, which may not have been paperless, so consider that if your handwriting is not legible to anyone other than yourself, then you may want to type a note of your diagnosis and treatment plan to attach to each note. These notes are the basis on which HMRC will decide the VAT liability, so you need to give them as much information as you can to assist them in understanding what you do and why. In particular, HMRC is focusing on any psychological diagnosis. This can be problematic as HMRC frequently confuses psychiatric and psychological so, again, clarity is key in explaining all of the facts around the diagnosis and the reason for the treatment plan. Ideally your notes should be sufficiently detailed so that if another medical professional were to read them without having met the patient, they could arrive at the same conclusion. For example it is not enough to write ‘patient wants to look younger’; it is more relevant to say why the patient wants to look younger and why in your opinion this is presenting as a psychological condition which you can treat. Is the patient undergoing a particularly stressful episode in their lives resulting in loss of confidence and/or emotional distress? Every patient is individual and every diagnosis is personal. If your notes do not contain all of that information, because you didn’t know you had to write it down, but you know the patient well enough to remember the facts that led you to the diagnosis, you should either make a note now to attach to the patient file or be prepared to explain it to the HMRC officer carrying out the review.

Understanding HMRC’s view As far as HMRC is concerned, exemption is a relief from VAT and so all supplies are subject to VAT unless you can prove the relief applies. The onus is on the taxpayer to prove that they meet the test for exemption. In my experience, aesthetic practitioners are usually very clear about why they treat patients, but have little understanding of the evidence HMRC requires to be satisfied as to the VAT liability. As such, both proceed to talk in different languages using jargon the other will not understand. Providing the officer approaches the business with an open mind and listens to the explanations being supplied, while the practitioner takes the time to make full explanations, then it is more likely that the correct answer will be reached. No fairy dust required, just a clear understanding of the purpose of the treatments and the evidence to explain it to HMRC.

13 & 14 MARCH 2020 / LONDON

Veronica Donnelly will be speaking at the Business Track at ACE 2020 on Saturday March 14. Register free using code 15100 aestheticsconference.com Veronica Donnelly is a partner at Campbell Dallas and head of the aesthetic sector team. She has been a VAT advisor for more than 30 years, working in HMRC and accountancy firms. Her work includes strategic planning for aesthetic businesses as well as providing advice to deal with compliance issues and disputes with HMRC. Donnelly is a chartered tax advisor and associate of the Institute of Indirect Taxation. REFERENCES 1. Gov.uk, VAT rates on different goods and services (UK: Gov.uk, 2020) https://www.gov.uk/guidance/rates-of-vat-on-differentgoods-and-services#health-<education-welfare-and-charities> 2. VAT ACT 1994, UK Public General Acts, Schedule 1, Item 1 <http://www.legislation.gov.uk/ukpga/1994/23/schedule/1> 3. VAT ACT 1994, UK Public General Acts, Schedule 9, Group 7, Item 1 <http://www.legislation.gov.uk/ukpga/1994/23/schedule/9> 4. d’Ambrumenil and Dispute Resolution Services Ltd v Customs and Excise Commissioners (Case C-307/01). [2005] BVC 741 <https://library.croneri.co.uk/cch_uk/bvc/2005-bvc-741> 5. Future Health Technologies Limited v The Commissioners for Her Majesty’s Revenue and Customs (Case C-86/09). [2009] <https://eur-lex.europa.eu/legal-content/EN/TXT/ HTML/?uri=CELEX:62009CJ0086&from=BG> 6. Skatteverket v PFC Clinic AB (Case C-91/12) {2013} BVC 117 <https://library.croneri.co.uk/cch_uk/bvc/2013-bvc-117> 7. United Biscuits Ltd T/A Simmers (EDN/90/0049) <https://www. gov.uk/hmrc-internal-manuals/vat-food/vfood2860> 8. Skin Rich Ltd [2019] TC 07310 <https://library.croneri.co.uk/ cch_uk/bvc/2019-tc-07310> 9. Taxes Management Act 1970, UK Public General Acts <https:// www.legislation.gov.uk/ukpga/1970/9/contents/enacted>

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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Mitigating Risks to Mitigate Costs Medical malpractice and risk specialist Martin Swann provides tips for mitigating your insurance risks and reducing the chance of a successful claim being brought against you The number one question I am asked as an insurance provider when talking to a prospective new client is ‘how much?’ Given that the premium levied for your insurance is reflective of your perceived risk to your insurer, reducing your risk could reduce the rates used to calculate your premium. In this article, I will provide my best tips for not only improving the risk your practice represents to insurers, but also for reducing the chance of a successful claim being brought against you and your clinic.

rationale/evidence for the proposed care plan, including any identified follow-up action, should also be specified. • Records completed at the time of the consultation. If done shortly after, then they should be recorded showing the date and time of the record being created, and the the actual event/consultation. • All records should be stored securely; for example, they should be encrypted when at rest in your network, and adequately backed up so they can be restored easily, in the event of a loss of data.2,4 • Legible text, which is explained in more detail below.

Insurers are starting to pay more attention to how data and patient records are stored and how a practice would deal with a breach as part of their underwriting process, which is understandable given the increased duty of care that the new regulations represent for practitioners.2 Those practices with good procedures and processes for data collation, storage and security are considered a better risk from a GDPR perspective and rates will be reflective of this.3

Risk assessment I have found that, ever increasingly, the purchase of insurance is regarded as a ‘commodity purchase’, with the cost of cover being a large factor in the decision of which provider to partner with. If you think of insurance in the same way a bookmaker would consider odds provided for horse racing, those with the best chance of winning (not having a claim) have the lowest odds (cheapest rates). If you are perceived to be a greater risk due to poor risk management, the processes and procedures you adopt, or just having a poor claims history, it will have an impact on the rate applied by an insurer.1 Sound risk management and risk mitigation should levy the most cost effective risk transfer (insurance) and reduce the chances of a successful claim being made against your practice. Below are my top three tips for minimising claims in your clinic. 1. Record keeping If a claim is alleged against your practice, your files and records are what insurers will rely upon to provide them with the evidence they need to try and successfully defend your position. In line with General Data Protection Regulations (GDPR),2 insurers will also be considering the risk associated with the storage and security of your patient records. They will also consider whether there has been a failure to exercise the required duty of care to securely store these records in line with the new regulations.3 An insurer would consider your records to include, but not limited to: consultation records, emails, telephone notes or call recordings, photos or images, text or social media messages and health records. From a GDPR perspective, you should extend this definition to any single piece of data held about any individual, not just patients, but also employees and prospective patients too, as this is considered personal data and therefore falls under GDPR.2 From an insurance/risk management perspective, the following is considered good record keeping: • Full and factual information, which includes relevant history, full details of all examinations, assessments, investigations and findings, and details of any concerns or referrals such as mental wellbeing assessments. Details of any problems/complications arising, action taken in response to these problems and clear

Record keeping do’s and don’ts • Do ensure that all consultation forms are fully completed and where sections are not relevant, record as such. Leaving sections blank could create ambiguity and call into question during litigation as to whether or not those matters left blank were discussed/considered. • Don’t leave consultation notes ‘for later’. In my experience, most insurers consider all notes being written up at the time of the event or directly after as best practice. If they cannot be completed immediately, then they should be written up by the end of a shift. • Do use black ink if you are going to handwrite notes to minimise the risk of fading. • Don’t use correction fluid, erasers, marker pen or overwrite any text when making corrections to patient records. If corrections need to be made, then a line through the incorrect text (so it’s still legible), with the date, time and a signature is considered best practice by most insurers. • Do ensure that all electronic records are securely backed up and that back-ups are tested regularly. It is likely that this will he handled by your security/technology provider. • Don’t amend computer records; create a new entry referring to the incorrect record.

2. Consent Since the Montgomery case of informed consent in 20155 (and subsequently Crossman and Webster in 2016/17),6 consent has been a hot topic for all within the insurance industry. Insurers will be interested in understanding your processes for obtaining the required consent from your patients, in line with the increased obligations the recent changes have created. As opposed to reviewing your actual consent forms, underwriters will often focus on obtaining an understanding of your consultation process, while a number of insurers will offer to review these forms for practitioners. An underwriter will be looking to establish that your consultation process allows adequate time to:

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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• Identify if there are any underlying medical conditions that need to be considered prior to treatment. • Discuss all the medical risks, not just those deemed relevant, associated with procedures being discussed. • Consider the reasons for treatment and access the mental and psychological wellbeing of the patient to confirm if referral to another experienced professional, such as a psychologist, is required. • Provide the patient with suitable time for reflection prior to treatment, which will depend on the treatment, but insurers take guidance from bodies such as the General Medical Council.7 In addition, I have found that the underwriter will usually want to ensure that there is confirmation that all of the above is suitably understood and certified by the patient, as well as being accurately documented and recorded by the practitioner. They will also want to confirm that your practice has processes and procedures in place that include: • Training around consent, the consultation process and managing customer expectations. • Quality assurance including file/consultation reviews, providing feedback, implementation of additional training and follow up/ check back on completion of the required training to ensure that your staff are developing their skills for the benefit of your patients. • Customer reviews/satisfaction monitoring following treatment and the use of that feedback as a way of improving services. • Identifying and referring patients where there are concerns around their mental wellbeing. The above will provide insurers with comfort that you have suitable processes in place for adequately accessing and obtaining informed consent from your patients. This alleviates some of the concern that insurers have in regards to defending a claim where there has been an allegation of failure to obtain adequate consent. 3. Complaints handling Complaints against medical practitioners have increased nationally.8 This is following the impact of the Francis Report,9 which discussed the leadership of staff at Stafford Hospital, and other similar industry reviews such as Keogh. Additionally, the impact of social media as a forum to share news has increased public awareness and expectations. However, not all complaints need to evolve into negligence claims and, in my experience, effective management of complaints can reduce the chance of them becoming so. A survey by The Medical Protection Society (MPS) found that something as simple as saying sorry could reduce claims, with 76% of patients surveyed saying that they would be less likely to complain if they had received an apology.12 Obviously, from an insurance and risk perspective, you have to balance apologies with the obligation not to admit liability found within all policy wordings, so I would always recommend taking the advice of your insurer on how they would like any apology to be worded. When it comes to managing complaints, underwriters will attain additional comfort in the risk posed by a practice that can demonstrate that they have: • A clearly documented complaints process that is communicated to the patients as part of the consultation process. • A process for reviewing complaints after the event, to understand how they could be avoided in the future and make improvements to their risk management processes as a result of these findings. • A process for identifying patterns of complaints and re-training staff/practitioners where required to mitigate repeat complaints. • A culture where staff/practitioners will raise internal issues or

incidents openly so that the practice can uphold its duty to the patient. • Have a complaints’ register showing previous complaints, the process of how these were handled and the outcome. The last point is an interesting one because some companies may question the benefit of a complaints’ register, suggesting that by showing insurers that you have had lots of complaints, it may increase your premium. However, demonstrating that you have a process where you record not only complaints, but also timeframes, key dates, outcomes, retraining or remedial action and a system for accessing patterns and mitigation, is of huge benefit. This is because it will demonstrate to insurers that you understand the need for effective risk and complaint management and you have tools to identify risks, which will mitigate the chance of repeat claims.

Conclusion The three areas highlighted in this article are integral to each other when it comes to effective risk management. They will not stop a claim being made against your practice, however, the chances of an allegation being successful could be reduced. Managing the patient expectations throughout their care at your practice is paramount to a harmonious relationship and makes it easier to have those difficult conversations when things don’t go according to plan or complaints arise. When issues do occur, record keeping will become your, and your insurer’s, best friend. Enhance Insurance is the sponsor of the ACE 2020 Business Track. The company will host two sessions: • Friday 13 10:50-11:20am • Saturday 14: 10:30-11:00am Register now using code 15100 aestheticsconference.com Martin Swann is the divisional director of Enhance Insurance and has been insuring medical and healthcare professionals and businesses for more than 15 years. Swann has extensive experience in risk identification, mitigation and management and provides advice on how best to reduce the risks faced by your practice. REFERENCES 1. Vaughan E, Vaughan T, Fundamentals of Risk and Insurance, 11th edition, John Wiley & Sons, 2014. 2. Swann M, ‘Getting Ready for GDPR’, Aesthetics journal, July 2017. <https://aestheticsjournal.com/ feature/getting-ready-for-gdpr> 3. Example of a cyber proposal form which outlines the kind of information Insurers look at in regards to Data Security. <https://www.aig.co.uk/content/dam/aig/emea/united-kingdom/documents/Financiallines/Cyber/aig-cyberedge-application-form.pdf> 4. ICO, Overview of the General Data Protection Regulation (GDPR),2017 < https://ico.org.uk/media/fororganisations/data-protection-reform/overview-of-the-gdpr-1-12.pdf> 5. Gollop K, McClenaghan F QC and Frances McClenaghan, The Latest on CONSENT and CAUSATION, Serjeants’ Inn Chambers, <http://ukhealthcarelawblog.co.uk/rss-feed/76-the-latest-onconsent-and-causation> 6. 12 King’s Bench Walk, Rodney Crossman v St George’s Healthcare Trust, 2017,<https://www.12kbw. co.uk/rodney-crossman-v-st-georges-healthcare-trust-2016-ewhc-2878-qb/> 7. GMC, ‘Giving patients time for reflection’, Guidance for doctors who offer cosmetic interventions, 2016, <http://www.gmc-uk.org/guidance/ethical_guidance/28712.asp> 8. Rebecca Smith, ‘Social media driving rise in complaints to GMC: report’, The Telegraph, 2014 <http:// www.telegraph.co.uk/journalists/rebecca-smith/10978904/Social-media-driving-rise-in-complaints-toGMC-report.html> 9. The Mid Staffordshire NHS Foundation Trust Public Inquiry 2010. <http://webarchive.nationalarchives. gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/> 10. Keogh, B, Review of the Regulation of Cosmetic Interventions (2013) <https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_Regulation_ of_Cosmetic_Interventions.pdf> 11. Smith, R,, ‘Social media driving rise in complaints to GMC: report’, The Telegraph, 2014 <http://www. telegraph.co.uk/journalists/rebecca-smith/10978904/Social-media-driving-rise-in-complaints-to-GMCreport.html> 12. The Medical Protection Society Limited, ‘Survey shows the value of saying “sorry” in healthcare’, 2016. <https://www.medicalprotection.org/docs/default-source/pdfs/press-releases/uk-pressreleases/the-value-of-saying-sorry-in-healthcare.pdf?sfvrsn=4>

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


This could be you.

My first month paid for my license, if you're serious about quality in aesthetics then a Tinkable license will fast track your success. Dr Tracey Hopwood, Tinkable Clinic Ashford

STAND UP FOR Q UA L I T Y AND STEP OUT FROM COMPETITION. Learn more at tinkablelicense.co.uk

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S TAN D F 8


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Enhancing Your Digital Reach Digital specialist Alex Bugg shares best practice advice on understanding local SEO Local search engine optimisation (SEO) is a digital marketing tactic that allows bricks and mortar businesses, such as aesthetic clinics, to take advantage of location-based search engine use. With 46% of all Google searches looking for local information,1 usually on a mobile device, local SEO is becoming more and more popular, as businesses look to get as much ‘free’ organic traffic as possible. The objective of search engines, such as Google, is to deliver results as accurately as possible, to learn consumer behaviour and build trust so that the public keeps coming back. Therefore, delivering service providers within a locality when someone searches for ‘dermal fillers’ or ‘microneedling’ on a mobile device that, more often than not, has location services enabled, allows for a positive outcome for the searcher. Aspiring to nationally rank on page one of Google for a treatment is fine; but be aware, this takes an ongoing, long-term SEO strategy. What is more useful to most clinics, however, is ranking highly on mobile searches for treatments in your local area. This means that more people who are nearby visit your website and book your treatments.

Making the best of your SEO Good SEO can drive more people to your website, have them spend longer browsing your site, and therefore generate more leads, via organic search results – appearing as high up as possible on the search engine results page (SERP). You will also want your business to appear in Google’s ‘three-pack’, which is the box with three businesses displayed on a map. Two key terms to be aware of when managing your SEO are: 1. Search intent: searching for a specific treatment usually indicates the searcher has a commercial interest. This is called search intent, and optimising your web content to inform and provide a simple way of contacting you is best practice in SEO, including local SEO.2 2. Near me: leading on from intent search, Google determines (or best guesses) your location and delivers the businesses it decides are the ‘best’, when you search for ‘dermal fillers near me’. The Google algorithms are made up of thousands of decisions to decide where to direct the searcher.2

Make the most of Google My Business Google My Business (GMB) is a free tool that businesses can use to maximise their online reach.3 Whilst Google isn’t the only search engine, it accounts for 92% of all search engine use,4 so it is key to provide Google with as much information as it asks for to increase your presence across both the Search and Maps tools. I recommend utilising the following GMB features that all aid effective SEO. Reviews Google considers reviews as a trust signal; someone took time out of their life to leave a review. Replying to reviews on whichever platforms you gather them on, but especially Google, can help build customer trust, so Google reviews which mention your location, your business by name, or the treatment the patient had, are especially useful in terms of SEO. Google values their reviews over other platforms, so prioritising Google reviews is key if you’re focussing on SEO. Platforms such as Facebook, TrustPilot and RealSelf will all provide traffic back to your website, and appear when people are searching for you, but will not boost your SEO as much as working on your GMB profile. Read more on reviews in the section below. GMB Posts Google Posts are like social media posts, but displayed in your business profile, or when somebody searches your exact name. Posts are classed as ‘What’s New’, ‘Event’, ‘Offer’ and

‘Product’, so you can tell Google more about your post. You can also include a call to action (CTA) in your post, to direct viewers to what you want them to do next, such as ‘Book Now’, ‘Learn More’ and ‘Call Now’. A 2020 case study by SEO software company Moz showed that 40% of businesses have never created a post on GMB, yet when a plastic surgeon posted, they received more than 80% increase in clicks each time someone searched for them.5 This shows that Google posts get interaction, and it is worth scheduling a weekly post, along with your regular social media. FAQs Using the Questions section of GMB allows users to ask questions about your clinic. A good way to use this is to leave these questions yourself, and respond to them through GMB. These are left anonymously by Google users, so you can leave your own or encourage others to do this. With three upvotes (thumbs up on GMB), these will appear natively in your GMB panel, so that you display more information about your clinic. You could perhaps ask your clinic if it provides a certain treatment, and answer that you do. Imagery By adding as many images of your clinic, both internal and external, and the team, Google has shown that business profiles receive 42% more requests for directions on Maps, and 35% more clicks through to their website.6 Social media Clinics should also link their social media to their GMB profile, so that it is displayed in the GMB panel, as most people researching a new business will visit your profiles for further validation.

Link building Getting backlinks – where a website that isn’t yours shares a link to your page – is often seen as an integral part of SEO. Backlinks tell Google that your site has relevance and legitimacy, if another site chooses to reference yours. The number, and quality, of these link signals is the single largest local SERP ranking factor. They are also the second most important factor in appearing in the local three-pack, after signals from a complete and popular GMB profile that has proximity to the search.1 Blogger outreach and PR are the most common ways of earning backlinks in aesthetics. Without working with a PR agency,

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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this requires some work. However, reviewing your patients who already have a blog with an audience you’d like to reach out to, making press releases and holding press or blogger events are a way to generate interest and stories written about your clinic. You should also consider creating your own quality content, with real industry insight, and you may find that other websites link to yours without you asking. For example, you could put an interesting case study using a particular product onto your blog, and find that the manufacturer shares this to their website and social media. This content will naturally mention the location of your clinic, which signals to search engines that your business is relevant in your area.

Directory listings Consistent NAP, which stands for name address and phone number, needs to be character for character, the same across all directories and listings. This ensures that search engines know that all of your assets, profiles, websites and references refer to one business – yours.7 Errors in this information, such as representing your business name as both ‘Dr Smith Aesthetics’ and ‘Doctor Smith Aesthetics’ will impact your SEO. This is because your listing could become confusing for your customers, if you are placing ‘1a High Street’ as well as ‘1 High Street’, it therefore makes it harder for Google to trust your information.7 Putting your business into the large online directories, such as Yell, Yelp, Thomson Local, as well as Apple Maps Connect and Bing Places, with a consistent NAP will provide more links back to your website.

Offline efforts = online rewards Reviews and testimonials Gathering reviews and testimonials online is key to successful local SEO. The value of Google reviews for SEO have been discussed, and other platforms such as Facebook, Trustpilot, RealSelf and Doctify are great places to publish them. According to BrightLocal, consumers on average read 10 reviews before engaging with a business and, with the 18-34 market, this increases to 13.6 Some practitioners are afraid to ask for reviews, for fear of negative responses. I would suggest asking for them in person, rather than doing so in a follow-up email; if the patient does have any negative feedback it will be easier to discuss on a one-to-one basis and people are generally more likely to leave a review when asked in person.

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Networking You can also source backlinks from local businesses, such as hair salons, other private medical clinics such as physiotherapists and dentists, and independent hotels, by offering to write guest posts and deliver value to their customer base. A local guide for visitors coming to your town or city could recommend multiple locations such as bars, restaurants, entertainment and attractions, and include your clinic as the place to visit for pampering and the best aesthetic treatment. Think about each treatment you offer, and relate them to as many hobbies as possible, such as sports or the arts. Your local Chamber of Commerce will hold regular events and training; joining your chamber may be a worthwhile investment. The Federation of Small Businesses is another organisation to explore. Holding your own networking event, in-clinic, by inviting nearby businesses, gives you the platform to speak about what you do, hold guided tours and share information you think might be useful for their audience; you will either generate referrals backlinks for yourself, or perhaps even bring in the business owners themselves as patients. Having great website content Ultimately, Google sees how many people visit your website, how long they spend there and how many pages they click on as an indicator of a quality website. Making your website as inviting, educational and interesting as possible will provide search engines with signals that it is worth delivering in the SERP to more people. Examples of content which is engaging: • Individual treatment pages, rich in information and FAQs. Aim for over 750 words on each • About Us section to introduce the clinic team • Contact Us page, using consistent NAP and multiple ways to contact and book • Concerns pages, if you offer multiple treatments for one condition, such as acne or rosacea • Video introduction to the clinic, or to each treatment, including video before and afters, patient testimonials, treatment-inprogress videos • Original photography – not stock – in as many places as possible, to set the scene • Clinic blog, offering insight into your business, education for visitors on skin or aftercare, and more

Producing this content is down to great collaboration between your clinic team and a web developer or self-build platform.

Invest your time All your actions here require an investment of time but do not have to cost a lot of money. By feeding Google as much information about your business, you will benefit from higher ranking in local searches, and conversely, receive more patient enquiries from organic search.

13 & 14 MARCH 2020 / LONDON

Alex Bugg will be speaking on Local SEO at the Business Track at ACE 2020 on Friday March 13. Register free using code 15100 aestheticsconference.com Alex Bugg has worked with the Web Marketing Clinic since 2012 and has a key interest in developing strategies for cosmetic clinics and biotechnology firms across the UK and abroad. Bugg also has a Master’s in chronic disease and immunity from the University of Leicester, graduating in 2016. REFERENCES 1. Patel N, 2019, The Definitive Guide to Local SEO, <https:// neilpatel.com/blog/definitive-guide-local-seo/> 2. Ahrefs 2019, Search Intent: The Overlooked ‘Ranking Factor’ You Should Be <Optimizing for in 2019, https://ahrefs.com/blog/ search-intent/> 3. About Google My Business (UK: Google, 2020) <https://support. google.com/business/answer/3038063> 4. Campaign Monitor 2019, 58 Mind-Blowing Digital Marketing Stats You Need to Know, <https://www.campaignmonitor. com/blog/email-marketing/2019/05/58-mind-blowing-digitalmarketing-stats-you-need-to-know/> 5. Moz 2020, Do Businesses Really Use Google My Business Posts? A Case Study, <https://moz.com/blog/google-mybusiness-posts-case-study> 6. BrightLocal 2019, Local Consumer Review Survey <https://www. brightlocal.com/research/local-consumer-review-survey/> 7. The Hoth, 2020, Local SEO: The Ultimate Guide, Chapter 4 -Local Citations, <https://www.thehoth.com/learn/local/seo/ local-citations/>

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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“We need unity and to focus on patient safety” Dr Lee Walker shares his journey to becoming an international trainer and key opinion leader One of seven children growing up in a busy terraced house in Liverpool, Dr Lee Walker’s unique sanctuary in his early years was detention, where he would voluntary go for peace and quiet to study. The study paid off, Dr Walker says, “After school, I did Biomedical Science at Manchester University and then I went to Liverpool University to become a dental surgeon, specialising in orthodontics. I finished in 1999 and worked for the NHS for a while, before opening my own practice. It wasn’t until 2001 that I started to dip my toes into the aesthetics pool after a friend introduced me to botulinum toxin.” Dr Walker says that, at the time, toxin was being used off-license for cosmetic indications, and there was not a lot of literature available. He explains, “Training was less than half a day and you basically had to learn on the job, which, as we now know, is not the best or safest way to do things – it’s scary looking back and wondering how things didn’t end up worse.” He adds, “Fillers hadn’t really evolved at that time, and I remember there was only three types of filler – thick, thick and thick! We now know that we require different fillers for different anatomical areas to achieve the best results.” Success didn’t happen overnight for Dr Walker. He reminisces, “Aesthetics was incredibly niche and treatments were expensive; there was only a small cohort of patients who could afford it. I slowly accumulated patients by opening a dialogue with my dental patients, who already trusted me. I originally had around 90% dental and 10% aesthetic patients, which shifted to 50/50 and then, gradually, in 2013, I stopped doing dentistry altogether.” Dr Walker believes that newer practitioners don’t always understand how long it takes to get patients. “New practitioners are trying to create an instant switch into aesthetics. They do a course and then expect a queue of patients, which, as a trainer, is frustrating. For me it was slow progress and took a lot of time.” Dr Walker’s aesthetic clinic in Liverpool, B City Clinics, is now entirely focused on non-surgical aesthetic treatments and he has three practitioners working for him there. However, the majority of his time is now dedicated to educating others. Dr Walker runs his own training academy and is an national and international trainer for Teoxane, recently becoming co-lead of medical education for the UK. So how did he get to this stage? “I started using Teosyal products about 12 years ago and I really liked them,” he explains, noting, “One day my sales rep got in touch with me because he was impressed with my industry and product knowledge and asked if I would consider doing some small scale training. It was really basic; we just invited a few practitioners to the clinic and did a lecture and a demonstration. After a while we started to build a small following, and I was asked by Teoxane to offer this training once a month; it gradually went from there.” Dr Walker recounts his first large-scale event at The Royal Society of Medicine. “I remember being incredibly nervous for fear of letting people down. I didn’t think I did myself justice, but the delegates and company seemed to like it. My journey into training started off from humble beginnings and I think that’s what most people need to become an international KOL.” Dr Walker highlights that to become a successful international representative for a leading company you need to be persistant and work hard. He says, “I always compare being a KOL to being in a rock band, like The Rolling Stones. They didn’t get successful overnight, they started off playing at small events, and then worked their way up.” Dr Walker has now spoken in 30 countries and is preparing for tours in Australia, the Middle East and Canada in 2020. Dr Walker has also obtained a Certificate in Clinical Education from the Royal College of Physicians and Surgeons Glasgow, which he says has been key in his success in training others. “I absolutely recommend other prospective trainers to complete formal education in training. I think it’s one thing that sets me apart as I understand how to teach and recognise different learning styles. I don’t like to call myself a teacher because it’s almost a position of dominance; instead,

I want to be a peer and be inspirational to people.” Other than training, Dr Walker works with the Aesthetic Complications Expert (ACE) Group, having been a part of the association since it was established in 2010. “My proudest achievement is seeing our credible work published because its evidence-based, which a lot of aesthetics isn’t. Another highlight would be speaking at big international conferences with world leaders on complications.” When asked his top tips of advice for other practitioners, Dr Walker says, “Be patient, be resilient, be safe. Aesthetics can be quite an intimidating environment to be in. The industry can become almost like a tribe and there is a lot rivalry. What we need is to stick together; we need unity and to focus on one thing, which to me is patient safety.”

What challenges you?

Staying up to date. I have a fear of being on stage and someone asking if I’ve seen a paper and I have to say that I haven’t. To avoid this I read every single day – a minimum of two new scientific papers a day actually!

What’s your top filler tip?

Understand the three pillars of anatomy, apply a safe technique to the injection area, and use the correct filler product for the indication.

What do most people not know about you?

I used to be a qualified athletics coach, was really into running and did a few marathons. I was also a semiprofessional footballer in Wales.

Dr Lee Walker will be speaking at the Teoxane Approach Symposium at ACE 2020 on March 13-14. Register free using code 15100 aestheticsconference.com 13 & 14 MARCH 2020 / LONDON

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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‘Hyaluronidase has no longterm effects on the patient’s own collagen or hyaluronic acid production’

The Last Word Dr Tahera Bhojani-Lynch encourages practitioners to question ‘facts’ in aesthetics, with a particular focus on hyaluronidase There was once a time in medicine when anything that defined our clinical practice had to be peer reviewed and was subject to medical trials before we took it on board as ‘best practice’. However, we all know that aesthetic medicine is a relatively new speciality and scientific papers can contain conflicting information, often recounting experiences and opinions rather than controlled or comparative clinical data. Many published papers are case records rather than clinical trials and studies are often cadaveric and in vitro, rather than in vivo, meaning interpretation is open to subjectivity and bias. So, where should we turn to in order to determine what is ‘best practice’ in our field? I regularly find it very frustrating when practitioners stand up on stage at a big congress and state an opinion as if it is proven to be correct. It is then taken by the audience as the gospel truth, irrespective of whether there is any clinical data to support it, and then they it repeat as if it is an absolute fact that cannot be questioned or discussed – it becomes a given and can subsequently turn into ‘best practice’. However, just because a claim is made by someone who is well-known and perhaps very reputable or knowledgeable, does that make it absolutely true? How often are their opinions unbiased, or without agenda and consequently the correct way to do

things? Are we even allowed to challenge them without calling our own reputations into question, when so called ‘influencers’ and ‘key opinion leaders’ have the following of social media or the backing of rich pharmaceutical companies? In this article, I present two statements or ‘facts’ about hyaluronidase that I have heard over the years on both national and international stages, that I believe can and should be questioned in order to help progress our ever-evolving specialty. I have chosen to focus on hyaluronidase because of its increased use associated with the rising number of aesthetic complications and poor aesthetic results over the years.1

I regularly hear at conferences that if a patient has a poor aesthetic result following treatment with a hyaluronic acid (HA) dermal filler, then the practitioner can ‘just hyaluronidase it’. But should we be acting as if there are no potential repercussions of this treatment? First and foremost, hyaluronidase is not licensed for aesthetic use, or for the correction of poor aesthetic treatments or for use in an aesthetic emergency.2 There must be clinical need and good evidence to use hyaluronidase for any such off-license indications. It is also a prescription-only medicine, but is often used with casual regard to its actual mode of action and potential side effects. Hyaluronidase is routinely used to correct poor treatments, granulomas, lumps and bumps, at the request of dissatisfied patients and in haste by worried practitioners. There are clinical publications discussing the effects of hyaluronidase as ‘dissolving’ hyaluronic acid,3,4,5 but there is little or no good evidence for damage to a patient’s own HA or collagen production following hyaluronidase use, and I am not aware of any that show clinical evidence that they do. In reality however, I believe that we do not actually know the long-term effects of hyaluronidase on the skin. Remember, just because there is no evidence published yet, it does not mean that there is no effect. Of course, in emergency vascular events following HA dermal fillers, hyaluronidase use to improve vascular perfusion is well-accepted as the best approach for successful patient outcomes, even though there is little consensus for dose, dilution, efficacy and safety.2

Just because someone states something, it doesn’t make it true, no matter how prominent, clever or important they are

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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However, anecdotally, myself and other practitioners have seen that when we have patients that have had repeated hyaluronidase use in skin, there are visible volume changes that do not recover with time, and textural changes, where the skin appears lax and thickened, with loss of subdermal support. I believe this is particularly evident in the periorbital area where there is naturally thinner skin and little or no subcutaneous fat.6 I had one patient referred to me who had received six doses of hyaluronidase in the periorbital area with two different practitioners, after both their original treating practitioner and the ‘expert second option’ thought the patient had persistent, protruding residual HA lumps following her treatment. When I assessed the patient, the tissue around one eye was completely de-structured – the skin was shiny, and the whole of the eyelid was affected – she looked awful. Upon examination, I discovered that the ‘lumps’ were not HA, but redundant skin that had thickened but felt like a hard pocket of residual HA. This had led her practitioners to repeatedly administer hyaluronidase with ever worsening aesthetic outcomes. It was evident from this case that not only is it important to have an accurate synopsis of previous interventions before any further remedy is initiated, but that also, quite possibly, repeated hyaluronidase injections may have an impact on the quality of the overlying and surrounding skin. I would urge practitioners to therefore think long and hard before they ‘just hyaluronidase it’ in non-emergency situations, and consider the possibility that hyaluronidase could potentially affect the patient’s skin. Ensure you take good before and after pictures and monitor the effects. When hyaluronidase is the only option for improved cosmetic effect, small volumes with low doses7,8 and allowing time for recovery of tissues between treatments might minimise disruption to the delicate balance of skin homeostasis.

‘Vascular occlusion with non-HA filler collagen stimulators cannot be treated with hyaluronidase’ When it comes to non-HA collagen stimulating fillers such as calcium hydroxylapatite (Radiesse), polycaprolactone (Ellansé), or poly-l-lactic acid (Sculptra), it is generally accepted that hyaluronidase is not an option for removal of the product, although I cannot find any clinical studies to reference this. Certainly, having contacted the manufacturers/

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distributors of these products, neither Sinclair nor Merz were able to give me any clinical data in favour for or against the use of hyaluronidase with these products, and so none advocated the use of hyaluronidase for emergency use or for poor cosmetic effect. There are even some verbal reports that treatment with hyaluronidase may actually make matters worse and cause unsightly nodules by reducing ‘volume’ in the surrounding skin. I have heard mixed reports from colleagues at conferences regarding this. I myself have experienced a venous occlusion following injection of a collagen-stimulating filler (polycaprolactone) which I successfully treated using hyaluronidase. Many people believe that hyaluronidase breaks down or dissolves hyaluronic acid, but its established mode of action is to change and increase the vascular permeability.9,10 Because of this mode of action, it could be possible to treat collagen stimulators with hyaluronidase and it may help in serious medical emergencies like vascular occlusions. I therefore don’t agree that non-HA fillers, like collagen stimulators, cannot be treated with hyaluronidase; I believe that further studies in this area should be performed.

Summary I am not saying we should never listen to experienced and renowned industry speakers as, most often, they do have fantastic tips and advice, which are supported by evidence. I simply want to try and persuade practitioners to consider themselves as scientists, as well as injectors, and look at the evidence rather than listen to and repeat the sound-bite. I encourage my peers to have the desire to question the facts they hear and relate it back to science. Aesthetics is an emerging specialty and there is not enough unbiased data to substantiate much of what is proclaimed as ‘best practice’. I think when presenting to others, key opinion leaders should acknowledge when there is limited, or conflicting evidence for their claims, and highlight that their way is not the only way, and encourage their delegates to learn through questioning their presentation, rather than accepting it. Practitioners must remember that just because someone states something, it doesn’t make it true, no matter how prominent, clever or important they are. If we keep regurgitating the same so-called

Aesthetics

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‘facts’ without questioning them, then we will never evolve – if we hadn’t stopped to question ‘established teaching’ we would all still be injecting directly into nasolabial folds! Personally, I believe hyaluronidase can be used to treat venous occlusions caused by non-hyaluronic acid dermal filler collagen stimulators and I have treated two with excellent effect. I also believe that hyaluronidase affects the underlying structure of skin and can have long-term detrimental effects on normal dermal appearance. However, just because I say this, it doesn’t mean that it is true! I would invite my colleagues to share their knowledge with me, question my assertions and take the debate forward for the benefit of patients and practitioners alike. Acknowledgements: Dr Bhojani-Lynch would like to thank nurse prescriber Helena Collier for her expertise and input in this article. Dr Tahera Bhojani-Lynch is an aesthetic practitioner and eye surgeon specialising in laser surgery, medical aesthetics and pharmaceutical medicine. As a member of the Royal College of Ophthalmologists, she was the first female British graduate to perform LASIK eye surgery in the UK, and is an international award winning clinical writer. She is an international trainer and country expert for Teoxane UK. Qual: MBChB MRCOphth MBCAM CertLRS DipCS REFERENCES 1. Kilgariff, S, News Special: Aesthetic Complications, Aesthetics journal, September 2019. <https://aestheticsjournal.com/feature/ aesthetic-complications> 2. King M, C Convery, E Davies, This month’s guideline: The Use of Hyaluronidase in Aesthetic Practice (v2.4), J Clin Aesthet Dermatol. 2018 Jun; 11(6): E61–E68. <https://www.ncbi.nlm.nih. gov/pmc/articles/PMC6011868/> 3. Cavallini M, et al, The role of hyaluronidase in the treatment of complications from hyaluronic acid dermal fillers, Aesthet Surg J. 2013 Nov 1;33(8):1167-74. Epub 2013 Nov 6. 4. Rao, V, et al., Reversing Facial Fillers: Interactions Between Hyaluronidase and Commercially Available Hyaluronic-Acid Based Fillers, Journal of drugs in dermatology: JDD 13(9):10531056 5. Salti G, Tempestini A, Adverse events of injectable fillers in the periorbital area, The European Journal of Aesthetic Medicine and Dermatology. 6. Vlcek I, et al., Infraorbital Dark Circles: A Review of the Pathogenesis, Evaluation and Treatment, J Cutan Aesthet Surg. 2016 Apr-Jun; 9(2): 65–72. 7. Menon H, et al., Low dose of Hyaluronidase to treat over correction by HA filler–A Case Report, The Cosmetic Surgery Institute Mumbai, India. 8. Lindau, M Hyaluronidase Caveats in Treating Filler Complications, Dermatologic Surgery : Official Publication for American Society for Dermatologic Surgery et al., 01 Dec 2015, 41 Suppl 1:S347-53. 9. DeLorenzi C, Complications of Injectable Fillers, Part 2: Vascular Complications, Aesthetic Surgery Journal, Volume 34, Issue 4, May 2014, Pages 584-600. 10. BA Buhren, et al., Hyaluronidase: from clinical applications to molecular and cellular mechanisms, Eur J Med Res. 2016; 21: 5.

Reproduced from Aesthetics | Volume 7/Issue 4 - March 2020


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